The majority of women experience no problems or complications once labour has started. Sometimes, however, problems do arise that require skilled management and care. Women and their families, as well as others in the community, need to know about these problems, and what to do if they develop.
Premature rupture of the membranes is the sudden gush of water from the vagina several days or even weeks before labour actually begins. By itself, it is not necessarily dangerous. The problem is that once the bag of water is ruptured, the woman can get an infection which can endanger her life and especially the life of the baby. Therefore, a woman whose membranes rupture early needs to be taken to a health facility for special care.
There is little that can be done to prevent premature rupture of the membranes. If the membranes rupture when the pregnancy is near term (36 weeks or later), but labour does not start within 24 hours, artificial means may be used to start labour at a hospital. The woman may also wait in the hospital for labour to start on its own. During this time she should be observed carefully and treated if any signs of infection develop.
If the membranes rupture before 36 weeks, the baby may be too small to live, so labour is usually not started artificially. In such cases, everything possible must be done to prevent infection, delay labour, and give the baby time to mature. The woman should be advised to stay in bed. She should also be advised to avoid getting an infection by not taking tub baths (she should take a shower or sponge bath instead), not having sexual intercourse, and not having vaginal examinations except with a sterile instrument. She may be given antibiotics to prevent an infection. It is best for her to stay in a hospital that can care properly for the baby if it is born early.
Box 11.1: Complications and Care During Labour
When complications develop during labour and delivery, it is often necessary for the midwife, nurse, or doctor to intervene. It may be necessary to refer the woman to a hospital where the complication can be managed. She may feel frightened and out of control. By remembering a few basic principles, the health worker can help her relax and feel proud of the difficult experience she has had.
· No woman "fails" when she is having a baby. Whatever the complication - whether delivering by Caesarean section, or in extreme cases delivering a baby that has died in the womb - women should be praised and supported throughout the experience. If a traditional birth attendant or relative has accompanied the woman to the hospital, she should also be praised and encouraged for recognising the problem and bringing the woman.
· All women should be encouraged to ask questions and receive answers about their care. When emergencies occur, it is sometimes necessary to take action without providing an explanation. Although quick action is necessary at times, women and their families have the right to know what is being done and why, and to ask questions.
Towards the end of pregnancy, about 95% of babies come to lie in the womb with their heads pointing downwards, so that the head is delivered first (see Figure 11.1). In 4-5% of cases, the baby lies with the feet or buttocks pointing down; these cases are called breech presentations (see Figure 11.2). Rarely, the baby may lie diagonally with the shoulder ready to come out first; this is called transverse lie (see Figure 11.3). All cases where the baby's head does not come out first are abnormal; childbirth may be more difficult and can result in injury or death of the baby or the mother. Transverse lie is especially dangerous, and should always be referred to a hospital. Abnormal lie is most common in women who have had many babies before, or those carrying twins (see Figure 11.4). It is usually possible for a trained person to tell whether the baby is lying in an abnormal position towards the end of the pregnancy. A trained and skillful person must assist in such deliveries. In some cases a Caesarean section (see next chapter) may be necessary.
Positions of the Baby
Figure 11.1: Normal Presentation (head down)
Figure 11.2: Breech Presentation (feet or buttocks first)
A breech presentation should be referred to a health facility if possible.
Figure 11.3: Transverse Lie (shoulder or arm first)
A transverse lie should always be delivered in a health facility; an operation may be necessary.
Women bearing twins are more likely to have complications such as obstructed or prolonged labour. There is also a higher risk of abnormal presentation such as breech or transverse. For this reason twins should he delivered in a health facility if possible.
This is the most common complication of labour in Africa, and one of the most dangerous. Labour is obstructed if the baby cannot be delivered normally through the birth canal without serious damage or injury to the mother or baby. Obstructed labour can sometimes be predicted during antenatal care, long before labour starts. Usually, however, the problem is only recognised after the woman has been in labour for many hours without making any progress.
CAUSES OF OBSTRUCTED LABOUR: Labour is obstructed when the baby is too big to pass through the mother's birth canal. Women in the following categories are more likely to have obstructed labour:
· Women who are less than 5 feet tall (150 centimetres). These women may have difficulties during childbirth because their pelvises may be smaller than normal. That is why height is measured during antenatal visits.
· Girls in their early teens, even if they are taller than 5 feet (see Chapter 21). This is because the pelvis grows more slowly than the rest of a girl's body, so the pelvis can be quite narrow in a girl under the age of 15 or 16 even if she is tall.
· Women with certain abnormalities of the spine or lower limbs. These affect the size or shape of the pelvis, and can therefore cause obstructed labour. Women with such abnormalities need careful attention during the antenatal period, and special supervision during labour.
· Women who have undergone female genital mutilation. These women often have scars in the vaginal area that may cause obstructed labour. Any woman who has had this operation should deliver in a hospital if possible.
· Women with babies that are unusually big. The average baby weighs around 6-7 pounds (about 3 kilos) at birth; babies much larger than this may be difficult to deliver normally. Babies of older women and of women suffering from diabetes tend to be heavier and bigger than average. A larger-than-average baby can sometimes be detected during antenatal care, and it may be recommended that the delivery take place in a hospital.
· Women with babies who are lying abnormally in the womb. Any abnormal presentation, such as breech, can also lead to obstructed labour. This is true even if the mother's pelvis is normal and the baby is of normal size.
In some parts of Africa, people believe that obstructed labour means the woman was unfaithful to her husband or misbehaved in some other way. Often, they believe that the baby will not be born until the woman has confessed what she did wrong. The families of pregnant women should understand that obstructed labour has nothing to do with a woman's past behaviour. It is a life-threatening condition for both the mother and baby. A woman with obstructed labour is in desperate need of medical attention, and needs to be taken to a hospital immediately so she can receive trained assistance.
Figure 11.5: Obstructed Labour
Obstructed labour is very dangerous for the woman and baby. If a woman has been in labour for 12 hours or more she should be taken to a hospital; she may need special help or an operation to deliver.
WHY IS OBSTRUCTED LABOUR DANGEROUS?
First, if labour continues for too long (over 12 hours) both mother and baby may become exhausted (see Figure 11.5). The mother may become very dry (dehydrated) because after many hours in labour she has perspired a lot and lost a great deal of body water. Second, the mother may catch an infection during the long hours in labour. The infection can spread upwards into the womb and affect the baby too. Third, if something is not done quickly to relieve the obstruction, the womb will continue to contract powerfully to try to push the baby out, and may tear or rupture. Severe bleeding may occur inside the abdomen. This will soon lead to shock in a mother already exhausted and dehydrated from prolonged labour.
If a woman is in labour for more than 12 hours without being able to deliver the baby, she should be taken to a hospital where she can be properly examined. Sometimes it is necessary to perform an operation to deliver the baby.
FISTULAE: During obstructed labour, the baby's head presses hard on the soft tissues of the mother's pelvic organs such as the bladder (the organ that holds urine) or the rectum (the organ leading from the bowel to the outside). After many hours or sometimes days of this pressure, the tissues pressed between the baby's head and the mother's bones die. After a few days they fall away, leaving a hole between the vagina and the urinary bladder or the rectum. If the bladder is torn, urine leaks uncontrollably through the vagina. If the rectum is torn, faeces pass out through the vagina without control. The constant flow of urine or faeces and the smell are extremely unpleasant for the woman. As a result, sometimes she is rejected by her husband, her neighbours, and even her family.
These holes between the vagina and the bladder or the rectum are called fistulae. Unfortunately, they are quite common in many parts of Africa. They develop especially often in young girls of 12, 13, or 14 years who become pregnant before their birth canals are big enough. These young girls, just starting their adult lives, are condemned to being social outcasts unless they can undergo an operation to repair the hole. This operation can be quite expensive and is not always successful.
Labour is "prolonged" when it continues for many hours without making any real progress towards delivery of the baby. The most common cause of prolonged labour is obstructed labour, as discussed in the previous section. Labour can also be prolonged for other reasons as well. Sometimes the womb is not contracting as it should, or the contractions even stop altogether. This is especially common in a woman having her first child. Other times the neck of the womb is not opening up enough to allow the baby to come out.
Normal labour can last anywhere from 5-18 hours. It can be longer in a woman having her first baby. It can be difficult for someone who is not a midwife or doctor to tell when labour is prolonged. In health facilities, partographs are often used to detect when labour is "too long", or when no progress is being made and action is therefore necessary (see Chapter 10). If a partograph is not being used (for example, if delivery is taking place at home), it is usually recommended that a woman who has been in labour for 12 hours without any signs that the baby is coming out should be taken to a hospital or health centre. This is especially true if the trip will be a long one.
Sometimes when the bag of water has broken, the liquid that comes out is coloured green or brown. This is called meconium and is a sign that the baby has passed his or her first stool (bowel movement). It may also be a sign that the baby is having a problem. If this happens, the birth attendant should check for other signs of distress, for example by listening to the baby's heartbeat. If this sign is noted, the mother should be taken to a hospital quickly.
These conditions often occur in the late stages of pregnancy (see details in Chapter 9). If they are not properly controlled during pregnancy, they can become worse during labour. Sometimes they appear for the first time during or after labour. Eclampsia causes fits or convulsions and loss of consciousness or coma (see Figure 11.6). It is especially likely to start suddenly during labour or even soon after the birth of the baby. Severe pre-eclampsia or eclampsia during labour may make it necessary to deliver the baby by Caesarean section. A woman who starts having fits before, during, or after labour should be taken immediately to a hospital for medical care, because her life is in danger.
Haemorrhage, or heavy bleeding, during labour, can be caused by obstructed labour or by problems with the placenta. The placenta may be lying below the baby, which can cause bleeding when the neck of the womb begins to open (see Chapter 9). An accidental haemorrhage can occur if the placenta separates from the womb too early. Haemorrhage can also be caused if the womb ruptures or is torn during labour. Whatever the cause, blood loss of more than two cups during labour requires skilled care in a hospital, because loss of a lot of blood endangers the mother and baby.
Figure 11.6: Eclampsia
Eclampsia causes fits or convulsions, and may cause a woman to faint. If a woman begins to have fits before, during, or after delivery, she should be taken to a hospital as soon as the fit stops.
Haemorrhage after the birth of the baby (postpartum) is always a serious problem. If bleeding has not stopped half an hour after the placenta has come out, or if it is severe (more than two cupfuls), the woman should be taken to a hospital as quickly as possible since she needs urgent attention (see Figure 11.7). Normal postpartum flow is similar to that of a heavy menstrual period. Postpartum haemorrhage can be due to a number of causes:
RETAINED PLACENTA: Sometimes the placenta does not separate completely from the wall of the womb after the baby is born. The womb cannot contract properly, and bleeding from the womb where the placenta is attached may occur. If the placenta has not come out and the woman is bleeding heavily, she should be taken to a health facility immediately. If the bleeding is minimal but the placenta has not come out within 30 minutes of the baby's birth, it is usually necessary to remove it. This is especially true if a drug called an oxytocin has been given to make the womb contract (see Chapter 10). If the placenta is not removed, the mother is likely to bleed again or go into shock. The procedure for removing the placenta is called manual removal of the placenta and should be done at a health facility; it is described in the next chapter. If trained help is not available, loss of blood may lead to shock or death in a woman already exhausted from the hard work of labour. Women who develop this complication are quite likely to do so again in later deliveries.
Figure 11.7: Postpartum Haemorrhage (heavy bleeding)
Postpartum haemorrhage after the birth of the baby is extremely dangerous. If the bleeding is severe (more than two cups) or prolonged (continues more than half an hour after the delivery of the placenta), the woman should be taken to the hospital as soon as possible.
WEAK UTERUS: In some cases the uterus may be weak or stretched out, and bleeding does not stop after delivery. This can happen because of prolonged labour, or because the woman has had too many pregnancies. It may be necessary to give her drugs to help the uterus contract. The drugs can be given either through an injection or an intravenous line. Breast-feeding, vigorous massage of the uterus, and emptying the bladder may also help with this problem. Sometimes bleeding occurs because the abdomen was massaged too hard or squeezed during the third stage of labour. This practice is dangerous and should be avoided.
RUPTURE OF THE UTERUS: If labour is obstructed and the baby cannot come out, the womb may tear or "rupture". Sometimes, if the woman is delivering at home, she may be given herbs to take during labour that cause contractions; these herbs can be very dangerous and may cause the womb to tear. This can also happen if the woman had a Caesarean section with a previous delivery and is trying to have a vaginal delivery this time. Whatever the cause, rupture of the uterus is a very serious, life-threatening complication. It must be dealt with in a hospital where an operation can be carried out to save the woman's life.
TORN VAGINA OR CERVIX: Sometimes the lips of the vagina or the cervix (neck of the womb) are torn during delivery. This can happen if the baby is very large, or if the presentation was abnormal (for example, breech or transverse). It can also happen if the woman was subject to female genital mutilation, which can leave heavy scars in the vaginal area which are then torn during delivery (see Chapter 2). A torn cervix or vagina will usually continue to bleed until it is stitched up. This should be done by a trained midwife or doctor in a properly equipped facility.
Summary: Complications Arising During Labour
Most women go through labour and delivery with no complications. Sometimes, however, complications can arise. This can happen even if there were no warning signs during pregnancy. Women with the following signs should be taken to a hospital or well-equipped health centre for proper care:
Strong labour (contractions) that lasts for 1 2 hours without the baby being delivered
Meconium, a green or brown fluid, is seen after the bag of water breaks