Expect unexpected stuff
If you’re healthy and your pregnancy and labour are normal, there probably won’t be many concerns…. but sometimes the unexpected happens. When things don’t go to plan, it can leave us feeling confused and in need of support. So, what are some of the complications that can happen in labour and birth?
Your midwife or doctor can tell how labour is progressing by checking how much the cervix has opened and how far the baby has moved down. If your cervix is opening slower than expected, or the contractions have slowed down or stopped your midwife or doctor may be concerned your labour isn’t progressing normally. It’s good if you can relax and stay calm – anxiety can slow things down more. Ask what you and your partner or support person can do to get things going.
The midwife or doctor may suggest some of the following:
- change your position
- walk around – movement can help the baby to move further down, and encourage contractions
- a warm shower or bath
- have a nap to regain your energy
- a back rub
- have something to eat or drink
If concerns continue your midwife or doctor may suggest inserting a hormone drip to make your contractions more effective.
Concern about baby’s wellbeing
Sometimes there may be a concern that the baby is distressed during labour.
These signs include:
- a fast, slow or unusual pattern to the baby’s heartbeat
- your baby passing a bowel motion (seen as a greenish-black fluid called ‘meconium’ in the fluid around the baby).
If this happens your baby’s heart rate will be monitored to watch for any signs of distress. If the baby is not coping well, we will recommend continuous monitoring. In the case of more serious concerns about your baby, the doctor or midwife may suggest other ways of keeping tabs on your baby. Suggestions may include applying a foetal spiral electrode (FSE). If there are ongoing concerns, the doctor may suggest taking a small blood sample from the baby’s head. This sample will give almost immediate answers about how your baby is travelling.
Losing some blood during childbirth is normal. Postpartum haemorrhage (PPH) is a complication that can occur after a baby is born and usually involves excessive bleeding after the baby’s birth. PPH is a common complication; however, if this happens your doctors and midwives will manage it quickly.
There are two types of PPH, depending on when the bleeding takes place:
- primary or immediate – within 24 hours of the baby’s birth
- secondary or delayed – 24 hours-six weeks after the birth. Depending on the type of PPH, the causes include:
- a uterus that doesn’t contract down well after baby’s birth, or doesn’t stay contracted
- part of the placenta remaining inside
- bleeding from tears or other damage down below
- infection of the womb
Your midwife will check your uterus regularly after the birth to make sure that it is firm and contracted.
Occasionally the placenta doesn’t come away after the baby is born, so the doctor needs to remove it. If this happens a procedure called a ‘manual removal’ is performed under a regional or general anaesthetic in theatre.
Perineal damage – it happens
Damage to the perineum is common during the birthing process. While it is a flexible and forgiving part of our body (after all, it was designed to stretch so that baby can be born), it does have its limits. However, due to the high volume of blood flow to the area, it also heals quickly. We classify damage down below into four basic kinds of tear, and/or a procedure called an episiotomy. You will find that any of the following may apply to your perineum:
- Intact perineum, with no damage
- Labial grazes (where the skin stretches, and the surface opens up just a little bit, but you don’t need stitches, and there is no muscle damage)
- 1st-degree tear (Involves only the skin layer of your perineum or labia. Most of the time these don’t need stitching, but it depends on the situation and where the tear is)
- 2nd-degree tear (involves skin and muscle. It is usually only the perineum or your vaginal wall that has this kind of tear. Most of these need stitching to heal properly)
- 3rd-degree tear (involves a second-degree tear plus some damage to the muscle of the anal sphincter muscles – the muscles that help you control your bum).
- 4th-degree tear (is a tear that goes all the way through your perineum or vagina to your rectum)
- Episiotomy – Episiotomies require repair due to the depth of muscle damage. Third- and fourth-degree tears are always repaired to maintain control of your bowels. Please speak to your midwife about how you can help avoid or minimise this damage during your birth.
An episiotomy is a procedure performed as your baby’s head is crowning. If an episiotomy is necessary, we make a small cut to create more space and assist with the birth of your baby. In Australia, these cuts are no longer standard practice. If this happens, it is usually only performed when your midwife or doctor feels it’s necessary. You must give consent before your care provider does this.
When the baby’s heart rate gets too high and doesn’t come down to normal, or too low and doesn’t come back up, he or she is showing signs of distress. This heart rate pattern suggests that your baby may not be getting enough oxygen, and must be born quickly to minimise the risk of harm. Under these circumstances, we may recommend an episiotomy to help your baby into the world a little faster.
Another reason we may cut an episiotomy is if we use forceps or a ventouse to assist with the birth. We make this cut to try and control the damage down below. Women who have had a severe tear or an episiotomy do not always suffer the dame damage in later pregnancies. Many women go on to birth future babies with little to no damage.
How is an episiotomy done?
An episiotomy is usually a simple procedure. We inject a local anaesthetic to numb the perineum so you will not feel any pain. Whenever possible, the doctor or midwife will make a small, diagonal cut from the side of the vagina and directed down and out to one side. Following the birth of your baby, we suture the wound together using dissolving stitches.
Recovering from an episiotomy
We repair episiotomy cuts within an hour of your baby’s birth. The incision (cut) may bleed a little to start with, but with pressure and stitches, this should soon stop. We use dissolving sutures so you won’t need to go to a doctor to have them removed. Stitches should heal within 4-6 weeks after your birth. Talk to your midwife or obstetrician about which activities you should avoid during the healing period.
After having an episiotomy, it is reasonable to feel pain around the cut for two to three weeks after giving birth. Pain may be more uncomfortable when walking or sitting. Passing urine can also cause the wound to sting. This procedure should comprise part of your birth plan discussion. That way, if it happens you understand what is involved and why.
Forceps or Vacuum birth
An instrumental birth is indicated if there are concerns in the second stage of labour. These concerns are usually around your baby’s heart rate. A vaginal assessment will determine how the doctor might assist you to birth your baby.
- A Vacuum cup (Ventouse) is a suction cup that is placed onto your baby’s head. As you push the doctor will assist you by pulling on the vacuum. Sometimes after a Ventouse, your baby may be left with some swelling or bruising on the head, which usually goes down very quickly without causing your baby any distress.
- Forceps look like salad spoons and are placed on either side of your baby’s head. As you push the doctor will gently pull downward to help to deliver your baby’s head. While they look quite alarming, both methods are safe for your baby. Please discuss any concerns you have with your care providers before consenting to any intervention.
With either of these methods of birth, there is a higher chance of an episiotomy.
In an emergency happens, there may not be much time to calmly and thoroughly discuss all the options of caesarean section. If continuing down the vaginal birth path becomes a high risk for you or your baby, the doctor may suggest a caesarean section is the safest option. Unless you are unconscious, the doctor must gain your informed consent to proceed.
Some of the reasons for an emergency caesarean include:
- baby is in distress
- labour is not progressing as expected
- induction of labour has not worked
- vaginal bleeding during your labour.
Following a stressful or traumatic birth happens, some people can experience difficulties in bonding with their baby. Reflecting on the birth and or talking about what happened can also be distressing. As a result, you may find yourself avoiding thinking or talking about your experience.
Whatever you may feel, it is essential to talk to your care providers about what happened during your birth and why. Please take every opportunity to debrief about your birth experience with your care provider.
To read more about birth debriefing, please click here.
Karen Milner (BSc) Registered Nurse, Registered Midwife
Photo by Michael de Nysschen, used under licence from Shutterstock.com