Childbirth сomplications are pathological conditions that occur during labor, are associated with it, affect the course and outcome of labor. They are manifested by a violation of the contractile activity of the myometrium, pain syndrome, bleeding, deterioration of the general condition of the woman in labor (dizziness, weakness, loss of consciousness, coma). For diagnosis, methods of external obstetric examination, vaginal examination, cardiotocography are used, less often — ultrasound, in the subsequent period — revision of the birth canal and uterus. The tactics of labor management in case of childbirth complications is determined by the nature of the revealed pathology, may involve both natural and operative delivery.
General information
To date, only 37% of births occur physiologically. In other cases, various types of childbirth complications are determined, and 23-25% of births are completed surgically. According to the results of research in the field of obstetrics and gynecology, the most frequent childbirth complications are ruptures of the cervix (up to 27% of cases of childbirth) and perineum (7-15%), premature discharge of amniotic fluid (12-15%), anomalies of labor forces (about 10%), infectious processes (2-8%), bleeding (2-5%) and premature placental abruption (0.45-1.2%). With improper management, complicated childbirth poses a threat to the health and life of both the mother and the fetus. Despite the constant decline in maternal mortality rates, up to 200 women die every year during childbirth in the United States.
Causes
The pathological course of childbirth may be caused by provoking factors on the part of the mother, fetus and its membranes. The main causes of disorders that occur in childbirth are:
- Pathological pregnancy. With a complicated gestational period, the risk of labor disorders increases — premature placental abruption, weakness of labor forces, decompensation of chronic diseases of the mother, bleeding.
- Anatomical features of the birth canal. A narrow pelvis, voluminous formations of the neck, vagina, pelvic organs, and a high perineum become physical obstacles to the passage of the fetus. With infantilism, saddle uterus and other developmental abnormalities, the contractile activity of the myometrium is more often reduced. An age-related decrease in the elasticity of tissues increases the likelihood of their rupture.
- Inflammatory diseases. In the presence of endometritis, cervicitis, colpitis, chorioamnionitis, the risk of bleeding, birth trauma of the mother, infection of the child during passage through the birth canal increases.
- Previously undergone invasive interventions. Scar-altered tissues of the genitals stretch worse, are less resistant to the stresses that occur during childbirth. Therefore, women after gynecological operations and diagnostic manipulations (abortions, curettage, etc.) are more likely to experience childbirth complications such as soft tissue injuries.
- Injuries in past births. Scars formed after past ruptures of the perineum, cervix and uterine body are more susceptible to damage.
- Extragenital pathology. Hypertension, diabetes mellitus, kidney failure, myopia and other chronic diseases can decompensate during childbirth. Some of them increase the likelihood of bleeding, prolonged course, DIC syndrome and other complications.
- Incorrect position and presentation. Childbirth in an oblique position, pelvic, frontal or occipital presentation is accompanied by birth trauma, premature discharge of amniotic fluid, loss of the umbilical cord and small parts of the fetus. Natural delivery with the transverse position of the fetus is impossible.
- Anatomical features of the child. With large sizes, hydrocephalus or gross birth defects, it is more difficult for the fetus to pass through the birth canal. In such cases, the likelihood of female and prenatal injuries increases.
- Multiple pregnancy. Childbirth with more than one child, especially if they are the first, is more often characterized by a complicated course with an increased risk of bleeding and injury.
- Pathology of fetal membranes. Bleeding, fetal hypoxia and other childbirth сomplications can be caused by early rupture of the amniotic bladder, entanglement or prolapse of the umbilical cord, low or polyhydramnios, tight attachment, increment, ingrowth, germination or premature detachment of the normally or low placenta.
- Medical errors. Incorrect tactics of pregnancy and childbirth, the choice of an inappropriate method of delivery or type of surgical intervention, unreasonable stimulation of labor activity are fraught with the risk of injury, other complications and even the death of a woman or child.
Classification
The clinical classification of childbirth complications is based on the level of emerging disorders (pathology of childbirth, damage to the mother or fetus), their nature and time of occurrence. The varieties of pathological childbirth are:
- Premature birth. At the beginning of labor up to 37 weeks, the probability of complications in the fetus is higher. Therefore, even with a normal course, they are considered complicated.
- Prolonged labor. An increase in the duration of labor due to weak or discoordinated labor, clinically or anatomically narrow pelvis and other reasons increases the risk of injury, hypoxia, postpartum bleeding.
- Rapid childbirth. With rapid contractions of the uterus, ruptures of the soft tissues of the birth canal, fetal injuries, placental abruption, violations of placental blood flow, hypotonic bleeding occur more often.
- Operative delivery. Since cesarean section, the imposition of a vacuum extractor or forceps, obstetric rotation and other interventions increase the risk of complications in women and children, such births are obviously considered complicated.
In a woman due to childbirth , the following types of complications are possible:
- Birth trauma. Under the influence of significant stretching loads during childbirth, ruptures of the perineum, vagina, cervix and her body occur. In the most severe cases, injuries of the sphincter and the rectal wall, the divergence of the pelvic bones are observed.
- Decompensation of extragenital diseases. Significant physical exertion associated with childbirth can provoke a hypertensive crisis, acute cardiac, cerebral, renal or hepatic insufficiency, diabetic coma, retinal detachment and other disorders.
- Bleeding. With tissue ruptures, disorders in the blood clotting system, partial or complete increment of the placenta, hypotension of the myometrium, prolonged bleeding often occurs, leading to significant blood loss, hypovolemic shock and DIC syndrome.
- Amniotic fluid embolism. A terrible childbirth complications caused by the ingress of amniotic fluid into the mother’s bloodstream. In 70-80% of cases, it ends with the death of a woman, in 60-80% — with the death of a fetus.
- Retention of parts of the afterbirth in the uterus. Even in the absence of bleeding, fragments of the placenta that have grown or grown into the uterine wall pose a threat to a woman’s health. They can become a nutrient substrate for the development of inflammation or be reborn.
- Postpartum inflammatory processes. With severe and prolonged labor, various invasive interventions, the risk of developing endometritis, adnexitis, cervicitis, peritonitis and sepsis increases.
The main childbirth complications on the part of the fetus are considered:
- Prenatal injury. During childbirth, a child may get a spinal injury, a fracture of the collarbone and humerus. Possible intra-organ hemorrhages in the tissues of the brain, kidneys, liver, adrenal glands, disorders of cerebral circulation, the formation of cephalohematoma.
- Acute hypoxia. A decrease or complete cessation of blood flow from mother to child due to placental abruption or umbilical cord compression is accompanied by oxygen starvation. With prolonged hypoxia, irreversible changes in fetal tissues may occur.
- Infection in childbirth. With the clinical course or asymptomatic carrier of birth canal infections in the mother, it is possible for the child to be infected with conditionally pathogenic flora, pathogens of herpes, gonorrhea, chlamydia and other diseases.
Taking into account the time of occurrence of the consequences associated with childbirth, there are childbirth complications of the period of labor (premature onset, prolonged course, etc.), the labor period (fetal hypoxia, birth trauma, decompensation of concomitant pathology), the postpartum period (bleeding), the postpartum period (inflammatory diseases). In addition, there are long—term consequences of childbirth associated with their complicated course – ectropion and scarring of the cervix, prolapse and prolapse of the vagina, uterus, chorionepithelioma in a woman, cerebral palsy, other disabling symptom complexes and diseases in a child.
Symptoms
The complicated course of labor may be indicated by changes in the strength and nature of contractions, pain syndrome, vaginal discharge, disorders of the general well-being of the woman, fetal movement. With weak labor, the woman in labor notes rare short contractions, which are usually less painful. Discoordinated contractions are accompanied by a noticeable increase in the tone of the myometrium, an irregular rhythm of its contraction and relaxation, uneven strength of contractions and soreness of labor. Usually, at the same time, a woman feels expressed anxiety.
Although in the absence of anesthesia, pain is always present during childbirth, a change in its intensity may indicate the development of complications. More often, a pronounced pain syndrome occurs with a threatening and incipient rupture of the uterus. Immediately at the moment of rupture, the pain decreases, and the contractions of the myometrium stop. If a woman complains of sharp (“shooting”) pain in the area of the pubic joint during childbirth or immediately after it, a discrepancy or rupture of the pelvic ring may be suspected.
The appearance of abundant watery discharge from the vagina indicates the outpouring of amniotic fluid. Unlike the timely opening of the fetal bladder in normal childbirth, its premature rupture is considered a complication, often provokes a weakening of labor activity, loss of parts of the fetus or umbilical cord in the vagina. Spotting in the first period of labor is usually the result of premature exfoliation of the placenta. In the second period, they most often accompany ruptures of the birth canal, and in the third they occur as a result of hypotension of the myometrium or retention of parts of the placenta in the uterine cavity.
With the development of extragenital childbirth complications, there are general changes in the woman’s well-being. She may feel sudden weakness, dizziness, loss of clarity of vision, “flies” or a veil before her eyes, a strong heartbeat, sweating, a feeling of cold, shivering. During the inter-uterine period and, moreover, during contractions, fetal movements are usually not felt, but when hypoxia occurs, the discomfort experienced by the child makes him actively move. Therefore, the increased activity of the fetus in the period between contractions should be a reason for the caution of the obstetrician-gynecologist.
Diagnostics
Diagnostic measures during childbirth are aimed at assessing the condition of the woman in labor and the child, timely detection of complications and determination of their severity. If a complicated course of labor is suspected , it is recommended:
- External obstetric examination. It allows you to determine the shape and size of the uterus, the height of its bottom, the degree of opening of the neck (approximately), the correspondence of the size of the pelvis and the head of the child, to assess the frequency, strength and rhythm of contractions, to identify areas of local soreness.
- Vaginal examination. It is used to determine the state of the cervix, the degree of its disclosure, the integrity of the amniotic bladder, the part of the fetus and the peculiarities of its progress along the birth canal. During the examination, blood, umbilical cord, and parts of the fetus may be detected in the vagina.
- Cardiotocography. It allows monitoring the contractile activity of the uterus and fetal heartbeat, detecting signs of hypoxia and other threats to the child in time, accompanied by increased or slower cardiac activity.
- Gynecological ultrasound. Due to the rapid dynamics of childbirth during their management, ultrasound examinations are prescribed much less often than during pregnancy. In some cases, they are used to clarify the position of the fetus, the umbilical cord, the condition of the placenta and the scar on the uterus.
- Examination of the birth canal after childbirth. Revision of the cervix with the help of special spoon-shaped mirrors makes it possible to identify and suture its ruptures in time. Then the vagina and perineum are examined for ruptures.
- Manual examination of the uterus. It is a therapeutic and diagnostic procedure. It is carried out in case of suspected delay in the uterine cavity of placenta fragments.
If necessary, a woman is prescribed a general blood test, an ECG, pulse monitoring and blood pressure. Since pathological conditions are directly related to the process of childbirth, differential diagnosis is carried out between different types of complications. According to the indications, an anesthesiologist-resuscitator, therapist, neurologist, neonatologist are involved in the management of childbirth.
Treatment
Obstetric tactics are aimed at choosing the optimal method of delivery with minimizing the consequences for the woman in labor and the fetus. The choice of specific drugs and techniques is determined by the type of complications. In natural complicated childbirth are prescribed:
- Stimulators of uterine contractions. They strengthen contractions and accelerate the process of childbirth in patients with complications in the form of primary or secondary weakness of labor activity.
- Tocolytics. They allow you to relax the uterine muscles during violent or discoordinated contractions, hypertension, and the threat of scar rupture.
- Painkillers. Depending on the intensity of pain and its subjective perception by the woman in labor, a wide range of drugs and methods are used, from the appointment of analgesics to epidural or paravertebral anesthesia and general anesthesia.
- Sedatives. Reduce emotional stress, potentiate the effect of analgesic therapy, allow a woman to better control the process of childbirth in response to the instructions of midwives and doctors.
Childbirth complications by bleeding serves as an indication for the appointment of infusion therapy using hemostatics, blood-substituting solutions and blood preparations, oxygen inhalation through a mask. With persistent bleeding after the birth of a child, a revision of the birth canal for ruptures with their subsequent suturing and a manual examination of the uterine cavity to detect and extract placental remnants is indicated. In rapid childbirth, at the birth of a large fetus, a child with hydrocephalus or in a non-physiological position / presentation, when using obstetric aids or operations, the threat of damage to the birth canal increases. Therefore, an episiotomy is performed on a planned basis for a woman in labor.
Incorrect presentation and position of the fetus is an indication for the use of one of the obstetric aids — the rotation of the fetus on the head (according to Arkhangelsk) or leg, the classic manual or Tsovyanov manual for pelvic presentation. If the position of the fetus prevents natural childbirth, a caesarean section is recommended. In case of a threat to the mother and child, obstetric operations can be used for faster completion of labor — vacuum extirpation of the fetus, its extraction by the pelvic end or the imposition of obstetric forceps. In the event of the death of a child and the impossibility of completing childbirth naturally or by caesarean section, fruit-destroying operations are performed.
Urgent delivery by caesarean section is indicated in case of acute threat to the life of the woman in labor and the child (rupture of the uterus, placental abruption, umbilical cord prolapse). In some cases, the abdominal operation is completed by extirpation of the uterus. Hysterectomy is performed with massive ruptures with the formation of intraligmental hematomas, ongoing bleeding, placental ingrowth, a prolonged anhydrous period with complication by its infectious process.
Prognosis and prevention
The prognosis of complicated childbirth depends on the type of pathology, the timeliness of its diagnosis and the adequacy of obstetric tactics. In the vast majority of cases, the outcome is favorable for the child and for the mother. In the USA, the maternal mortality rate decreased from year to year and in 2016 reached a historic low of 8.3 cases per 100 thousand births. Infant mortality, including intranatal mortality, is also constantly decreasing. For the prevention of сhildbirth complications, timely registration and dynamic follow-up in the antenatal clinic, treatment of identified concomitant diseases and complications of pregnancy, planned hospitalization in the maternity hospital in the presence of indications is important. The right choice of the delivery method and the professionalism of the medical staff in the management of childbirth play a key role in preventing intranatal threats.