5 Complications of Labor and Birth

Reading fetal heart rate patterns

Complications during labor and birth can threaten the pregnant patient, fetus, or both. Safety depends on recognizing deterioration early, correcting reversible causes, summoning appropriate help, and choosing the safest timely route of birth. Trained clinicians carry out these responses using local protocols and the patient's informed preferences whenever the situation allows.

Interpreting fetal heart rate patterns

Fetal heart rate (FHR) monitoring helps assess the fetus's response to labor. Category I is reassuring, Category II is indeterminate and requires ongoing assessment, and Category III is abnormal and may indicate impaired fetal oxygenation. Interpret a tracing in context, considering variability, changes over time, the contraction pattern, and the clinical situation rather than treating one finding in isolation.

For an abnormal tracing, assess for reversible causes. The team may reposition the patient, reduce or stop oxytocin, address maternal hypotension, and assess for excessive contractions or cord compression. Uterine tachysystole means more than $5$ contractions in $10$ minutes, averaged over $30$ minutes; it can reduce the time available for fetal recovery between contractions.

If Category III findings persist despite corrective measures, expedite birth by the safest feasible route. Depending on fetal station and position, this may be operative vaginal birth or cesarean birth.

Responding to intrapartum emergencies

Shoulder dystocia

Shoulder dystocia occurs when the fetal head is born but the shoulders do not deliver with gentle routine traction. It is an emergency because delay can injure the newborn or parent. Call for help, clearly announce the emergency, and note the time. Trained clinicians typically begin with the McRoberts position and suprapubic pressure, then use additional internal maneuvers or deliver the posterior arm as appropriate to their training and the circumstances. Do not use fundal pressure or forceful traction on the fetal head. After birth, assess the newborn for injury and the parent for hemorrhage and severe perineal tears, and document the event and maneuvers.

Umbilical cord prolapse

Umbilical cord prolapse occurs when the cord descends through the cervix beside or ahead of the presenting part after the membranes rupture. Compression can abruptly reduce fetal blood flow. Suspect prolapse when sudden fetal bradycardia or recurrent decelerations follow membrane rupture; confirm promptly with examination when indicated. Call for immediate assistance and prepare for urgent birth. While birth is arranged, trained staff relieve pressure on the cord by elevating the presenting part; maternal positioning may also reduce compression. Avoid unnecessary handling of an exposed cord, and do not let temporizing measures delay delivery.

Uterine rupture

Uterine rupture is a tear through the uterine wall, most often considered during labor in a patient with a prior uterine scar. Warning signs can include sudden persistent fetal bradycardia, abdominal pain, vaginal bleeding, loss of fetal station, or maternal instability, though presentation varies. Treat it as an emergency: activate the obstetric and anesthesia teams, stabilize the patient, and arrange immediate operative birth and surgical management.

Severe hypertension or seizure

A seizure during pregnancy or labor may be eclampsia, a life-threatening complication of preeclampsia. Protect the patient from injury, summon emergency help, support breathing and circulation, and treat the seizure and severe hypertension according to protocol. Magnesium sulfate is commonly used to prevent or treat eclamptic seizures. Stabilize the patient and then plan birth; the route and timing depend on the clinical circumstances.

Assessing labor progress

Labor dystocia means labor is progressing slowly or has stopped. Before intervening, assess cervical change, fetal position and descent, contraction adequacy, maternal condition, and fetal status. ACOG considers $6\text{ cm}$ the start of active labor.

Active-phase arrest is diagnosed when the patient is at least $6\text{ cm}$ dilated, the membranes are ruptured, and there is no cervical change despite $4$ hours of adequate uterine activity or $6$ hours of inadequate activity with oxytocin. Once active-phase arrest is diagnosed, cesarean birth is recommended. Second-stage decisions are individualized; before cesarean for second-stage arrest, an experienced clinician may assess whether operative vaginal birth is appropriate.

Oxytocin may be used to induce or augment labor when appropriate, but excessive contractions can compromise fetal oxygenation. Monitor uterine activity and fetal response, and adjust or stop oxytocin if needed. Explain options, benefits, and risks, and include the patient's preferences in decisions when circumstances permit.

Choosing an operative birth

Operative vaginal birth uses forceps or a vacuum device to assist birth through the vagina. Possible reasons include concerning fetal status when birth is near, lack of descent despite pushing, or a maternal condition that makes continued pushing unsafe. It is appropriate only when specific clinical prerequisites are met, the clinician is trained, and cesarean birth is available if the attempt fails. Forceps and vacuum have different risks, including maternal genital-tract injury and newborn scalp, facial, or head injury. Avoid sequential use of instruments unless specifically justified by expert judgment.

Cesarean birth may be needed for persistent fetal compromise, labor arrest, cord prolapse, uterine rupture, or conditions that make vaginal birth unsafe. It can be lifesaving, but it is surgery and carries risks such as infection, hemorrhage, blood clots, and complications in future pregnancies. Urgency varies: an unresolved immediate threat requires faster action than a nonurgent indication. Explain the reason and obtain consent when feasible without delaying essential care.

Preparing for maternal safety

Prepare for hemorrhage by recognizing risk factors, monitoring blood loss and vital signs, and escalating promptly for heavy bleeding or instability. After birth, uterine atony is a common cause of postpartum hemorrhage. Care may include uterine massage, uterotonic medicines, intravenous fluids, blood products, and additional procedures according to response and protocol.

Team communication, clear role assignment, and timely escalation support safety in any obstetric emergency. After a complicated birth, assess both parent and newborn for injury or signs of impaired oxygenation and arrange appropriate follow-up.