Labour and Birth

Complications and unexpected outcomes during birth

Complications and unexpected outcomes during birth

As you may now be aware, labour and birth can be a challenging time for the mother and baby, both physically and emotionally. The aim of the second stage of labour is for the mother to safely birth a healthy baby in a rewarding manner whilst retaining physical and psychological wellbeing.

Naturally, for this to occur, birthing should occur within an optimal timeframe. For this reason, various obstetric professional bodies worldwide have placed time limits on the duration of birth based on the available research evidence. The current recommendation is that for first-time mothers birth should occur within 3 hours of the start of the active phase and for mothers who have previously birthed a baby or babies, birth should take place within 4 hours.

What if your birthing progress slows down?

Variation in the duration of the second stage of labour is due to many different factors and the length of time in second stage is not the only consideration. In general, progress may slow due to factors associated with the mother, her pelvis, the baby or the contractions and pushing efforts. When considering whether your progress has slowed your obstetrician and midwife will assess:

  • Whether this is your first time or you have birthed a baby/babies previously
  • When your cervix reached full dilation
  • How long you have been actively pushing
  • You and your baby’s wellbeing during second stage as well as during the first stage of labour e.g. vital signs, heart rate, tiredness and whether supportive measures such as an IV infusion may be appropriate
  • How much pain you are experiencing and whether different or more pain relief is appropriate
  • What progress has been made with regard to the baby’s size, presenting part, position and how far she/he has moved down the birth canal and whether a change in your position will assist the baby to rotate into a more favourable position for birth
  • The quality of your contractions and pushing, whether the baby descends with pushing, and whether augmentation is appropriate
  • Whether you have an epidural in place. Extra time is allowed in this case, as discussed earlier
  • Your pelvic shape and size and whether a change in your position may optimise the pelvic diameters
  • Any existing pregnancy, labour or medical risk factors that may require the birth to occur sooner than later

Taking into account all of the above factors, your obstetrician will discuss with you and your birth partner/support person, the safest and most appropriate option for you and your baby. Options include:

  • Allowing more time and employing methods described above to promote better progress
  • Recommending immediate birthing of the baby by assisted or instrumental methods
When your baby shows signs of not coping with the birth

Sometimes during birthing, as in the first stage of labour, the baby may show signs of not coping. These signs, how it is managed and the available options are similar to when fetal compromise occurs during the first stage of labour (please see the section called When baby shows signs of not coping with the labour). Your obstetrician and midwife will also consider how you have progressed during the second stage in deciding and discussing with you the available options. However, if your baby has been showing signs of compromise throughout your labour, and continues to show signs of not coping with the birth, then it may be safer and more appropriate that the birth occur sooner than later and assisted, instrumental or caesarean birthing may be recommended to you by your obstetrician. Sometimes events like these can occur suddenly, out of the blue, and because it may be an emergency situation where time is of the essence, a full informed consent discussion may not be possible because your Maternity Team will be working hard to optimise the outcome for you and your baby. You and/or your family will receive as much explanation as circumstances allow at the time and a more comprehensive debriefing afterwards when the emergency has passed.

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Shoulder dystocia (difficulty with birthing baby’s shoulders)

There is a small chance that during birth the baby’s shoulders can become stuck behind the mother’s pelvic bone. Shoulder dystocia occurs after the head has been birthed but the rest of the baby’s body does not emerge due to the impaction of the shoulders. This may occur during normal or instrumental birth and can be associated with a previous difficult birth, with birthing larger babies, when the mother has diabetes, when labour has been induced or progress has been slow. However, it is not usually possible to predict when this might occur because it can happen out of the blue with a normal pregnancy and birth, but your midwife and obstetrician are aware of this possibility with every birth.

What can be done?

If your midwife or obstetrician recognises shoulder dystocia during birth, there are some specific ways they can manage this and safely deliver the baby. The midwife and/or obstetrician will:

  • Explain the situation to you and your birth partner so you understand and can assist in these measures
  • Ask you to stop pushing and to change positions to allow the midwife or obstetrician to perform certain manoeuvres. These are designed to maximise the space within the pelvis and/or rotate the baby into a more favourable position to allow birth of the baby’s shoulders.

There will likely be other members of the Maternity and Neonatal Teams assisting. Because shoulder dystocia is considered an emergency situation, it can be stressful for everyone concerned and it can sometimes result in injuries or complications to the mother and baby. These include:

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Perineal tears and episiotomy

During birthing the perineum (the tissues in the area between the vaginal opening and the anus (back passage) and vagina gradually stretch to allow passage of the baby, but these tissues can also tear spontaneously or may need to be cut (this is called an episiotomy).

It is estimated that up to 9 in 10 women will tear to some extent during childbirth. There are 4 degrees of tears:

  • First degree tears are small, skin-deep tears which usually heal naturally and do not require stiches
  • Second degree tears are deeper tears affecting the muscle of the perineum and vagina as well as the perineal skin. These usually require stitches.
  • A third-degree tear extends downwards from the vaginal wall and perineum to the anal sphincter, the muscle that controls the anus
  • A fourth-degree tear extends to the anal canal as well as the rectum (further into the anus)

First and second degree tears are more common. Severe perineal tears such as third and fourth degree tears are less common. Women with Asian ethnicity, first time mothers, very rapid birthing, when the baby’s head is not in an optimal position and heavier birth weight are factors associated with these more severe tears.

Can tears be reduced in severity or prevented?

Yes, there are ways that the likelihood of tearing can be reduced or prevented. Research indicates that perineal massage and pelvic floor exercises during pregnancy, placement of warm compresses on the perineum in the second stage of labour, and maternal positioning (e.g. birthing on your hands and knees), can be used successfully to prevent or reduce the severity of perineal tears. Perineal massage during birthing is not recommended and, as described earlier, it is advisable to be guided by your own urges to push during birthing.

An episiotomy is a surgical cut (usually with surgical scissors) made by your obstetrician or midwife into the perineum. It is performed under local or regional anaesthesia to make the vaginal opening larger to facilitate or hasten birth of the baby. The cut involves the skin and some muscle of the perineum and vagina internally (similar to a second degree tear). These days episiotomy is not as routinely performed as in the past.

Your obstetrician and/or midwife will carefully examine you following childbirth to visualise the extent of any tears or episiotomy and will provide you with pain relief if repair is necessary. If you have an epidural, this is usually ‘topped-up’ or if not, local anaesthetic can be injected into the tissues to numb the pain. The tear or episiotomy will be sutured by your obstetrician or midwife after childbirth using self-dissolving stitches both internally, in the vagina and perineal body and externally, on the perineal skin.

Your midwives will assist you and show you how to care for your perineum after childbirth. Ice packs and pain relieving medications can be used to reduce swelling and pain and pelvic floor exercises can improve recovery and reduce the likelihood of urinary problems. If there has been damage to the anal sphincter or rectum, you will need additional treatment and ongoing care. More information on tears and episiotomies can be found in the resources section.