by Hannah Farrell
Pregnancy and childbirth are usually uncomplicated, however it is important that the team caring for the mother and unborn child are aware of complications and how to manage them appropriately. The correct care of the mother and baby during childbirth, including knowing when to escalate for more complex care, is vital for the survival of both mother and child.
An initial assessment of the woman in labour should be performed to assess if midwife-led care is suitable:
- Detailed review of antenatal notes
- History of contractions
- Pain assessment
- Maternal observations (blood pressure, pulse rate)
- Urinalysis
The unborn baby should also be observed, and a history taken:
- Baby’s movements over previous 24 hours
- Palpate fundal height
- Baby’s lie, presentation, position, engagement
- Foetal heart rate.
If it is decided that midwife-led care is unsuitable, the woman will be transferred to an obstetric unit. Reasons for transfer to an obstetric unit include:
- Maternal observations: raised pulse (>120bpm), hypertension, proteinuria, raised temperature, vaginal blood loss, membranes ruptured >24hours before onset of labour, abnormal pain.
- Foetal observations: abnormal presentation, transverse/oblique lie, high or free-floating head, foetal growth restriction, macrosomia, suspected anyhydramnios/polyhydramnios, abnormal heart rate (below 110bpm or above 160bpm), deceleration of foetal heart rate on auscultation, reduced foetal movements.
- Delayed labour
- Regional analgesia is requested
- Meconium staining
- Retained placenta
- Repair of perineal trauma
- Neonatal concerns
- Known specific medical conditions
- Complications of previous pregnancy
- Known complications of current pregnancy
Birth Injury
Childbirth can be dangerous for the unborn child. The foetal cardiovascular system undergoes sudden changes during delivery and the contractions of the uterus begin to compromise the placenta. Further, there is a risk of birth trauma in the following circumstances:
- Large baby
- Cephalopelvic disproportion – the foetal head is too large for the maternal pelvis, leading to failure to progress with labour.
- Instrumental delivery
- Breech delivery
- Prematurity
- Shoulder dystocia (foetal shoulder becomes trapped during delivery)
- Primagravida – first time pregnancy
- Prolonged labour
- Oligohydramnios – low level of amniotic fluid
- Macrosomia – enlarged foetal head
Types of injury that the foetus can sustain include:
- Skull fractures
- Cuts and abrasions
- Subcutaneous fat necrosis
- Cranial nerve injury
- Laryngeal nerve injury
- Spinal cord injury
- Fractured clavicle, arm, or leg bones
- Abdominal bleeding
- Hypoxia
Shoulder dystocia
Shoulder dystocia is a medical emergency where the baby’s shoulder(s) gets trapped during vaginal delivery. The baby can suffer brain damage due to hypoxia. It may also lead to:
- Brachial plexus injury
- Erb’s palsy
- Klumpke’s paralysis
- Fractured clavicle
- Subluxation of cervical spine
- Cervical cord injury
- Facial palsy
- Phrenic nerve paresis
Cerebral Palsy
Cerebral palsy is an acquired brain injury
Stillbirths & Neonatal Deaths
A stillbirth is defined as the death of a baby before or during birth, after 24 weeks of gestation. A neonatal death is defined as the death of a baby within the first 28 days of life.
The biggest risk factor for stillbirth is foetal growth restriction (FGR) i.e., a foetus that does not grow at the normal rate inside the womb. FGR has multiple causes including problems with the placenta and numerous maternal health conditions. FGR can be detected through measuring the woman’s bump and through ultrasound measurements of the foetal head and abdomen.
Caesarean Delivery
The mode of birth should always be discussed with the pregnant woman from early on in pregnancy, with the benefits and risks of caesarean and vaginal birth being clearly explained. Whilst it is generally always down to the personal preference of the pregnancy woman, some circumstances result in a caesarean section being necessary to preserve the life of the woman and foetus. The caesarean section may be performed as planned or as an emergency.
Planned caesarean sections are often performed in the following circumstances:
- Patient choice
- Breech presentation
- Multiple pregnancy
- Preterm birth
- Placenta Praevia
- Morbidly adherent placenta
- Mother-to-child transmission of maternal infections e.g. poorly controlled HIV.
Caesarean Birth Urgency
The urgency of a C-section can be classified as below:
- Category 1 – There is an immediate threat to the life of the woman or foetus;
- Category 2 – There is a degree of maternal of foetal compromise, which is not immediately life-threatening. The procedure should be done ideally within 75-minutes of making the decision;
- Category 3 – There is no maternal or foetal compromise, however an early birth is required; and
- Category 4 – The birth can be timed to suit the woman or healthcare provider.
Category 1 Caesarean Section
This urgent/emergency C-section must be performed as soon as possible, often within 30-minutes of making the decision to proceed with a C-section. A category 1 C-section is performed in circumstances such as:
- Failure to progress
- Suspected uterine rupture
- Major placental abruption
- Cord prolapse
- Foetal hypoxia
- Persistent foetal bradycardia
Our medico-legal expert witnesses in obstetrics are available to opine on topics related to complicated labour, caesarean sections, and birth injuries.