What can commonly "go wrong" while birthing?

[Emily's Mama]

I'm planning to VBAC in early Sep, and recently realised I've been so caught up in trying to avoid a malpostioned baby, trying to feel relaxed about UR risk, trying to do hypnobabies to avoid augmentation, avoid epidurals, and planning breastfeeding etc, that I've realised there are probably other things that could "go wrong" in birth that I should know about beforehand but don't, to prepare myself for, just in case I'm faced with making decisions about it while birthing.

I had "failure to progress" with DD1, who was posterior. I thought I knew a lot going into it (induction, ended up with epidural and C-section), but turns out now I did not. I know MUCH more now about theses issues. I feel much more equiped to deal with those same situations again if they come up again (having midwife birth in hospital with doula and doing hypnobabies, all of which I'm comfortable with).

But what are the other common things I should think/know about before? I've been inquiring about cord clamping and 3rd stage management, so that's one area I'm learning about. I've heard a few things about baby cord problems and "nuchal hand" (?) but don't really know much about that. Should I? What about babies who "get stuck" coming out? When is that a concern? how long would you expect to be trying to push for before it's a problem?

I just want to be able to research these things in advance and be able to feel informed if it comes down to it on the day that there are issues besides those I've already thought of.

thanks.

Sharon

[onlyboys]

It seems to me that there are two types of "going wrong." There are complications and emergencies. Which are you interested in hearing about?

I don't want to go into detail about emergencies if all you want to know about is complications, you know?

As far as cord clamping goes, I think there are two good reasons to leave the cord intact until the placenta is out or until it stops pulsing. First, it connects you to your baby and no one can remove them from you for anything at all. Second, the blood in the placenta belongs to your baby, and it is still oxygenating your baby even after he or she is out.

Most hospital practicioners that I have seen do 3rd stage active management, which generally involves using pitocin to hasten the removal of the placenta plus gentle cord traction to get the placenta out. The midwives I work for just wait and see what happens after birth; I've rarely seen a shot of pit to deliver the placenta, though we have it readily available if it's needed.

Nuchal hands and cords aren't usually scary, though a nuchal hand can cause some tearing and a tough pushing stage. Nuchal cords are common from what I've seen--about 1 in 4 births. The midwife will just loosen and pull it over the baby's head, though I've heard of babies just coming out with the nuchal cord.

I think the "getting stuck" thoughts are probably shoulder dystocia and it is a true emergency. Usually care of shoulder dystocia means the assistants putting your legs way back while the practicioner tries to free the baby's shoulder. Some will then flip the mom to hands and knees, which I think might work well, but have rarely seen in practice.

I've seen moms push (with resting periods) for up to 7 hours. I imagine as long as everyone was healthy, the mom could have pushed longer, if she needed to. This was in an out of hospital birth. For in hospital births, the norm is around 2 hours before the staff gets anxious and wants to perform a cesarean section.

If there's anything else specific, ask away!

[lovingbeingmom]

Wow great answer Onlyboys! I think the second birth is much easier than the first, so try and think positive instead of thinking about what happened with number 1. Every birth and delivery is different.

[Kidzaplenty]

Yep, everyone is different. And instinct seems to take a big hand in what to look for and when something is not right.

[mwherbs]

in some ways it seems that you are very aware of problems in labor ...
if you are very interested in looking into complications more- I would say read something like obstetric emergencies I think that looking at actual problems can limit your fears, but I also think that we are overwhelmed with fears about the possible problems- and would say if you are going to look into emergencies more closely keep in mind that the % of complications is somewhere between 5-10 and serious complications are closer to 5% or less.
here is a web site--

http://cchs-dl.slis.ua.edu/clinical/...cies/index.htm

[turtlewomyn]

I would talk to your care provider about this. The midwife that I plan to use for my VBAC has a 80-90% success rate with her VBAC's. This means that her VBAC clients are no more likely to end up with a section than her other clients. Her transfers for c-section are things like prolapsed cord, abruption, etc.

[Emily's Mama]

Thank you all for your responses so far. I"m finding them interesting and reassuring.

Originally Posted by onlyboys

It seems to me that there are two types of "going wrong." There are complications and emergencies. Which are you interested in hearing about?

I don't want to go into detail about emergencies if all you want to know about is complications, you know?

I think my confusion actually is trying to distinguish between what would be a true emergency and what is a simple complication that requires little panic. With my first baby, I had "failure to progress" and still wonder if baby would have delivered naturally if we'd waited longer. I knew nothing about posterior births, monitoring, and swelling cervixes, etc beforehand and felt annoyed after that I didn't go into birth feeling more prepared.

We will have a doula there with us this time, so that should help us to discern what is silly hospital policy, what is true emergency and to help us through those decisions on the spur of the moment, so that does help me to feel more calm about it. If there is a real emergency and I need another C-section that is fine, but I don't want to feel afterwards that it was unavoidable if only I"d been better informed about the risks.

[onlyboys]

Originally Posted by Emily's Mama

Thank you all for your responses so far. I"m finding them interesting and reassuring.



I think my confusion actually is trying to distinguish between what would be a true emergency and what is a simple complication that requires little panic. With my first baby, I had "failure to progress" and still wonder if baby would have delivered naturally if we'd waited longer. I knew nothing about posterior births, monitoring, and swelling cervixes, etc beforehand and felt annoyed after that I didn't go into birth feeling more prepared.

We will have a doula there with us this time, so that should help us to discern what is silly hospital policy, what is true emergency and to help us through those decisions on the spur of the moment, so that does help me to feel more calm about it. If there is a real emergency and I need another C-section that is fine, but I don't want to feel afterwards that it was unavoidable if only I"d been better informed about the risks.

I hear you.

I think that knowing what can go wrong is important for some people to be able to let it go and know that statistically it's not likely to happen. For others, however, it causes them to dwell on those possibilities and not be able to let go of the fear.

So, the things that I've seen as far as complications:

Labor dystocia caused by OP (occiput posterior) babies--This is the most tiresome and exhausting complication in my mind. Some don't even consider this to be a complication, because normally OP babies turn and come out fine. But, they can cause days and days of contractions which especially first time moms have trouble coping with. This can also cause a prolonged pushing phase while the baby rotates in order to be born OA (occiput anterior) or just stays OP.

PROM--Premature rupture of membranes, where the membranes rupture and then labor doesn't follow. This is frustrating because while most babies and moms would be perfectly fine with this complication, some are not. Some care providers are rabid about it--they want baby out within 24 hours. Some don't care as much--I've seen an OB allow for 50 hours of ROM. In the hosptial, it almost always necessitates pit, and pit almost always causes epidural. Since you're a VBAC you have to consider very carefully whether you want ANY augmentation of your labor.

Issues with FHT--When the baby's heart rate doesn't stay in the safe range or have variations that are reassuring, the staff may get anxious and want you to have oxygen, change position, or even recommend another cesarean. If you can arrange intermittent monitoring it can be good, though I've heard some research that indicates one way to to truly show a rupture of the uterus is with fetal heart tone strips. I've also heard that if you don't look for trouble you don't find it. I'm sure you'll come to your own comfort level with fetal surveillance, which will be different than mine, I'm sure.

Restriction of movement, food, and drink--I do feel that this is a complication of labor because it changes the way that you would normally deal with labor and delivery. This can make labor more painful as well as more complicated because your range of movement is restricted. Some women do choose to lay in bed and labor, but for the vast majority of women, they like to move--shower, walking, birth ball, rocking chair, back to bath, squatting, swaying, dancing with partner, hands and knees, side-lying, semi-sitting--a woman might go through all of this as she labors. If you are restricted to a bed, this complicates the labor. I usually recommend to my clients that they stay home or even wandering around near the hospital until they are very progressed in labor.

Excessive vomiting--This is a complication of labor because it makes the woman flat out miserable. If a mom can't keep anything down for a prolonged period of time, it's a good plan to get some hydration, perhaps via IV. This shouldn't require any other cascade of intervention--like pit or anything.

These are the things I would have a cesarean for:

Placental Abruption--where the placenta becomes detached during labor or before.
Placenta Previa--placenta covers the os of the cervix.
Brow presentation--where the baby doesn't flex his head and presents brow first. Babies rarely come out vaginally in this case.

Other emergencies:
Shoulder dystocia, postpartum hemorrhage. These can't be cured with cesarean section, though.

I hope this helps you. Have a terrific birth and let us know how it goes!

[honeybee]

I think you're on the right track with looking into the 3rd stage of labor. I remember with my first this is the part I glossed right over, so I was totally surprised when they started pushing on my belly afterwards, and I really didn't expect those afterpains to hurt so much!

I think it's great to be well informed, but sometimes things come up that we just don't know about and have to make the best decision we can at the time. With my first, I started labor with a fever. I had read about fevers with epidurals, or as a sign of infection after your water has been broken for awhile, but this one through me. So, I ended up agreeing to the IV antibiotics, even though my birth plan called for no helplock.

In retrospect, I may have had a virus (which antibiotics wouldn't help), or it may just have been how my body reacted to labor. I think my fever was down by the time I was in L&D... before they even gave me any antibiotics. So, really, I should have waited on the abx. But hindsight is ALWAYS 20/20.

Be prepared with standard questions when anything unexpected comes up. There's probably a good list online somewhere, but this is the general gist:

Is this an emergency, or do we have time to talk it over?
What are the possible risks of not doing the procedure?
What are the possible risks of the procedure?
Are there other courses of action we could take?
How about waiting a while?

[Emily's Mama]

Great, great, thank you for more answers. Yes, I don't want to scare myself or start obsessing about the rare risks of birthing, so I won't dwell on them, and I know I also won't be prepared for every situation. I'll probably do my bit of research and then file th info in the back of my mind!

Onlyboys, I note what you said about the brow presentation...my first baby was born direct OP deflexed with "forehead first" I remember the doctor saying, then we went to a C-section. He said we could wait and see what happened, but he recommended a C-section ("I think it would be better for you and the baby" he said) when I was about 7cm and still cervix not really soft and baby not descending (and 9.5lbs). I know it's hard to say without knowing all the details, but do you think it would have been unlikely baby would have come out vaginally? I keep going over this in my mind, wondering if she would likely have turned if we'd waited, and haven't really directly asked many people if they think my C-section was necessary or not? I'd love to hear your thoughts/opinion on it. I wonder if I were in the same situation again, would i wait longer or go to C-section again?

[onlyboys]

Sometimes babies will still right themselves, but once they are engaged (at station 0 or greater) with a face or brow presentation, they are not likely to be able to flex their heads. Face presentations are easier to get out--the diameter of the head is less than that in the brow presentation.

I've seen two brow presentations in my life--both ended in cesarean section. One woman got to complete dialation, pushed for 4 hours and transferred for fetal bradycardia/distress. He was born with APGARS of 3/5, so not good at all. One woman labored for 3 days, got to 5cms, had a swollen cervix that was persistent, never got any more dialated. She consented to a cesarean section after 10 more hours in the hospital laboring. Her baby was born with an infection that needed antibiotics, but no one is really sure why.

Anecdotally, my husband was a brow presentation plus fetal bradycardia that resulted in cesarean section in the 70s, when c-section wasn't as common as it is now.

So, brow presentation isn't common--less than 1%. And while 30% of those cannot be explained, there are some potential reasons that it happens. Small babies, who have increased mobility can sometimes get themselves in wonky positions--this clearly was not the case with you with a 9.5 pound baby. Fetal issues, like tumors or other anomalies. PROM before the baby's head is engaged. Did you have your waters broken for augmentation or did your waters break before the baby was at 0 station? If so, then perhaps the baby's head was trapped extended and couldn't move to occiput. Do you have any uterine anomalies like a bicornate uterus? This could encourage this position too.

It is very unlikely that you will have another baby with a deflexed head, in the absence of those things I mentioned above. The incidence is really rare, and unfortunately sometimes mamas get to be that 1% in 1000, you know?

One of the women I mentioned above did go on to have a VBAC, 3 years after her cesarean section. Have hope!

It sounds to me like you made a good call. How long did you labor? How was your baby at birth?

[Emily's Mama]

Boy, I didn't realise the brow first was so hard to get out! I was just so focused on the "posterior" part.

Yes, I did have my waters broken early on (was induced and it was taking a while. I would not consent to this again if possible). I labored for about 24 hours, but not all of this was active labor I think, maybe half of it. I got to about 7cm, don't know what station my daughter was at. I had a swollen cervix and something about blood in my urine (which they said was not a positive sign, although someone after told me it could have been due to the catheter not being fit properly and cutting me, as I had an epidural). My daughter was 100% fine when she came out 1 hour after we decided to do the surgery. 9 and 10 scores I think. She was never in distress. I thought I totally trusted in my OB at the time and believe he had my best interests in mind, but afterwards I heard that he has a HUGE C-section rate anecdotally from friends, so I have become more skeptical that he just did the surgery because that's what he does! hearing that this deflexed position is an extra tough one does bring me a huge amount of relief.

Thank you so much!

[Eresh]

Regarding brow presentation, if I've interpreted her story correctly, one of the women in my Bradley class had one. She ended up with a c/s after 40 hrs of labor. I don't remember what she said about her dilation, but her baby had molding forwards on his head by the time they got him out.