Labour in women: common complications

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Extract from the article: La très grande majorité des accouchements par voie basse se déroule sans incident. Néanmoins, certaines situations en maternité peuvent être source de complications et de stress. Le point avec Dr Jean-Christophe Ayao Gynécologue Obstétricien à la cli

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The vast majority of vaginal deliveries take place without incident. However, certain situations in the maternity unit can be a source of complications and stress. Here's an update from Dr Jean-Christophe Ayao, obstetrician and gynaecologist at the « La Harpe de David » clinic in Lomé.

Some of the following complications or anomalies develop or manifest themselves during labour or delivery.

Shoulder dystocia

This is an event that is becoming rarer thanks to the widespread use of ultrasound scans: the baby (often weighing more than 4 kg) is blocked in its progress towards the exit at the moment when the shoulders pass. « The head is outside but the shoulders are stuck at the entrance to the pelvis.The umbilical cord is compressed between the wall of the pelvis and the baby's body. With the umbilical cord compressed, exchanges between mother and baby are either considerably reduced or completely interrupted. The baby then lacks everything, especially the oxygen it needs to survive. Getting the baby out of the womb becomes an extreme emergency, as its vital prognosis is very serious », explains Dr Jean-Christophe Ayao, obstetrician and gynaecologist at the « La harpe de David » clinic in Lomé.

A well-trained and experienced obstetrician knows the manoeuvres to be used to extract the baby quickly in order to save its life. According to Dr Jean-Christophe Ayao, an obstetrician and gynaecologist, they ideally have less than a minute to perform the manoeuvres (e.g. Rubin's manoeuvre) to free the shoulders and extract the baby quickly.

Complications can arise, such as « peri- and neonatal asphyxia, which can later lead to psychomotor growth retardation, epilepsy and a considerable reduction in the child's intelligence quotient. Fracture of the humerus and/or clavicle, with possible medium- and long-term sequelae. An elongation of the brachial plexus (a bundle of nerves running from the spinal column to the neck, and extending into the upper limb for its innervation) leading to paralysis and atrophy of the upper limb concerned compared with the contralateral upper limb », says Dr Jean-Christophe Ayao, obstetrician and gynaecologist. Worse still is the death of the baby if the obstetrician lacks the experience to perform the life-saving manoeuvres.

Ultimately, recommends Dr Jean-Christophe Ayao, all those involved in the monitoring and care of pregnant women « must know how to carry out end-of-pregnancy examinations that can predict the prognosis for a safe delivery, in order to avoid the occurrence of these unfortunate events, such as shoulder dystocia, which can be considered professional misconduct in the majority of cases ».

Breech births

Dr Jean-Christophe Ayao points out that « breech births are high-risk deliveries. They are almost never performed in developed countries, where the preferred option is a caesarean section.  In Togo, they are still practised, but under strict conditions that must be met before the decision is made, because breech vaginal delivery is a road of no return ».  The difficulty lies in the fact that the largest part of the baby (the head) comes out last, unlike in a normal delivery where the head comes out first. « These deliveries present a formidable risk, which is the retention of the last head, due to the deflection of the head, which favours its blocking in the woman's pelvis. Several manoeuvres have been described for extracting the last head, but unfortunately in some cases they fail, especially when the midwife is not well trained », says Dr Jean-Christophe Ayao.

« At the end of the day, the baby's body is outside and hanging between the woman's thighs, while its head is retained in her pelvis. There's no going back on the decision to have a vaginal breech birth, which is why it's called a road of no return. You have to be very sure that you're going to succeed before you start, otherwise the baby and sometimes even the mother will die », continues Dr Ayao.

As a result, says the obstetrician-gynaecologist, « the baby ends up dead and still hanging between the mother's thighs.  What's even more frightening is how this complication is managed.The dead baby has to be extracted at all costs in order to free the mother, who is more often than not the victim of a psychological shock caused by the situation ». In the majority of cases, the extraction is carried out in the operating theatre and consists of decapitating the baby to isolate the body from the head, followed by a caesarean section to extract the head by the upper route.  « This is a practice of major force, psychologically deleterious for the practitioner and for the woman, who will have lost out twice over in a situation that was avoidable.We should have opted for a caesarean section from the start!A feeling of deep regret sets in, which can push the mother into depression, hence the need for immediate psychological care », insists the obstetrician-gynaecologist. These days, says Dr Jean-Christophe Ayao, more and more gynaecologists and obstetricians in Togo are refraining from breech vaginal deliveries, preferring to systematically recommend a caesarean section because of this formidable risk.

Total or partial placental retention

When the placenta is not completely or partially expelled spontaneously 40 minutes after giving birth, this is called retained placenta. The obstetrician or midwife then performs an artificial delivery or uterine revision by removing the placenta with his or her hand and pushing it into the uterus through the woman's vagina. « If the mother has had an epidural, the uterine revision is performed under the same epidural. If she has given birth without an epidural, a spinal anaesthetic or, failing that, a general anaesthetic lasting a few minutes is given to facilitate the manoeuvre, which will then be painless.If a uterine revision is not carried out, serious post-delivery haemorrhage will occur and the mother may die if nothing is done urgently », explains the obstetrician-gynaecologist.

Acute foetal asphyxia

Acute foetal asphyxia (lack of oxygen to the brain at the time of birth) affects foetuses (babies in the mother's womb) during labour. « This can lead to the death of the baby in the hours or minutes that follow.It is therefore an emergency for the baby, as its vital prognosis is very serious. Asphyxia of the baby during labour can be detected by monitoring the baby in the mother's womb by checking the frequency and regularity of the baby's heart sounds at least once an hour, and by inspecting the colour of the amniotic fluid if the water sac has broken, or by amnioscopy », explains Dr Jean-Christophe Ayao.A well-trained midwife who keeps a close eye on a woman in labour cannot fail to notice that the baby has gone into acute asphyxia.

« Once the baby's asphyxia has been detected, the obstetrician's reflex must be to remove the baby from the mother's womb as quickly as possible for resuscitation if necessary. The decision may be taken to perform an emergency caesarean section or to hasten the expulsion of the baby using well-known obstetric techniques; all depends on the situation presented to the midwife and her personal experience.The responsibility of the midwife is very much engaged in this situation », says the obstetrician.Management protocols are well established, and those involved are trained to deal with them. « The most important thing is to make the diagnosis as early as possible, so that the asphyxia does not persist over time, so that the baby can be saved without suffering subsequent complications such as psychomotor growth deficits, IQ deficits, etc., because acute asphyxia in a baby is very quickly deleterious to the brain », recommends the specialist.

Foetal pelvic disproportion

Fœto-pelvic disproportion « occurs when the dimensions of the baby's head are greater than the dimensions of the mother's pelvis.The most common reasons for this are that the baby weighs more than 4 kg, or there is a constitutional narrowing of the mother's pelvis, or both.The diagnosis is often made at the end of pregnancy, and delivery is then carried out by prophylactic caesarean section » stresses Dr Ayao.

Delivery haemorrhage

This is a serious, profuse haemorrhage that can occur as soon as the baby is delivered or up to several hours later. This is an emergency and warrants a close observation period of at least 2 hours in the vicinity of the delivery room. Delivery haemorrhage is the leading cause of maternal death in Togo.

The obstetrician-gynaecologist explains that the treatment is standardised: « It ranges from the injection of drugs to make the uterus retract to embolisation. If this fails, the vessels can be ligated surgically, but the uterus may have to be removed », he says.

Post-partum fever (after childbirth)

The onset of fever after childbirth should prompt a search for an infectious cause (endometritis, urinary tract infection, episiotomy infection, etc.). « In maternity wards, it is essential to monitor the mother's temperature in the hours and days following childbirth.However, on the 3rd day, when the milk comes in, a slight fever can occur quite normally », says Dr Jean-Christophe Ayao, obstetrician and gynaecologist.

Abel OZIH