Questions and Answers: Complicated Labour

1. How can labour be complicated?

Labour can be complicated in two ways:

- A normal labour which develops complications at any stage.

- A labour which is complicated from the beginning due to an abnormality in the position of the baby or due to any maternal complication.

2. What are the complications of labour in 1st, 2nd and 3rd stage.

Complications in the first stage of normal labour

(Foetal Distress, Prolonged Labour)

Complications of second stage of normal labour

(Delayed Second Stage, Maternal Injuries, Perineal tear, Vaginal Tears, Cervical tear, Vulval Haematoma)

Complications of the third stage of normal labour

(Postpartum Haemorrhage, Retained Placenta)

3. How to identify the complications in the 1st stage of labour?

Complications in the first stage of normal labour :-

Foetal Distress : The foetus may show signs of distress at any time in the first stage of labour.

The signs of foetal distress are:

passage of meconium (foetal stool) in the liquor amnii.

Increase of foetal heart rate above 160 per minute.

Deceased oxygen saturation in the foetal blood.

Decrease of foetal heart rate below 100 per minute.

4. What are the management?

Management/ Treatment : Caesarian Section should be done at the earliest possible time.

Prolonged Labour : Labour is defined as prolonged when it lasts for more than 18 hours.

Causes:

more common in a first pregnancy and in elderly patients

Malpresentations: When the foetus is not in a normal position, e.g in a breech presentation.

Cephalopelvic Disproportion ( CPD ): When the size of the foetal head is bigger then the size of the maternal pelvic passage or birth canal.

When the uterine muscle is grossly distended and fails to contract properly as in twin pregnancy, hydramnios (excess liquor amnii), presence of tumours in the uterine musculature like fibroids.

Excess use of painkillers or anaesthesia to decrease the pain of normal labour.

Cervical dystocia or stenosis (when the cervix fails to dilate).

Signs and Symptoms :

Labour extends for more than 18 hours.

Patient looks exhausted and distressed. Dehydration may be present. Mouth may be dry due to prolonged mouth breathing.

Pain may be more on the back radiating to the thighs rather than affecting the abdomen. This is due to pressure over the muscles and ligaments.

Labour pains may initially be severe, frequent and prolonged but later decrease and become very mild.

Pulse rate is often high.

The large intestines are dilated and can be palpated along both sides of the uterus as large, thick structures filled with air. They give off the hollow sound of drums on tapping.

The uterus is tender on palpation and does not relax fully between contractions.

Ketosis may develop due to prolonged starvation.

Foetal distress may develop.

Membranes may or may not rupture early. In early rupture, there is a risk of infection of the uterine contents if proper antibiotics are not prescribed.

Management / Treatment : With the discovery of various drugs capable of accelerating labour, prolonged labour is a rarity nowadays. After 3cms of dilatation, the cervix should dilate at the rate of 1cm per hour. If there is lack of dilatation for a reasonable period of time, then an oxytocin drip is started. Drugs like epidosin causes softening of tissues in the cervix. If the cervix fails to dilate in spite of adequate uterine contraction, epidosin or buscopan can be safely given to cause softening of the cevix. Intensive clinical monitoring should be done, recording the pulse, BP, foetal heart sound (FHS), and dilatation of the cervix at intervals of two hours. FHS should be checked even more frequently if necessary. If in spite of the above procedures, labour fails to be accelerated or if foetal distress should develop, Caesarian Section should be done.

5. What are the complications of 2nd stage of normal labour?

Complications in the second stage of normal labour :

Delayed Second Stage : The second stage of labour may be delayed due to:

Uterine inertia secondary to prolonged first stage.

Malpresentation of the foetus, e.g. face presentation.

Compound presentation: when two parts of the foetus present at the pelvic canal at the same time,e.g. the head and one arm.

Undiagnosed contracted pelvis.

Obstruction in the vagina: congenital or acquired (e.g.by a tumour).

Improper use of anaesthesia

6. What is the management of the delayed 2nd stage of labour?

Management / Treatment:

If the cervix is fully dilated as is the case in the second stage of labour, but the presenting part of the foetus is very high up, an attempt is made to increase labour pains with the help of medicines like oxytocin. If after 1 hour there is no progress and the presenting part is still high up, caesarian section is done.

If presenting part is high up and there are signs of foetal distress, an immediate caesarian section is done.

If the greatest diameter of the presenting part is below the ischial spine of the pelvic canal, then labour pains are augmented by medicines like oxytocin and a normal delivery expected.

If there are signs of foetal distress, and the head is low down, Forceps Delivery or Vacuum Extraction of the foetus is done.

Forceps Delivery or Vacuum Extraction of the foetus is also done where there is maternal distress due to prolonged labour.

7. What is the management of maternal injury?

Maternal Injuries : Most maternal injuries occur during the second stage of labour. The commoner ones are:

Perineal tear : The perineum is the region between the vaginal opening and the anus. The cause of injuries to this part is due to overstretching of the perineum during the delivery of a big baby, malpresentated baby, average sized baby with a narrow vaginal outlet, forceps delivery and difficulty in delivering the shoulders of the baby.

There are different degrees of perineal tear. There may be only a mild degree of laceration of the skin; there may be rupture of the muscles of the perineum with tears at the vaginal wall: there may be a complete perineal tear with the tear extending from the vaginal opening through the posterior vaginal wall and the perineal muscles upto the anus with injuries to the external anal sphincter.

Management/Treatment: Prevention is the best management. The second stage of labour should be properly conducted. An episiotomy should be performed to prevent tear of the perineum.

Repair : If a tear has already occurred, it should be repaired as early as possible, preferably within the first 24 hours.

Vaginal Tears : They can occur at any part of the vaginal wall, but are seen mostly at the junction between the lateral and posterior walls. The vagina should always be examined under proper light for any such tears. All tears are repaired immediately.

Cervical tear : Cervical tears usually occur at the lateral wall. Delivery through an undilated cervix whether spontaneously or by forceps and precipitate labour are the common causes. The injury should be immediately repaired.

Vulval Haematoma : Blood from a rupture of the deep veins of the vagina can collect in a closed space if there is no opening for it to come out. This shows up as a steadily increasing swelling to one side of the vagina. The swelling is tense and tender to the touch. The bleeding can be severe enough to cause the patient to go into shock.

Repair : To control the bleeding, the swelling is incised, the blood clots removed and the bleeding points ligated. The patient is supported with fluids and blood transfusion is given if necessary.

8. What are the complications of normal labour in the 3rd stage and what are the management of those?

Complications in the Third Stage of Normal Labour :

The commonest complications of the third stage of labour are :

(a) Postpartum haemorrhage

(b) Retained Placenta

A. Postpartum Haemorrhage

Postpartum haemorrhage is defined as bleeding occurring at any time after the birth of the baby to 6 weeks after delivery where the bleeding amounts to a degree affecting the general condition of the patient. There are three clinical types:

Third Stage Haemorrhage occurring after the delivery of the baby but before the expulsion of the placenta.

Primary Postpartum Haemorrhage - Bleeding within 24 hours after the delivery of the placenta.

Secondary postpartum haemorrhage - bleeding occurring after 24 hours of the delivery of the placenta upto 6 weeks after the delivery. This condition will not be described in this section.

Causes :

Atonic haemorrhage - or due to lack of contraction of the uterus. The bleeding occurs from the placental site as the uterus fails to contract properly.

This can occur in cases of partial or complete retention of the placenta

Where the uterine muscles are exhausted after prolonged labour

Overdistension of the uterus as in cases of twin pregnancy or hydramnios

Tumours like fibroids preventing proper contraction of the uterine muscles

High blood pressure

Traumatic haemorrhage - Bleeding can occur from cervical, vaginal or perineal tears.

Mixed - a mixture of both.

Management / Treatment: The main principles of management are

(a) to prevent further blood loss

(b) to restore proper blood volume.

Where the placenta has not separated from the uterine muscle :

Ergometrine is injected and controlled cord traction is given to try and deliver the placenta, especially in a case of home delivery.

If the above method fails, manual removal of the placenta should be done under general anaesthesia in the operating theatre.

Where the placenta has been delivered but bleeding is still present :

Bimanual palpation of the uterus by gripping it with one hand over the abdomen and the other placed in the vagina stimulates the uterus to contract.

Ergometrine is injected.

The cervix, vagina and perineum is examined under proper light for any tears and injuries and if present, they are repaired.

An USG is done to see if the uterus is completely empty of any placental contents. If present, they are removed under GA.

Occasionally, in rare intractable caases, a hysterectomy (removal of the uterus) may be the only option left.

General support of the patient.

B. Retained Placenta :

Retained Placenta is diagnosed when the placenta is retained for more than half an hour after delivery.

Causes :

The placenta may fail to separate completely due to the lack of contraction of the uterus.

Morbid adhesion of the placenta can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate.

The placenta may separate but fail to be delivered due to any constriction of the uterine walls or due to early closure of the cervix.

Management / Treatment:

If bleeding is present, active treatment is done to control the blood loss and support the general condition of the patient.

Manual removal of the placenta under GA in the Operative theatre.

If the placenta is too deeply embedded into the uterine musculature (called placenta accrete), a hysterectomy operation may be indicated.

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