Complications in Labor and Birth

Source: *The Birth Partner* (5th ed.) — Penny Simkin with Katie Rohs

The Birth Partner's Role When Things Get Complicated

Complications feel different from expected difficulty. The birth partner's response shifts.

**Principles:**

• Stay informed. Ask what is happening and what it means. Do not accept "we need to move quickly" without understanding why.
• Remain assertive and cooperative at the same time. You can ask questions and still trust the team.
• In a true emergency, follow caregiver instructions immediately and ask questions after.
• Help the laboring person focus on one contraction at a time. When circumstances are changing around them, the most helpful thing is to stay in the immediate moment.
• Allow time to process after. Complications often leave emotional residue that needs space to surface later.

**The priority hierarchy:**

1. A healthy full-term pregnancy

2. Spontaneous onset of labor

3. Normal labor without intervention

4. Medications as planned

5. Spontaneous vaginal birth

6. Successful breastfeeding

7. **A healthy birthing person and a healthy baby — this overrides everything above**

When a complication arises, the question is always: will this intervention improve the odds of a healthy outcome? If the answer is clearly yes, the priorities above adjust. If it is unclear, ask the key questions (see medical interventions file).

Complications Involving the Birthing Person

Premature Labor (Before 37 Weeks)

Labor beginning before 37 weeks of gestation.

**What it looks like:** Regular contractions with cervical change before term. May be accompanied by pelvic pressure, low back pain, fluid changes.

**Call the caregiver immediately.** Early treatment may stop or slow premature labor. Do not wait to see if it resolves.

**Medical management:** Vaginal exam and contraction assessment; bed rest; tocolytic medications (terbutaline, ritodrine, indomethacin, nifedipine) to slow contractions; corticosteroids (betamethasone) to accelerate fetal lung development; continuous EFM; antibiotics if infection is suspected; transport to a hospital with a NICU if under 33 weeks; neonatologist present at birth.

**For the birth partner:**

• Do not contribute to guilt or self-blame. Premature labor is not the laboring person's fault.
• Take on household responsibilities, especially if bed rest is required.
• Connect with online communities for premature birth or bed rest — they are genuinely helpful.
• Prepare for the possibility that the NICU will be part of the baby's early life, and learn what that experience involves.

High Blood Pressure

**Chronic hypertension:** Pre-existing high blood pressure (present before pregnancy or before 20 weeks).

**Gestational hypertension (GH):** Blood pressure above 140/90 developing after 20 weeks with no other features of preeclampsia. Affects 5 to 8% of pregnancies.

**Preeclampsia:** GH with additional findings: protein in the urine, severe headache, visual changes (spots or flashing lights), right upper quadrant or epigastric pain, sudden severe swelling of the hands or face.

**Severe preeclampsia/eclampsia:** Includes seizures (eclampsia) or very high BP readings (>160/110). A medical emergency.

**HELLP syndrome:** A severe form involving Hemolysis (red blood cell breakdown), Elevated Liver enzymes, and Low Platelets. Requires urgent delivery regardless of gestational age.

**Management in pregnancy:** Bed rest, antihypertensive medications, magnesium sulfate (to prevent seizures), frequent monitoring, possible induction/cesarean.

**Management in labor:** Left-side-lying to take weight off the vena cava; continuous EFM and IV; frequent BP checks; if magnesium sulfate is being given, Pitocin may be added to maintain contractions (mag sulfate can slow labor).

**What the birth partner watches for:** Sudden severe headache, visual changes, or confusion in the laboring person. Report these immediately to the nurse.

**For the birth partner:** The laboring person may feel frightened. Discuss comfort measures specifically for laboring while confined to bed. Stay informed at every step. Be present.

Gestational Diabetes (GDM)

Insulin resistance developing during pregnancy, resulting in higher-than-normal blood glucose levels.

**Management in pregnancy:** Dietary changes (reduced simple carbohydrates); blood glucose monitoring; exercise; insulin if diet alone is insufficient; dietitian consultation.

**Risks to the baby:** Large size (macrosomia), making birth more difficult; low blood sugar at birth; prolonged jaundice; respiratory problems; higher risk of developing type 2 diabetes later.

**Labor management:** Induction is often recommended at 38 to 39 weeks; IV glucose or insulin during labor to manage blood sugar; higher cesarean rate due to baby's size; frequent newborn blood sugar checks after birth.

**For the birth partner:** Learn about GDM. Help with dietary management. Support the emotional weight — GDM often comes with fear and guilt that is not proportionate to what is actually happening. Emphasize what the person can do rather than what they must avoid.

Herpes Simplex (Active Lesion)

An active sore or outbreak at the time of labor onset requires evaluation. If a sore is present on the genitals or in the birth canal, cesarean delivery is recommended to prevent transmission to the baby.

**Prevention:** Antiviral medications (acyclovir or valacyclovir) taken in the last weeks of pregnancy substantially reduce the risk of an outbreak at term.

**If no sore is visible at labor:** Vaginal birth proceeds. The baby may be treated prophylactically or observed closely.

**For the birth partner:** This may be sensitive. If you were the source of a herpes transmission, do not be defensive and do not add pressure or blame. Give the laboring person time to adjust to a changed birth plan. Help them explore what a satisfying cesarean birth might look like.

Excessive Bleeding During Labor

**Placenta previa:** The placenta is implanted low in the uterus, partially or fully covering the cervical opening. Causes visible, painless bright red bleeding, often without contractions. Diagnosis is made by ultrasound. Cesarean is required.

**Placental abruption:** The placenta separates from the uterine wall before birth. Causes a very firm, board-hard uterus with constant pain (not intermittent), usually with vaginal bleeding. More severe abruptions are emergencies.

**Both are acute emergencies.** Stay with the laboring person. Keep them focused on the present moment. Follow the care team's instructions without delay.

Postpartum Hemorrhage (PPH)

Excessive bleeding after birth. Defined as more than 500 mL for vaginal birth (roughly 2 cups), or more than 1000 mL for cesarean. Normal blood loss is up to about 2 cups.

**Three causes:**

1. **Uterine atony:** The uterus does not contract firmly after birth, allowing blood to pool at the former placental attachment site. Most common cause of PPH.

2. **Retained placenta or fragments:** Pieces of placenta remain in the uterus, preventing it from contracting completely.

3. **Lacerations:** Tears in the vagina, cervix, or uterus.

**Routine prevention:** Pitocin injection immediately after the birth is now standard practice and has significantly reduced PPH rates.

**Treatment for atony:** Uterine massage (fundal massage); breastfeeding or nipple stimulation to release oxytocin; Pitocin IV or IM; Methergine injection; in severe cases, surgical intervention.

**Treatment for retained placenta:** Manual removal by the caregiver (very painful — IV narcotics or anesthetic gas first); D&C if needed; possible OR transfer.

**Treatment for lacerations:** Gauze compression; suturing under local anesthetic.

**Lochia:** The normal postpartum bloody discharge that continues for 2 to 6 weeks, starting heavy and red, gradually shifting to pink, then brown, then yellow-white. This is normal. Large clots (golf ball size) or sudden increase after lightening should be reported to the caregiver.

Complications Involving the Baby

Shoulder Dystocia and the Gaskin Maneuver

Source added from: *Ina May's Guide to Childbirth* — Ina May Gaskin

Shoulder dystocia occurs when the baby's head is born but one or both shoulders become stuck behind the pubic bone. The umbilical cord is compressed between the baby's body and the birth canal. It is a time-critical emergency.

Signs: the baby's head is born but does not proceed. The head may retract slightly back toward the perineum (the "turtle sign").

**Standard medical responses:** McRoberts maneuver (the birthing person's thighs are flexed sharply onto the abdomen, flattening the lumbar spine and rotating the pubic symphysis); suprapubic pressure (a nurse pushes downward on the pubic bone from above to dislodge the shoulder); internal maneuvers to rotate the baby; deliberate episiotomy to allow room.

**The Gaskin Maneuver:** Ina May Gaskin documented that turning the birthing person onto their hands and knees, a position she had seen used in traditional midwifery, reliably resolved shoulder dystocia in cases where standard techniques had failed. The shift in gravity and the change in pelvic geometry created room for the stuck shoulder to free itself. This technique is now named after her and included in standard obstetric training, though it remains underused.

The hands-and-knees position for shoulder dystocia is not a last resort. It is simple, fast, and non-invasive. If shoulder dystocia is happening and staff are not moving the birthing person to hands-and-knees, the birth partner can ask about it directly.

**For the birth partner:** Shoulder dystocia is resolved in the birth room by the clinical team. The birth partner's role is to stay present and visible to the birthing person, to hold their hand or face if they cannot be touched elsewhere, and to speak calmly. Do not be in the way of the team. After the birth, allow time to process what happened before celebrating. Shoulder dystocia births are often frightening even when the outcome is good.

Prolapsed Umbilical Cord

The umbilical cord slips through the cervix ahead of or alongside the baby, where it becomes compressed between the baby's presenting part and the pelvis. This cuts off the baby's oxygen supply within minutes. It is a true emergency.

**Risk factors:** Breech presentation; the baby's head was not engaged (was still high and floating) when the bag of waters broke.

**How to know:** Ask your caregiver at late-pregnancy appointments: "Is the baby's head engaged?" or "Is the presenting part high and floating?" If yes, this risk factor is present.

**If the bag of waters releases with a gush and the baby was floating:**

1. Immediately assume the open knee-chest position: knees on the ground, chest lower than hips, bottom in the air. This uses gravity to move the baby away from the cord.

2. Call 911 and the hospital simultaneously. State: "I need emergency help — prolapsed cord."

3. If someone else is driving: ride to the hospital in the back seat in the open knee-chest position. Do not sit up.

4. Enter through the emergency entrance. State the suspected prolapsed cord immediately.

5. If a cord is visible at the vaginal opening: do not push it back; do not let it dry out. Cover with a warm wet cloth.

The goal is rapid cesarean — the only treatment for a prolapsed cord.

Fetal Heart Rate Concerns

**Terms used:**

• "Reassuring" — heart rate pattern is normal
• "Indeterminate" — not clearly normal or abnormal; watch closely
• "Nonreassuring" or "fetal intolerance of labor" — pattern suggests possible oxygen stress

**What causes concerning patterns:**

• Umbilical cord compression (variable decelerations on the EFM strip)
• Placental insufficiency (late decelerations)
• Prolonged or very strong contractions (often from Pitocin or positioning)
• Maternal hypotension (a side effect of epidurals)

**Management:** Position change (to relieve cord pressure or improve blood flow); oxygen mask; reducing or stopping Pitocin; IV fluid bolus; fetal scalp stimulation test to confirm the baby is oxygenating adequately.

**The birth partner's role:** Before agreeing to cesarean for "fetal distress," ask whether a scalp stimulation test has been done. If the test shows the baby is oxygenating adequately, the EFM pattern may be a false positive. This is not always possible — in truly urgent situations, act on the caregiver's judgment without delay.

Newborn Complications

**Breathing problems:** Fluid in the lungs (transient tachypnea), meconium aspiration, effects of narcotics or anesthesia, immature lungs (prematurity), or infection. Treatment: oxygen, suctioning, incubator, mechanical ventilation in severe cases.

**Low body temperature (hypothermia):** The newborn uses oxygen and energy to self-warm. Prevent with immediate skin-to-skin contact, hat, and warm blankets. Kangaroo care (the baby placed chest-to-chest) is more effective than a warming unit.

**Infection:** Newborns with suspected infection undergo heel sticks, blood cultures, possibly spinal taps, and IV antibiotics. Infection can be subtle — watch for poor feeding, unusual sleepiness, or fever.

**Jaundice:** Yellow discoloration of skin and eyes caused by elevated bilirubin (a byproduct of red blood cell breakdown). Common in newborns. Treated with phototherapy: continuous bright light exposure for one to several days. Frequent breastfeeding (8 or more times per day) helps the body clear bilirubin. Fiber-optic blankets (bili blankets) allow phototherapy at home. In rare, severe cases, exchange transfusion may be needed.

**Low blood sugar (hypoglycemia):** Common in babies of diabetic mothers, large or small-for-gestational-age babies, premature babies, and babies exposed to large IV glucose doses during labor. Treatment: immediate breastfeeding; glucose water or formula if needed; repeat blood tests.

**Birth trauma or injury:** Bruises, a broken clavicle, cuts, or nerve damage can occur even with uncomplicated births, particularly with large babies or rapid deliveries. Most resolve without intervention.

**Drug effects:** Narcotics given to the birthing person cross the placenta. The baby may be sleepy, have poor muscle tone, or have difficulty initiating breathing or suckling. Effects may last hours to days. Naloxone (a narcotic antagonist) can counteract respiratory depression.

**Kangaroo care:** Placing the baby skin-to-skin on the parent's chest, covered with a blanket. Even with IV lines, oxygen, or feeding tubes in place, this is possible and beneficial. Research shows kangaroo care results in faster weight gain, better suckling, less crying, more stable body temperature, and earlier discharge compared to warming units.

Death of a Baby

The death of a baby at or near birth is among the most devastating experiences possible. Stillbirth, neonatal death, or the death of a baby born with a life-limiting condition requires specialized support.

**What helps in the immediate period:**

• Create memories while you can. Hold the baby. Take photographs. Keep a lock of hair or a footprint if offered.
• Most hospitals have staff trained in compassionate care after perinatal loss.
• Plan ahead if a life-limiting diagnosis is known before birth: what do you want the birth to look like? What goodbye rituals matter to you?

**Resources:** Now I Lay Me Down to Sleep provides free remembrance photography for families. Postpartum Support International and Faces of Loss offer community and counseling referrals.

There is no right way to grieve. Both parents grieve differently and at different paces. Give each other and yourselves time.