9.14 MB | 22:47 Min
Dr. Keith Eddleman is the Director of Obstetrics and a senior member of the Division of Maternal-Fetal Medicine at The Mt. Sinai Medical Center. He also co-authored the books Pregnancy for Dummies and The Pregnancy Bible with Dr. Joanne Stone.
Susan Scott Gill is a Certified Professional Midwife at Blessed Beginnings Midwifery in California. She is also certified in Neonatal Resuscitation, Adult, Child and Infant CPR and Standard First Aid and IV Therapy. She has taken advanced training in water birth.
Welcome to your Pea in the Podcast. I’m Bonnie Petrie with everything you need to know about your body, your baby and the big changes ahead in your life as you begin your journey as someone’s mom.
This week, we’ll prepare you for some of the things that can go wrong during your labor.
”In the opinion of the doctor, the baby’s head was too big to go through.”
“As soon as they started fiddling around down there I went crazy.”
And what doctors can do about them.
”You give the patient oxygen, increase the IV fluids. You turn the patient on the side to reposition them.”
Stick around to learn about labor complications in this Pea in the Podcast.
Well it’s the big day. The baby is coming. You’ve got your birth plan; you’ve taken your classes. You think you’re ready, but are you ready for what might go wrong?
”Fetal heart rate abnormalities are very common. Protractive labors or labors that stall, those are pretty common things that we run into every day.”
Things that can take your birth plan that you and your partner lovingly created over hours of discussion and toss it out the window in seconds. I know, I’ve been there.
So has Emily Hull, whose plans for labor – whatever they might have been – changed at an OB appointment when her doctor decided her baby was just too big to carry much longer.
”They induced me at 38 and a half weeks because they thought he was about 10 and a half lbs.” And still growing.
Dr. Keith Eddleman, Maternal-Fetal Specialist at The Mt. Sinai Hospital in New York City, and author of the book Pregnancy for Dummies says there are many reasons your doctor might decide to jump start labor.
”High blood pressure or preeclampsia, which is a disorder that is unique to pregnancy that is related to blood pressure and swelling and protein in the urine. Sometimes you need to induce for that. Sometimes you need to induce for medical reasons or sometimes for fetal reasons like if the baby is not growing appropriately or if the level of amniotic fluid decreases too much then that’s a fetal indication that you need to induce labor.”
Emily’s induction lead to a very long day for her and her husband.
“They had me hooked up to the IVs by 7:00 AM and I didn’t have to have the cervix ripening gel because I was already 3.5 centimeters dilated so they figured I was good to go on that front. So they started me on the pitocin right away and basically they just kept jacking it up, I want to say every 15 minutes to half hour, probably every half hour. Because it wasn’t doing anything.”
Pitocin is the synthetic form of oxytocin.
“Oxytocin is a naturally occurring substance, that’s what you normally produce in your brain during labor. The oxytocin that’s used during an induction of labor is titrated or adjusted so that it mimics normal labor.”
As Emily said, the pitocin really wasn’t doing much for her.
“I was having tiny, little bitty contractions and they weren’t in any sort of pattern. They were completely random. It wasn’t until about noon that they started getting painful but they never developed any sort of a pattern.”
Emily asked for some narcotic pain relief, Stadol, and she got some fitful sleep over the next couple of hours. She woke up when it wore off though and asked for an epidural. Later they checked her progress.
”I was about 6 centimeters by 3:30 or 4:00PM and I kept going. The epidural was fine; there were no problems or complications with that at all. At 6 o’clock give or take they checked me again and found that I had somehow gone back to 4 centimeters, which is definitely failure to progress.”
Wait. Her cervix started to close?
“I was pretty shocked, I’d never heard of that before and I’ve never heard of it since. I kind of wonder if maybe somebody mismeasured at some point.”
Dr. Eddleman says it probably wasn’t a measurement problem.
”The cervix, whenever it’s not dilating well, can swell. That swelling can make it seem like it’s going backwards but it’s really just a swollen cervix. But that is a sign that labor is not progressing as it should.”
Emily’s labor had stalled, and Dr. Eddleman says there are three reasons why that might occur in your labor.
“The passenger, the passage and the power. The power is the contractions, so either they’re not strong enough, the passage is the birth canal, the birth canal’s too small to let the baby out or the passenger is the baby itself and the baby itself can be too big.”
Eddleman says there are a couple of options for you if this happens to you. You can augment labor with medication and keep trying to get your body and your baby to cooperate with a vaginal delivery…or not.
“If the baby’s too big or you think the pelvis – or the passageway – is not big enough, then sometimes you might not do that. Sometimes you might say, ‘You know, look, we gave it a try and my suspicion is that this is a big baby and it ain’t going to fit through this pelvis.’ So at that point sometimes you don’t try the augmentation or the oxytocin because it may be safer to get the baby out by cesarean rather than subjecting it to trying to come out when it’s too big.”
This is the situation in which the Hulls found themselves.
“The doctor gave us the option of continuing or having the C-section and left us alone to talk about it and we talked about it for probably 15 or 20 minutes. The doctor was pushing a little bit for the C-section, that’s what he recommended but he would have let us try longer if we really wanted. We got the impression that it wouldn’t do any good and at that point having gone backward in the numbers it just didn’t seem likely that the baby was going to come out.”
So off they went to the O.R.
“The baby was born by C-section just short of 7 PM that night. He was 10 pounds, 1 ounce at 38 and a half weeks.”
He was just about as big as billed. So how do you feel after a day of labor and delivery like that?
“Exhausted, really, really wiped out. 3 hours of just drug induced sleep isn’t exactly restful and it was a long day and not having slept much the night before didn’t help because of course you’re all excited and you stay up late in anticipation. We got up probably at 4:30 or something, we had to be at the hospital at I think 5:30 so it just kind of wipes you out.”
A labor that takes these kinds of unexpected turns can also make the first couple of weeks postpartum more of a struggle than they otherwise might be.
“As far as the baby goes, the baby’s perfectly healthy either way so I’m grateful he came out, I’m grateful he was healthy, but there are other repercussions from the surgery. I lost some blood in the surgery and so I was pretty exhausted, even more exhausted than I would have been for the next week or two. All my pictures with the new baby I’m strange shade of grey.”
So be prepared moms. Before the big day you should probably prepare yourselves emotionally that things may not follow your plan.
But also you need to make some practical preparations, you should have some frozen food ready like casseroles or lasagnas, whatever you like. Stock up your freezer with those nourishing foods that you only have to warm up. And have some help available too, whether it’s family or friends or even a postpartum doula that you hire.
I went that route after my labor stalled and my baby struggled and we ended up having a C-section. My postpartum doula was really a lifesaver. She helped me recover and she encouraged me when I was tired and breastfeeding was difficult. I thank her for so many things, among them for getting me through those difficult, early weeks of nursing compounded by recovery from surgery. So make sure you have help lined up, because stalled labor is not the only thing that can go wrong.
Since we’re talking about size, let’s talk about my primary fear during my pregnancy, which was shoulder dystocia.
“Shoulder dystocia, the head comes out fine and then after that she can’t get anything else out.”
Your baby’s shoulders are too broad to allow them to descend easily and they get stuck.
“Usually it’s when you have an infant of a diabetic mother because their babies tend to be bigger but it can occur in women that don’t have diabetes.”
Dr. Eddleman says 1 out of every 100 births or so will present doctors with some form of shoulder dystocia. When it’s at its worst, when the baby gets stuck, their very life is at risk, but Dr. Eddleman says you can save a shoulder dystocia baby.
“Fortunately most of the time even when you have a shoulder dystocia there is a series of maneuvers that we have burned into our brains that you go through and you do step 1, step 2, step 3. You go through those maneuvers and again the majority of times those maneuvers will reduce the shoulder dystocia and you can deliver the baby safely without having any consequences.”
With shoulder dystocia though, time is of the essence.
“The first maneuver is to look at the clock and see where you are because you need to know where you’re starting from so you know how much time you have to do the other maneuvers.”
Because you don’t want the baby to be without oxygen for very long. Of course, the very last resort in a case like this push the baby’s head back inside and do a cesarean section.
Dr. Eddleman says you can sometimes assess who might be at risk for a shoulder dystocia.
“People who are sort of no-brainers that are risks are diabetics, people with big babies, people who have had a shoulder dystocia in the past in a previous pregnancy. Those are all set ups for a repeat shoulder dystocia or a shoulder dystocia.”
But as he said, shoulder dystocia sometimes just happens in moms with no risk factors. Also as he said, most times the outcome is good and you leave the hospital with a healthy baby.
Another problem can occur when your baby tries to be born in an awkward position. You’ll hear about babies trying to make their way through the birth canal facing up rather than down — or sunnyside up — which makes the trip more difficult for them and more painful for you. It can cause the infamous back labor, which can happen in up to 25% of labors. So what do you do then?
“Usually you can overcome that either by manually rotating the head once the cervix is dilated enough or by allowing labor to correct it. Usually sort of labor will naturally correct that. If it doesn’t, some people can push a head out that is sunnyside up.”
Positioning can also help mom deal with her discomfort. You can have someone push down on that point of your back just above your tailbone and see if that helps. You can try heat and cold in that area too. Mom can also get on her hands and knees, that might make you feel more comfortable and it also might give the baby a little bit of room to rotate. Pelvic tilts are also worth a shot. Also try getting in a tub or on all fours in the shower. Things like birth balls can be helpful in labor whether you’re having back labor or not. One thing, though, that is not advised is trying to labor on your back — that will increase your pain. Also some say an epidural may increase your risk of having your baby descend in a bad position and some say an epidural will decrease the chance that your baby will turn.
If your baby doesn’t turn and doesn’t want to descend anymore…
“Then you don’t have many options except for either a forceps delivery if you think that’s safe or a cesarean section.”
The mother of all position problems for you and your baby is a breech baby. Ask Nicole Rosenleaf-Ritter.
“The doctor, I guess at about 32 weeks told me ‘it’s looking like he’s breech, that doesn’t mean anything because it’s 32 weeks, but you should be prepared that that could be the way it goes,’ and at 37 weeks he turned around.”
But this Pea in the Podcast is about labor complications so you know that’s not the end of the story.
“I guess it must have been about 38 weeks and maybe 5 days they said that he had turned back around again.”
Nicole’s OB then suggested she schedule a C-section. She didn’t really want surgery, though, and apparently her son, Connery, didn’t want it either.
“That evening while I was watching television and having dinner with my husband, my water broke.”
She went to the hospital and they told her that while they thought she should stay, nothing would happen that night.
“And then about midnight things started to progress really rapidly and by the next time they checked me I was something like 7 centimeters dilated and it was pretty clear that I was going to have the baby then.”
Nicole’s son was a frank breech, which means he was butt down and feet up, sort of folded in half. Other breech presentations include complete breech in which your baby is butt down with its legs folded and its feet down by its bottom and a footling breech in which if born vaginally it would arrive feet first.
Nicole’s labor with her frank breech baby was moving quickly.
“Everything up to the pushing point when very quickly. It was painful but it wasn’t excruciating or anything else. But then I spent more or less 4 hours in the pushing phase.”
Which is tough without pain medication. Yeah, you heard me right.
“Well it was partially a function of how quickly things moved. To go from the stage one to stage two to bam all of the sudden being ready to push, there really wasn’t time. By the time I realized I really would like something to help, it was too late.”
Nicole says during the hours it took to push out her breech baby she sometimes got discouraged.
”I remember thinking pretty vividly at a certain point this is never going to happen. I’m going to have to walk home with this baby sort of half in and half out and I’m never going to have a baby because he’s going to be stuck.”
But he wasn’t stuck, and with an episiotomy, young Connery arrived bottom first quite healthy. It was then as they tried to stitch her cut, the strain of this very complicated labor hit Nicole.
“As soon as they started fiddling around down there, I went crazy. It hurt like hell and I didn’t know what they were doing and so they were trying to talk to me and I was like you need to get away from me NOW. They finally talked to my husband and said we really think that if we’re going to get this done, we’re going to need to put her under general anesthetic. And so that’s what they did.”
But looking back at her birth story, Nicole feels really a deep sense of pride.
“Oh definitely. Instead of just constantly trashing my body for not being thin enough or not measuring up I felt like okay it’s true I’m not thin but my body did an amazing thing and if my body can do that, I can do anything.”
Nicole delivered Connery in the Czech Republic. If she had been in the United States her son likely would not have come vaginally.
“Most of us won’t deliver breeches vaginally anymore because of the risk associated with them.”
Certified Professional Midwife Susan Scott Gill says she actually has delivered one here.
“My heart was pounding out of my chest. It’s not your ideal situation but it does happen sometimes.”
Gill says since she mostly attends home births she has to be ready for anything.
“The thing is in midwifery schools we’re trained in how to deal with a breech birth. Whereas in obstetrics the training is prep them for surgery. So it’s a different type of training.”
Nicole says if she carries another breech — which is more likely for her since her first baby did present that way — she would try to find an OB that would let her shoot for a vaginal birth. Oh but the next time, she says she’d take the epidural.
Sometimes your baby doesn’t respond well to labor. This also happened to me and my daughter. Her heart rate dropped with every contraction. Dr. Eddleman says there are many reasons a baby’s heart rate might drop during labor.
“It could be due to a cord entrapment or a cord prolapse. It can be due to a placental abruption. It can be due to the placenta not getting enough oxygen to the baby. Those situations are emergent and you need to have active intervention at that time.”
Troubles with a fetal heart rate might lead you to the O.R. for a C-section, but they don’t always.
“There are maneuvers that you go through. You give the patient oxygen, increase the IV fluids, you turn the patient on the side to reposition them. So there are lots of things that you do that you can completely reassure yourself and keep going with labor.”
Labor complications can be very hard on mom, particularly if she’s worked diligently on her birth plan and is very attached to her idea of the perfect labor and delivery. Even a very practical Emily Hull, whose labor stalled and ended in a C-section, had some mixed feelings.
“Yay, the baby’s out, the baby’s fine, we’re grateful for that, we’re grateful there is the technology to get the baby out and keep the baby healthy but you know you do wonder what would have happened if I’d had a regular birth. Would have been an easier recovery, etc., etc.”
This is normal, mom. I still struggle with these feeling and I can get quite emotional about it if I think about it even now that my beautiful, healthy daughter is 14 months old. Dr. Eddleman says you need to be flexible because no matter how hard you work on your birth plan, there is no way to anticipate everything that could happen during labor.
“Really the bottom line is the patient needs to trust their doctor, or their midwife or whoever’s taking care of them. They need to trust their caretaker. And if they trust their caretaker then you have to trust that they’re going to do the right thing and if there are options then that caretaker are going to discuss the options and give you the pros and cons of each option.”
Ultimately a labor that doesn’t go as planned is not necessarily the end of the world.
“Even when there are complications, there are things that we can do to deal with them and still get a good outcome.”
A good outcome of course is that beautiful, healthy baby that you get to take home with you.
We hope you’ve enjoyed this Pea in the Podcast: Labor Complications. Please visit our website, peainthepodcast.com, for more information about our experts, to find links and transcripts, and to register to receive tailored week-by-week shows for each week and stage of your pregnancy. It’s everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy. For Pea in the Podcast, I’m Bonnie Petrie, thanks for listening.
A Special Thank You To…
Emily in Texas and Nicole in Montana who graciously shared their dramatic birth stories with us for this podcast.