What to expect when you're expecting (216 page)

What is it?
Shoulder dystocia is a complication of labor and delivery in which one or both of the baby’s shoulders become stuck behind the mother’s pelvic bone as the baby descends into the birth canal.

How common is it?
Size definitely matters when it comes to shoulder dystocia, which occurs most frequently in larger babies. Fewer than 1 percent of babies weighing 6 pounds have shoulder dystocia, but the rate is considerably higher in babies weighing more than 9 pounds. For that reason, mothers who have uncontrolled diabetes or gestational diabetes—and therefore may give birth to very large babies—are more likely to encounter this complication during delivery. The chances also rise if you go past your due date before delivering (since your baby will probably be larger) or if you’ve previously delivered a baby with shoulder dystocia. Still, many cases of shoulder dystocia occur during labors without any of these risk factors.

What are the signs and symptoms?
Delivery stalls after the head emerges and before the shoulders are out. This can occur unexpectedly in a labor that has progressed normally up to that point.

What can you and your practitioner do?
A variety of approaches may be used to deliver the baby whose shoulder is lodged in the pelvis, such as changing the mother’s position by sharply flexing her legs onto her abdomen or applying pressure on her abdomen, right above the pubic bone.

Can it be prevented?
Keeping your weight gain within the recommended range can help ensure that your baby doesn’t get too big to maneuver through the birth canal, as can carefully controlling diabetes or gestational diabetes. Picking a labor position that allows your pelvis to open as widely as possible might also help you avoid dystocia.

What is it?
The pressure of your baby’s large head pushing through the delicate tissues of your cervix and vagina can cause tears and lacerations in your perineum, the area between your vagina and your anus.

First-degree tears (when only the skin is torn) and second-degree tears (when skin and vaginal muscle are torn) are common. But severe tears—those that get close to the rectum and involve the vaginal skin, tissues, and perineal muscles (third degree) or those that actually cut into the muscles of the anal sphincter (fourth degree)—cause pain and increase not only your postpartum recovery time, but your risk of incontinence, as well as other pelvic floor problems. Tears can also occur in the cervix.

How common is it?
Anyone having a vaginal delivery is at risk for a tear, and as many as half of all women will have at least a small tear after childbirth. Third- and fourth-degree tears are much less common.

What are the signs and symptoms?
Bleeding is the immediate symptom; after the tear is repaired, you may also experience pain and tenderness at the site as it heals.

What can you and your practitioner do?
Generally, all lacerations that are longer than 2 cm (about 1 inch) or that continue to bleed are stitched. A local anesthetic may be given first, if one wasn’t administered during delivery.

If you end up tearing or having an episiotomy, sitz baths, ice packs, witch hazel, anesthetic sprays, and simply exposing the area to air can help it heal more quickly and with less pain (see
page 423
).

Can it be prevented?
Perineal massage and Kegel exercises (see
pages 352
and
295
), done during the month or so before your due date, may help make the perineal area more supple and better able to stretch over your baby’s head as he or she emerges. Warm compresses on the perineum and perineal massage during labor may help avoid tearing.

What is it?
A uterine rupture occurs when a weakened spot on your uterine wall—almost always the site of a previous uterine surgery such as a C-section or fibroid removal—tears due to the strain put on it during labor and delivery. A uterine rupture can result in uncontrolled bleeding into your abdomen or, rarely, lead to part of the placenta or baby entering your abdomen.

How common is it?
Fortunately, ruptures are rare in women who’ve never had a previous C-section or uterine surgery. Even women who labor after a previous C-section have only a 1 in 100 chance of rupture (and the risk is far lower when a woman undergoes a repeat C-section without labor). Women at greatest risk of uterine rupture are those who are attempting a vaginal birth after cesarean (VBAC) and have been induced with prostaglandins and/or Pitocin (oxytocin). Abnormalities related to the placenta (such as placental abruption, a placenta that separates prematurely; or placenta accreta, a placenta that is attached deeply in the uterine wall) or to the fetus’s position (such as a fetus lying crosswise) can also increase the risk of uterine rupture. Uterine rupture is more common in women who have already had six or more children or have a very distended uterus (because of multiple fetuses or excess amniotic fluid).

What are the signs and symptoms?
Searing abdominal pain (a sensation that something is “ripping”) followed by diffuse pain and tenderness in the abdomen during labor are the most common signs of uterine rupture. Most typically, the fetal monitor will show a significant drop in the baby’s heart rate. The mother may develop signs of low blood volume, such as an increased heart rate, low blood pressure, dizziness, shortness of breath, or loss of consciousness.

What can you and your practitioner do?
If you have had a previous C-section or abdominal surgery in which the uterine wall was cut through completely, you’ll need to weigh your risks when considering your labor options, especially if you want to attempt a vaginal birth. Discuss with your practitioner the data that show that prostaglandins should not be used to induce labor in a woman who’s had previous uterine surgery.

If you do have a uterine rupture, an immediate C-section is necessary, followed by repair of the uterus. You may also be given antibiotics to prevent infection.

Can it be prevented?
For women with increased risk factors, fetal monitoring during labor can alert your practitioner to an impending or occurring rupture. Women who are trying for a VBAC delivery should not be induced.

What is it?
Uterine inversion is a rare complication of childbirth that occurs when part of the uterine wall collapses and turns inside out (in effect, very much like a sock being pulled inside out), sometimes even protruding through the cervix and into the vagina. The full range of problems that can cause uterine inversion is not fully understood, but in many cases it includes the incomplete separation of the placenta from the uterine wall; the placenta then pulls the uterus with it when it emerges from the birth canal. Uterine inversion, when unnoticed and/or untreated, can result in hemorrhage and shock. But that’s a remote possibility; the condition occurs rarely and is unlikely to go unnoticed and untreated.

How common is it?
Uterine inversion is very rare; reported rates vary from 1 in 2,000 births to 1 in several hundred thousand. You are at greatest risk for a uterine inversion if you’ve had an inversion during a previous delivery. Other factors that slightly increase the very remote risk of an inversion include an extended labor (lasting more than 24 hours), several previous vaginal deliveries, or use of drugs like magnesium sulfate or terbutaline (given to halt preterm labor). The uterus also may be more likely to invert if it is overly relaxed or if the cord is pulled too hard in the third stage of childbirth.

What are the signs and symptoms?
Symptoms of uterine inversion include:

Abdominal pain

Excessive bleeding

Signs of shock in the mother

In a complete inversion, the uterus will be visible in the vagina

What can you and your practitioner do?
Know your risk factors and inform your practitioner if you’ve had a uterine inversion in the past. If you do have one, your physician will try to push your uterus back up where it belongs, and then give you drugs like Pitocin (oxytocin) to encourage any floppy muscles to contract. In rare cases, where this does not work, surgery is an option. In either case, you might need a blood transfusion to make up for blood lost during the inversion. Antibiotics may be given to prevent infection.

Can it be prevented?
Because a woman who has had one uterine inversion is at an increased risk for another, let your practitioner know if you’ve had one in the past.

What is it?
Bleeding after delivery, called lochia, is normal. But sometimes the uterus doesn’t contract as it should after birth, leading to postpartum hemorrhage—excessive or uncontrolled bleeding from the site where the placenta was attached. Postpartum hemorrhage can also be caused by unrepaired vaginal or cervical lacerations.

Hemorrhage can also occur up to a week or two after delivery when fragments of the placenta are retained in, or adhere to, the uterus. Infection can also cause postpartum hemorrhage, right after delivery or weeks later.

How common is it?
Postpartum hemorrhage occurs in somewhere between 2 and 4 percent of deliveries. Excessive bleeding may be more likely to occur if the uterus is too relaxed and doesn’t contract due to a long, exhausting labor; a traumatic delivery; a uterus that was overdistended because of multiple births, a large baby, or excess amniotic fluid; an oddly shaped placenta, or one that separated prematurely; fibroids that prevent symmetrical contraction of the uterus; or a generally weakened condition of the mother at the time of delivery (due to, for example, anemia, preeclampsia, or extreme fatigue). Women taking drugs or herbs that interfere with blood clotting (such as aspirin, ibuprofen, ginkgo biloba, or large doses of vitamin E) are also at greater risk for postpartum hemorrhage. Rarely, the cause of the hemorrhage is a previously undiagnosed bleeding disorder in the mother that is genetic.