OBSTETRICAL EMERGENCIES, HIGH

RISK PREGNANCY MANAGEMENT

(MID104)

Complication During Labor and Birth

Submitted By:
MS. JESSICA R. ALMUETE
Student

Submitted To:
DR. GLENDA GANZON,
Subject Instructor

DESCRIPTION
 1. Discuss the Sign and Symptoms, Causes, Risk Factor of complications during labor
and Birth.
2. Management of complications during labor and birth as a midwife.

INTRODUCTION:
In every pregnancy it is different during Labor and Birth. The complication may arise
during the 1st trimester, 2nd trimester up to 3rd trimester that can cause problems during labor and
birth.

A. DEFINITION:

LABOR
Labor is a series of continuous, progressive contractions of the uterus that help the cervix dilate
and effaced.
BIRTH
Birth is the completion of pregnancy where one or more babies exits the internal environment of
the mother via vaginal delivery or cesarian section.

COMPLICATION OF LABOR AND BIRTH

A secondary disease or condition aggravating an already existing one such as:

1. DYSFUNCTIONAL LABOR
- dysfunctional or prolonged labor refers to prolongation in the duration of
labor, typically in the first stage of labor. Diagnosis of delay in labor is
dependent on careful monitoring of uterine contraction intensity, duration and
frequency, cervical dilation, and descent of the fetus through the pelvis.
- Irregular timing, strength, or both and do not contribute to cervical changes or
fetal descent.

Two uterine dysfunctions

I. Hypertonic uterine dysfunction refers to a labor with uterine contractions of

poor quality that are painful, are out of proportion to their intensity, do not cause
cervical dilation or effacement, and are usually uncoordinated and frequent. This
is more common with a first pregnancy or an anxious woman who has intense
pain and lack of labor progression. The latent period of labor is prolonged, which
increases her exhaustion and anxiety. Often there is not adequate relaxation of
muscle tone between contractions, which causes the woman to complain of
constant cramps and results in ischemia or reduced blood flow to the fetus.

Maternal & Fetal risks:

nonprogressive labor (prolonged rupture of membrane)
Infection (because of frequent IE)

II. Hypotonic uterine dysfunction (secondary uterine inertia) occurs with

abnormally slow progress after the labor has been established. The uterine
contractions become weak and inefficient and may even stop. The contractions
are fewer than two or three in a 10-minute period and usually are not strong
enough to cause the cervix to dilate beyond 4 cm, and the fundus does not feel
 firm at the height (or acme) of the contraction. Consequently, labor fails to
progress. A prolonged labor can occur, which can increase the risk of intrauterine
infection, placing both the mother and newborn at risk.

Signs and symptoms hypotonic uterine contraction

 Slow progress of labor: Labor progresses at a slower rate than expected, with
contractions that are weak, irregular, or insufficient to effectively dilate the cervix.
 Prolonged early labor phase: The early phase of labor, known as the latent phase, may
be prolonged, with contractions that do not intensify or become regular.
 Failure to progress: Despite efforts to stimulate labor, including walking, position
changes, or using natural methods, there is limited progress in cervical dilation and
descent of the baby.

Risk Factors:
-If membranes ruptured, may increase risk for infection due to prolonged labor.
-Higher risk of developing postpartum hemorrhage.

Causes of Hypotonic Uterine dysfunction

 Exhaustion: Prolonged labor can lead to maternal exhaustion, which can contribute to
weak contractions.
 Fetal factors: Certain fetal factors, such as malposition, large fetal size, or abnormalities,
can impede the progress of labor and result in hypotonic contractions.
 Uterine muscle dysfunction: Weakened or ineffective contractions may occur due to
abnormalities in the uterine muscle, such as uterine atony or scarring from previous
surgeries.
 Maternal factors: Maternal factors, such as hormonal imbalances or medical

Management:
- Rule out cephalopelvic disproportion (CPD) and fetal malposition
- Oxytocin to augment labor or nipple stimulation to increase endogenous oxytocin.
- monitoring of Labor
- monitoring Vital signs
- Refer to Hospital

2. DYSTOCIA
Known as obstructed labor, is a condition which the baby cannot exit the pelvis
during childbirth. It is a serious medical condition that can lead to complications for both
the mother and the baby, it is common complication of labor.

Sign and Symptoms of dystocia

 Prolonged or difficulty of labor
 Slow or no dilatation of the cervix Weak or infrequent uterine contractions.
 Fetal distress
 Painful contraction that does not produce progress.

Causes of Dystocia

 Fetal malpresentation - this means that the baby is not in the optimal position for
delivery, such as breech or face presentation.

 Cephalopelvic disproportion (CPD) – that the baby’s head is too large to fit through
the mother pelvis.

 Uterine inertia – when the uterus does not contract strongly.

  Cervical dystocia – when the cervix does not dilate properly.
Causes of dystocia are diverse and include problems with any of the
4 P’s
1. Powers: abnormal uterine activity (ineffective uterine contractions)
2. Passageway: abnormal pelvic size or shape and other conditions that interfere
with descent of the presenting part (such as tumors or soft tissue resistance)
3. Passenger: abnormal fetal size or presentation (excessive size or less than
optimum position)
4. Psyche: past experiences, culture, preparation, and support system

3. MALPOSITION / MALPRESENTATION

 Malpresentation – fetal presenting part other than vertex & includes breech, brow,
transverse, face.
 Malposition – Refers to position other than ab occipito-anterior position.
Sign and symptoms
 slow progress of labor is the commonest manifestation of fetal malpresentations and
malpositions in labor.
 pendulous abdomen and non-engagement of the presenting part at term in a
primigravida. Preterm or early rupture of membranes in term labor and
 delay in the descent of the presenting part during labor are notable.

Causes of malpresentation and malposition

In most cases malpresentation and malposition does not have a pathological basis.
However, some maternal and fetal factors may predispose to the condition:

Maternal factors:

 pelvic inflammation
 pelvic or septate uterus
 oligohydramnios
 placenta previa

Fetal factors:

 prematurity
 multiple pregnancy
 fetal malformation e.g. hydrocephalus
 intrauterine death

Management:

 monitor the presentation and the position during prenatal.

 Refer to hospital for management.
 Monitor the fetal Status.
 Monitor the Vital Signs
 Health Teaching

4. PRECIPITATE OF LABOR

Precipitous labor is extremely rapid labor and delivery. It is defined as expulsion of the
fetus within less than 3 hours of commencement of regular contractions. It has been supposed
to result from an abnormally low resistance of the soft pass of birth canal, from abnormally
strong uterine and abdominal contractions, or rarely from the absence of painful sensations. The
prevailing opinion has been that too rapid a labor can result in maternal injury and place the
fetus at risk for traumatic or asphyxia insults.

Signs and symptoms of precipitous labor include:

 The sudden onset of very intense contractions

 Very little time between contractions for recovery
 Strong urge to push, which often feels like the need for a bowel movement.
With normal labor, contractions start slowly and are weak. They are hard to predict and may
occur at irregular intervals. This process can last hours or even days. In precipitous labor, the
slow and weak contractions never happen. A person experiences fast, intense contractions
almost from the get-go.
Causes

 Several factors can increase your risk for precipitous labor:

 birth history. Subsequent pregnancies tend to have speedier deliveries.
 The baby is on the smaller side.
 The uterus is exceptionally strong and efficient at contractions.
 the birth canal is soft and flexible.
 the labor is induced with prostaglandins.
 exposed to certain drugs such as cocaine.
 blood pressure - High blood pressure or preeclampsia puts you at greater risk for
experiencing precipitous labor.
Complication of Precipitate of Labor.
Rapid labor is unplanned and not how most people expect their birthing experience to happen.
This loss of control can be hard to handle, both physically and emotionally. Because it all
happens so fast, you may have trouble getting to the hospital and be too late for pain
medication or an epidural. This can make for a scary and chaotic delivery.
Other complications for the birth parent include:

 Heavy bleeding or postpartum hem.

 Shock (not enough blood and oxygen get to your organs and tissue).
 Higher risk of perineal tears and vaginal lacerations.
 Retained placenta or placenta getting stuck in the uterus.
 Delivery in an unsterilized area, like a car.
 Emotional distress.
 Not receiving necessary antibiotics for certain infections, before delivery, which puts your
baby at risk for infection.
 Difficulties for the baby include breathing in meconium infection due to delivery in an
unsterile area or injury.

Management of Precipitate of Labor

 calm thoughts and practice deep breathing.

 Make sure someone is always with you if possible.
 Try to keep the area clean or stay in a clean area.
 Lay down on the left side.
 Refer to the nearest hospital or Clinic.
5. MULTIPLE PREGNANCY
The development of more than one fetus in utero at the same time.
There are two types of twins which is the Identical and non- identical
twins.
 Types of twins
A. Monozygotic / uniovular (IDENTICAL TWINS)
 Develop from the fusion of one oocyte and one spermatozoon.
 Same sex twins, same genes, same blood groups and physical features
 However, may be of different sizes & very different personalities &
characters.
B. Dizygotic / Binovular Twins (NON-IDENTICAL TWINS)
 Develop from two separate oocytes that are fertilized by two different
spermatozoon.
 Can be of the same sex or different sex.
 Can be boy-girl pairs.

 Labor and Birth

 Onset of labor is early, term for twins is 37 weeks and approximately born pre-
term, small for gestational age (SGA),

 If labor is early, the chance of survival outside is small. Mother given drugs to
inhibit uterine activity (Intravenous Salbutamol & Sulindac tablets). If with UTI,
treat ASAP with antibiotics.
Induction of labor at 38 weeks, if the first twin is cephalic, normal vaginal delivery can
occur, but if other way then elective cesarean section.
 Effects of pregnancy

 Exacerbation of common disorders – because of high levels of

hormones, sickness, nausea, and heartburn

 Anemia I iron deficiency & folic acid deficiency.- 60 mg iron, 5mg FA or

400 mcg

 Polyhydramnios – with monochorionic twins. This can lead to

miscarriage or premature labor.

 Pressure symptoms – increased tendency to varicose veins and edema,

backache is common, marked dyspnea and indigestion.
Two main ways of multiple pregnancy can happen:
o One fertilized egg (ovum) splits before it implants in the uterine lining.
o Two or more separate eggs are fertilized by different sperm at the same time.

Signs And Symptoms of a Multiple Pregnancy.

The only way to know of more than one baby during the pregnancy is through an ultrasound
exam with the healthcare provider. During this test, the provider can look at images of the inside
of the uterus and confirm how many babies are in there.
It might experience more intense symptoms during a multiple pregnancy than with a single
pregnancy. These can include:
 Severe nausea and vomiting (morning sickness).
 Rapid weight gain in the first trimester of pregnancy.
 Sore or very tender breasts.
Complication of Multiple Pregnancy
Possible complications include:

 Premature labor and birth: The most common complication of multiple births is
premature labor. Multiple pregnancy is most likely to go into premature labor (before 37
weeks) than a woman carrying only one baby. The goal for many moms of multiples is to
complete 37 weeks. This is considered term in a twin pregnancy and reaching this week
of gestation increases the chance the babies will be born healthy and at a good weight.
Babies that are born prematurely are at risk of another complication of multiple births —
low birth weight.
 Preeclampsia or gestational hypertension (high blood pressure): High blood
pressure is called hypertension. During pregnancy, the healthcare provider will watch the
blood pressure carefully to make sure you don’t develop gestational hypertension (high
blood pressure during pregnancy). This can lead to a dangerous condition called
preeclampsia. Complications related to high blood pressure happen at twice the rate in
women carrying multiples compared to women pregnant with only one baby. This
complication also tends to happen earlier in pregnancy and be more severe in multiple
pregnancies than single pregnancies.
 Gestational diabetes: it is developing diabetes during pregnancy. This happens
because of the increased number of hormones from the placenta. The size of the
placenta can also be a factor in this condition. If have two placentas, there’s an
increased resistance to insulin.
 Placenta abruption: This condition happens when the placenta detaches (separates)
from the wall of the uterus before delivery. This is an emergency. Placenta abruption is
more common in women who are carrying multiples.
 Fetal growth restriction: This condition can also be called intrauterine growth
restriction (IUGR) or small for gestational age (SGA). This condition happens when one
or more babies is not growing at the proper rate. This condition might cause the babies
to be born prematurely or at a low birthweight. Nearly half of pregnancies with more than
one baby have this problem.
 Fraternal twins always have two placentas. The risks of pregnancies with fraternal
twins are similar to those of pregnancies with only one baby. However, the number of
possible risks is increased when compared to pregnancies with one baby.
 Identical twins may have one placenta (70% of the cases) or two placentas (30% of the
cases). The risks of identical twins with two placentas are similar those listed above for
fraternal twins. Identical twins with one placenta (called monochorionic) have risks that
are unique to them. In 5 to 15% of the cases, they may develop a condition called twin-
twin-transfusion-syndrome (TTTS). This is the consequence of vascular communications
at the placenta level between the twins. Due to these communications, the twins may
share their blood. When this happens — if nothing is done — there is a 90% risk that the
twins will die in-utero. In-utero procedures are performed to decrease the fetal death risk
for the twins.

Causes of multiple pregnancy

Many factors are linked to having a multiple pregnancy. Naturally occurring factors are:
 Heredity. A family history of multiple pregnancy raises the chances of having twins.
 Older age. People assigned female at birth who are older than 30 have a greater
chance of multiple pregnancy. Today, many people assigned female at birth are waiting
to have children until later in life. They may have twins as a result.
  Past pregnancies. Having 1 or more previous pregnancies, especially a multiple
pregnancy, raises the chances of having multiples.
 Race. African American people assigned female at birth are more likely to have twins
than any other race. Asian Americans and Native Americans have the lowest rates for
twins. White people assigned female at birth have the highest.
 rate of higher-order multiple births (triplets or more). This is especially true for those
older than 35.
Other factors that have greatly raised the multiple birth rate in recent years are reproductive
technologies, such as:

 Ovulation-stimulating medicines. These include clomiphene citrate and follicle

stimulating hormone (FSH). These helps produce many eggs. If fertilized, they can result
in multiple babies.
 Assisted reproductive technologies. In vitro fertilization (IVF) and other methods may
help couples get pregnant. These technologies often use ovulation-stimulating
medicines to produce multiple eggs. These are then fertilized in the lab and returned to
the uterus to grow.

Management of multiple pregnancy

Specific management for multiple pregnancy will be determined by your doctor or midwife based
on:

 The pregnancy, overall health, and medical history

 The number of fetuses
 The tolerance for specific medications, procedures, or therapies
 Expectations for the course of the pregnancy
 The opinion or preference

Management of multiple pregnancy may include the following:

 Increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and other micro-
nutrients, including iron, iodine, calcium, folic acid. Higher weight gain is also
recommended for multiple pregnancy. The Institute of Medicine recommends that
women carrying twins who have a normal body mass index should gain between 37 and
54 pounds. Those who are overweight should gain 31-50 pounds; and obese women
should gain 25-42 pounds.
 More frequent prenatal visits
Multiple pregnancy increases the risk for complications. More frequent visits may help
detect complications early enough for effective treatment or management. The mother's
nutritional status and weight should also be monitored more closely.
 Referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for special testing
or ultrasound evaluations, and to coordinate care of complications, may be necessary.
 Increased rest
Some women may also need bedrest — either at home or in the hospital depending on
pregnancy complications or the number of fetuses. Higher-order multiple pregnancies
often require bedrest starting in the middle of the second trimester. Preventive bed rest
has not been shown to prevent preterm birth in multiple pregnancy.
 Maternal and fetal testing
Testing may be needed to monitor the health of the fetuses, especially if there are
pregnancy complications.
 Tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or stop
contractions of the uterus. These may be given orally, in an injection, or intravenously.
Tocolytic medications often used include magnesium sulfate.
 Corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the fetuses. Lung
immaturity is a major problem of premature babies.

6. PREMATURE RUPTURE OF MEMBRANES

Spontaneous rupture of the amniotic sac more than 1 hour before onset of true labor is referred
to as premature rupture of membranes (PROMs). Rupture of the membranes before 37 weeks’
gestation is known as preterm premature rupture of the membranes (PPROMs). The exact
cause is unknown,

Risk factors.
 educational status of the mother,
 poor nutritional status of the mothers,
 cervical insufficiency,
 cigarette smoking during pregnancy,
 urinary tract and sexually transmitted infections, such as Gonorrhea and syphilis
 having high volume of amniotic fluid (polyhydramnios),
 multiple gestations – more than 5 of pregnancy
 history of threatened abortion
 poor socioeconomic status,
 maternal age – more than 35 years of age
 connective tissue disorders.

Sign and symptoms

 a sudden gush of fluid from your vagina,
 leaking of fluid,
 a feeling of wetness in your vagina or underwear.

Causes of Premature Rupture of Membrane

 Low socioeconomic conditions (as women in lower socioeconomic conditions are less
likely to receive proper prenatal care)
 Sexually transmitted infections, such as chlamydia and gonorrhea.
 Previous preterm birth.
 Vaginal bleeding.
 Cigarette smoking during pregnancy.
 Unknown causes.
 Urinary Tract Infection

Management
1. consist of bed rest with bathroom privileges and observation for infection, NST,
2. Avoid digital vaginal examination to prevent infection.
3. Monitor FHT (tachycardia mean infection),

4. maternal – monitor temperature, pulse, uterine tenderness and any purulent or

offensively smelling vaginal discharge.

5. Referral

6. Monitor the fetal status.