Complications of labour

Foetal Complications

Foetal distress: Abnormal foetal heart rate patterns (e.g., bradycardia, tachycardia, late decelerations), meconium-stained amniotic fluid.
Shoulder dystocia: Difficulty delivering the shoulders after the head has emerged, often indicated by the “turtle sign” (retraction of the foetal head back into the perineum).
Cord prolapse: Umbilical cord descends through the cervix alongside or ahead of the foetus, leading to potential cord compression and foetal hypoxia.
Neonatal asphyxia: Impaired gas exchange leading to acidosis, hypoxia, and potential multi-organ dysfunction, often assessed using Apgar scores.

Maternal Complications

Postpartum haemorrhage: Blood loss >500 mL after vaginal delivery or >1000 mL after caesarean section, may result from uterine atony, retained placenta, or genital tract trauma.
Uterine rupture: Sudden onset of severe abdominal pain, vaginal bleeding, loss of foetal station, and signs of maternal shock, often in a woman with a history of caesarean section.
Amniotic fluid embolism: Acute onset of hypotension, hypoxia, and coagulopathy during labour or immediately postpartum, high maternal mortality.
Perineal tears: Lacerations to the perineum, categorised into four degrees based on extent, with fourth-degree involving the anal sphincter and rectal mucosa.
Infection (e.g., chorioamnionitis, endometritis): Fever, uterine tenderness, foul-smelling lochia, usually occurring postpartum or post-prolonged labour.

Labour Complications

Prolonged labour: Labour lasting >20 hours in nulliparous or >14 hours in multiparous women, associated with increased risk of maternal and foetal morbidity.
Obstructed labour: Failure to progress despite adequate contractions, may result from cephalopelvic disproportion or malpresentation (e.g., breech, transverse lie).
Precipitate labour: Labour lasting <3 hours from onset to delivery, may lead to perineal tears, foetal distress, or intracranial haemorrhage in the neonate.
Intrapartum infection: Often due to prolonged rupture of membranes (>18 hours), characterised by maternal fever, foetal tachycardia, and uterine tenderness.
Retained placenta: Failure to deliver the placenta within 30 minutes of the baby’s birth, increasing risk of postpartum haemorrhage and infection.

Onset and Duration

Labour duration: Prolonged labour may suggest cephalopelvic disproportion, while a short labour could increase risk of precipitate delivery complications.
Contraction pattern: Abnormal contraction patterns (e.g., hypertonic or hypotonic contractions) can indicate labour dystocia or uterine rupture.
Rupture of membranes: Time since rupture is important, with prolonged rupture (>18 hours) increasing risk of infection (chorioamnionitis).

Associated Symptoms

Pain: Sudden, severe abdominal pain may suggest uterine rupture or abruption; persistent lower abdominal pain could indicate obstructed labour.
Vaginal bleeding: Heavy bleeding during labour could indicate placenta previa, abruption, or uterine rupture.
Fever: A sign of infection such as chorioamnionitis or endometritis, especially with prolonged rupture of membranes.
Foetal movements: Decreased or absent foetal movements may suggest foetal distress or demise.
Urinary retention: May occur post-delivery due to perineal trauma or epidural anaesthesia, leading to bladder distention and infection.

Background

Past obstetric history: Previous caesarean section, history of postpartum haemorrhage, or shoulder dystocia increases risk in current labour.
Medical history: Conditions like pre-eclampsia, diabetes, and obesity increase the risk of complications during labour.
Drug history: Use of uterotonics (e.g., oxytocin) can increase risk of uterine rupture or hyperstimulation; anticoagulants increase risk of haemorrhage.
Family history: History of genetic conditions that could affect labour (e.g., muscular dystrophy leading to weak contractions).
Social history: Smoking, alcohol use, and drug abuse can complicate labour and increase risks such as placental abruption and preterm labour.

Bedside Tests

Cardiotocography (CTG): Continuous monitoring of foetal heart rate and uterine contractions, detects foetal distress and labour progress.
Vaginal examination: Assess cervical dilatation, effacement, and station of the presenting part, as well as any abnormalities (e.g., cord prolapse).
Urinalysis: Checks for proteinuria (pre-eclampsia) and signs of infection.
Temperature monitoring: Elevated maternal temperature can indicate infection such as chorioamnionitis.
Blood pressure monitoring: Hypertension may suggest pre-eclampsia or abruption; hypotension could indicate haemorrhage or shock.

Blood Tests

Full blood count: To assess for anaemia, infection, and platelet count, important in managing haemorrhage and infection risk.
Coagulation profile: Important in cases of suspected DIC (disseminated intravascular coagulation) or in preparation for surgical intervention.
Group and save/crossmatch: Necessary for cases where blood transfusion might be required, such as postpartum haemorrhage.
CRP: Elevated levels can indicate infection such as chorioamnionitis.
Liver and renal function tests: To assess for organ dysfunction, especially in cases of pre-eclampsia or HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets).

Imaging and Special Tests

Ultrasound: Useful for assessing foetal position, placental location, amniotic fluid volume, and confirming intrauterine demise.
MRI: May be used in complex cases to assess placental abnormalities (e.g., placenta accreta) or pelvic anatomy in obstructed labour.
Foetal blood sampling: Performed during labour if there is concern about foetal hypoxia, provides information on foetal acid-base status.
Amniocentesis: Rarely performed in labour but may be considered in cases of suspected infection to analyse amniotic fluid for pathogens.

Obstetrics