Complications

Part of Midwifery and Childbirth

Recognizing and managing birth complications when surgical backup is not available.

Why This Matters

The majority of births proceed normally with no intervention needed beyond skilled, supportive presence. But a minority of births produce life-threatening complications that arrive suddenly and require rapid, competent response. In modern obstetrics, these complications are managed with surgical teams, blood transfusions, and advanced resuscitation equipment. Without these, the birth attendant’s knowledge and speed of response are the only tools available.

Understanding complications does not mean intervening routinely — over-intervention itself causes complications. It means having a clear protocol ready for each emergency scenario, so that when one occurs, response is automatic rather than paralyzed.

The complications covered here — hemorrhage, cord prolapse, shoulder dystocia, breech, neonatal non-breathing — are responsible for the vast majority of preventable childbirth deaths.

Framework: Recognition, Response, Limits

For every complication, apply this framework:

1. Recognize — what signs tell you this is happening?
2. Respond — what specific actions should you take, in what order?
3. Know your limits — at what point is this beyond your capability, and what is your escalation path?

Prolonged Labor

Definition: Active labor lasting more than 12 hours in a first birth, or more than 8 hours in subsequent births. Or active labor that has stopped progressing for more than 2 hours.

Causes: Inadequate contractions (uterine inertia), cephalopelvic disproportion (baby’s head too large for the pelvis), abnormal fetal position (posterior, transverse lie), or obstruction.

Assessment:

• Is the baby descending with pushes?
• Are contractions regular and strong?
• Is the mother exhausted?
• Are fetal heart tones normal?

Response:

1. Change position (upright, hands-and-knees, squatting)
2. Ensure adequate hydration (oral rehydration, broth)
3. Encourage rest between contractions
4. Check for full bladder (a full bladder can obstruct descent — encourage urination)
5. Nipple stimulation may strengthen contractions (causes oxytocin release)
6. If position changes and nipple stimulation fail after 2 hours: consider whether the baby is likely to fit (assess pelvic dimensions relative to baby’s head). If not, this is obstructed labor.

Obstructed labor: Labor that cannot progress because the baby cannot pass through the pelvis. This is beyond non-surgical management. Without cesarean section, obstructed labor leads to maternal and fetal death. If transport to surgical care is any option — even distant — initiate it.

Shoulder Dystocia

Definition: After the baby’s head delivers, the shoulder fails to emerge — it is stuck behind the maternal pubic bone.

Recognition: Head delivers, then retracts back against the perineum (“turtle sign”). Shoulder does not deliver within 60 seconds of head delivery despite normal pushing.

This is an obstetric emergency. Act immediately.

McRoberts Maneuver (first action):

1. The woman lies on her back (if not already).
2. Pull her thighs sharply up toward her chest — as far as they will go, hyperflexed, knees to shoulders.
3. Apply firm, continuous suprapubic pressure (not fundal pressure!) — an assistant pushes firmly down and to one side on the area just above the pubic bone, aiming to dislodge the shoulder.
4. Ask the mother to push with the next contraction while the above is applied.

McRoberts maneuver resolves approximately 90% of shoulder dystocia cases.

If McRoberts fails:

• Try other shoulder: position the woman on all fours (hands-and-knees). The shoulder that was anterior is now posterior and may release.
• Rubin II maneuver: insert two fingers vaginally on the posterior aspect of the anterior shoulder and push the shoulder toward the baby’s face (closing the shoulder width).
• Deliver the posterior arm: Insert a hand along the baby’s posterior arm. Flex the arm at the elbow and sweep it out across the baby’s chest.

Do not: Apply traction to the baby’s head. Pull the head laterally. Apply fundal pressure. These increase impaction.

Time is critical: Each minute of shoulder dystocia increases the risk of neonatal brain injury from oxygen deprivation.

Uterine Inversion

Definition: The uterus turns inside-out, partially or completely, after delivery. The fundus descends through the cervix.

Recognition: Mass of tissue visible at or protruding from the vaginal opening. Sudden severe pain and hemorrhage. Mother may collapse from vasovagal shock.

Cause: Usually from pulling on the umbilical cord to deliver the placenta before it is separated. This is exactly why cord traction must be gentle and only after signs of placental separation.

Response:

1. Do not remove the placenta if it is still attached — leave it, as removal causes more hemorrhage.
2. Immediately attempt manual replacement: cup the inverted mass in your hand and push it back up through the cervix. Apply steady upward pressure. The natural uterine shape can guide replacement.
3. If pain causes spasm that prevents replacement, massage the uterus through the vaginal wall to help it relax, then reattempt.
4. Once replaced, massage the fundus externally until the uterus contracts firmly. Do not allow re-inversion.
5. Manage hemorrhage (see hemorrhage article).

Eclampsia

Definition: Seizure in a woman with pre-eclampsia (hypertension and protein in urine in pregnancy).

Recognition before seizure: High blood pressure (if measurable), severe headache, visual disturbances, upper right abdominal pain, swelling of hands and face.

Recognition of eclamptic seizure: Tonic-clonic seizure (muscle rigidity followed by rhythmic jerking). May occur before, during, or after labor.

Response:

1. Position on left side — prevents aspiration if vomiting.
2. Protect from injury — clear surrounding area of hard objects. Do not restrain, do not put anything in the mouth.
3. Ensure airway open after seizure.
4. Darkness, quiet, minimal stimulation — additional seizures can be triggered by light, noise, or touch.

Magnesium sulfate (if available) is the standard treatment — prevents seizure recurrence. Dose: varies by preparation, requires medical knowledge to administer safely. If available, consult any medical reference for dosing. Without magnesium, seizure management is supportive only.

Eclampsia is life-threatening. Delivery is the definitive treatment. Escalate to any available surgical care if any option exists.

The topics of hemorrhage, cord prolapse, and breech presentation are covered in dedicated articles.