Complications in Pregnancy
Babies are sometimes reluctant to enter into the world and must be assisted out by the doctor. Forceps have been used for 150 years to help the baby's head through the pelvis. They can be used not just to help pull out the child, but to turn the head into a more appropriate position if the head is coming out at an inappropriate angle. In a breech birth (bottom first), the forceps actually protect the following head and prevent the cervix from clamping around the neck.
Forceps consist of two spoon-shaped stainless steel blades. They slide around the side of the baby's head and fit snugly between the wall of the vagina and the head. Once placed carefully in position, the doctor, in time with the contractions, will apply traction (and sometimes rotation) to deliver the head. The baby may be born with some red marks on its face and head from the forceps, but they disappear after a week or so.
Another method of assisted delivery is vacuum extraction, in which a suction cap (ventouse) is attached to the baby's head, and traction is applied to the cap to help pull out the baby.
bleeding from vagina during pregnancy
Extensive studies have not shown any increase in infant abnormalities after bleeding in early pregnancy. The bleeding may be due to a slight separation of the placenta from the wall of the womb as it grows, and it almost certainly does not involve the baby directly. About 30% of all pregnant women suffer from some degree of bleeding during pregnancy, and some have quite severe bleeds without losing the baby.
Bleeding in early pregnancy may also be a sign of an impending miscarriage. Unfortunately nothing except rest can help the mother in this situation. Doctors cannot usually prevent miscarriages once bleeding has started.
Other causes of bleeding in pregnancy include an ectopic pregnancy, vaginal ulcers or erosions, or hormonal imbalances.
Babies normally come into the world head first, but occasionally the wrong end fits into the mother's pelvis and cannot be dislodged. About 3% of babies are in the breech position at birth. They may be delivered by a cesarean section, or normally, but with the assistance of forceps to protect the head. Breech labors tend to take longer than head first ones, and there can be more problems for the baby, as the cord will be compressed during the delivery before the head is free to start breathing. Even so, the vast majority of breech births result in no long-term complications to the mother or child.
Diabetes in Pregnancy
Pregnancy may trigger diabetes in a woman who was previously well but predisposed towards this disease. One of the reasons for regular antenatal visits to doctors and the urine tests taken at each visit is to detect diabetes at an early stage. If diabetes develops, the mother can be treated and controlled by regular injections of insulin. In some cases, the diabetes will disappear after the pregnancy, but it usually recurs in later years.
If the diabetes is not adequately controlled, serious consequences can result. In mild cases, the child may be born grossly overweight but otherwise be healthy. In more severe cases, the diabetes can cause a miscarriage, eclampsia, malformations of the fetus, urinary and kidney infections, fungal infections (thrush) of the vagina, premature labor, difficult labor, breathing problems in the baby after birth, or death of the baby within the womb.
Diabetic women tend to have difficulty in falling pregnant, unless their diabetes is very well controlled.
A fetus normally grows within the womb (uterus). An ectopic pregnancy is one that starts and continues to develop outside the womb. About one in every 200 pregnancies is ectopic. Conditions such as pelvic inflammatory disease and salpingitis increase the risk of ectopic pregnancies, as they cause damage to the Fallopian tubes. Other infections in the pelvis (e.g. severe appendicitis) may also be responsible for tube damage.
Symptoms of an ectopic pregnancy may be minimal until a sudden crisis from rupture of blood vessels occurs, but most women have abnormal vaginal bleeding or pains low in the abdomen in the early part of the pregnancy. Many ectopic pregnancies fail to develop past an early stage, and appear to be a normal miscarriage. Serious problems can occur if the ectopic pregnancy does continue to grow.
The most common site for an ectopic pregnancy is the Fallopian tube, which leads from the ovary to the top corner of the womb. A pregnancy in the tube will slowly dilate it until it eventually bursts. This will cause severe bleeding into the abdomen and is an urgent, life- threatening situation for the mother. Other possible sites for an ectopic pregnancy include on or around the ovary, in the abdomen or pelvis, or in the narrow angle where the Fallopian tube enters the uterus.
If an ectopic pregnancy is suspected, an ultrasound scan can be performed to confirm the exact position of any pregnancy. If the pregnancy is found to be ectopic, the woman must be treated in a major hospital. Surgery to save the mother's life is essential, as a ruptured ectopic pregnancy can cause the woman very rapidly to bleed to death internally. If the ectopic site is the Fallopian tube, the tube on that side is usually removed during the operation. With early diagnosis and improved surgical techniques, the tube may not have to be removed. Even if it is lost, the woman can fall pregnant again from the tube and ovary on the other side.
It is rare for a fetus to survive any ectopic pregnancy.
Normally the baby presents the crown of its head to the opening of the uterus during birth, with the neck bent and the chin on the chest. This lets the smallest diameter of the head pass through the birth canal. In a very small number of cases, the neck becomes extended (bent back) instead of flexed (bent forward), and the face presents itself to the outside. This is a significant problem, as in a face presentation the largest diameter of the head is trying to force its way through the birth canal. The result is a very long labor, and damage to both mother and baby is possible.
Obstetricians can sometimes disengage (push up) the head from the pelvis and bring it back down again with the crown of the head presenting, but in most cases a cesarean section is the treatment of choice.
In the womb, the baby is surrounded by and floats in a sac filled with amniotic fluid. This fluid acts to protect the fetus from bumps and jarring, recirculates waste, and acts as a fluid for the baby to drink. If an excessive amount of fluid is present, the condition is called polyhydramnios.
Normally there is about a liter (1000 mL) of amniotic fluid at birth. A volume greater than 1500 mL is considered to be diagnostic of polyhydramnios, but it may not become apparent until 2500 mL or more is present.
Polyhydramnios occurs in about one in every 100 pregnancies, and it may be a sign that the foetus has a significant abnormality that prevents it from drinking or causes the excess production of urine. Other causes include a twin pregnancy, and diabetes or heart disease in the mother. In over half the cases no specific cause for the excess fluid can ever be found.
The condition is diagnosed by an ultrasound scan, and if proved, further investigations to determine the cause of the condition must follow. The treatment will depend upon the result of these tests, but often none is necessary.
The reverse condition, when insufficient amniotic fluid (less than 200 mL) is present, is called oligohydramnios. This may also be caused by abnormal development of the fetus, but in most cases, there is again no reason for the problem. Abnormal function of the placenta is another possible cause.
A pregnancy that goes beyond about 42 weeks can put the baby at risk because the placenta starts to degenerate. It is therefore sometimes necessary to start (induce) labor artificially. Labor may also be induced for a number of other reasons, including diseases of the mother (e.g. pre-eclampsia, diabetes), and problems with the baby (e.g. fetal distress from a twisted cord or separating placenta).
Labor can be induced in a number of ways, including rupturing the membranes through the vagina, stimulating the cervix, by tablets or (most commonly) a drip into a vein in the arm. Using these methods, doctors can control the rate of labor quite accurately to ensure that there are no problems for either mother or baby.
Pre-Eclampsia and Eclampsia
Eclampsia is a very serious disease that occurs only in pregnancy. In Australia it is very uncommon, because most women undertake regular antenatal visits and checks. Pre-eclampsia is a condition that precedes eclampsia, and this is detected in about 10% of all pregnant women. The correct treatment of pre-eclampsia prevents eclampsia.
The exact cause of pre-eclampsia is unknown, but it is thought to be due to the production of abnormal quantities of hormones by the placenta. It is more common in first pregnancies, twins and diabetes. Pre-eclampsia normally develops in the last three months of pregnancy, but may not develop until labor commences, when it may progress rapidly to eclampsia if not detected.
The early detection of pre-eclampsia is essential for the good health of both mother and baby. Doctors diagnose the condition by noting high blood pressure, swollen ankles, abnormalities (excess protein) in the urine and excessive weight gain (fluid retention). Not until the condition is well established does the patient develop the symptoms of headache, nausea, vomiting, abdominal pain and disturbances of vision.
If no treatment is given, the mother may develop eclampsia. This causes convulsions, coma, strokes, heart attacks, death of the baby and possibly death of the mother.
Pre-eclampsia is treated by strict rest (which can be very effective), drugs to lower blood pressure and remove excess fluid, sedatives, and in severe cases, early delivery of the baby.
A pregnancy normally lasts 40 weeks from the last menstrual period. A birth that occurs at less than 37 weeks is considered to be premature. Before 20 weeks, any birth that occurs is considered to be a miscarriage.
Babies under 500 grams have only a 40% chance of survival, under 1000 grams a 65% chance, and over 1500 g a nearly 100% chance of survival. It is rare for an infant born before 26 weeks to survive, and only after 30 weeks are the chances of survival considered to be good.
Premature labor occurs in about 7% of pregnancies. There is no apparent cause in over half the cases, but in others, high blood pressure, diabetes, two or more babies, more than six previous pregnancies, fetal abnormalities, polyhydramnios and abnormalities of the uterus may be responsible.
The problems that very premature babies face include liver failure and jaundice, inability to maintain body temperature, immature lungs, inability to maintain the correct balance of chemicals in the blood, patent ductus arteriosus, increased risk of infection due to an immature defense system, bleeding excessively, and eye problems including blindness. The smaller the baby, the greater the problems, and the more intensive the care required from specialized units in major hospitals.
The activity and processes of immature babies must be monitored carefully. Tubes and leads to and from the infant may appear to overwhelm it but are necessary to monitor the heart and breathing, supply oxygen, assist breathing in some cases, feed the baby, drain away urine, keep the temperature at the correct level, and maintain the correct chemical balance in the blood.
Even some of the treatments to help these babies can have serious complications. Many require oxygen to allow them to breathe, but too much oxygen can cause a condition called retrolental fibroplasia that damages the retina (light sensitive area) at the back of the eye to cause permanent blindness.
A baby born prematurely will be a little later in reaching the milestones of infancy and should have routine immunizations delayed. The delay is roughly the number of weeks of prematurity before 37 weeks (i.e. a baby born at 31 weeks is 6 weeks before 37 weeks, and can expect its milestones and vaccinations to be delayed by 6 weeks). The delay is halved by the time the child reaches six months of age, and disappears completely by one year of age.
Very rarely, when the waters break, the umbilical cord slips down into the birth canal. This is a medical emergency, as the start of labor usually follows soon after the waters break, and the cord will be compressed as the baby moves down into the birth canal, cutting off its oxygen supply. This problem is more common with breech births, as the smaller bottom is more likely than the larger head to allow the cord to slip past it into the birth canal.
The only treatment for a prolapsed cord is a cesarean section as soon as possible. In the meantime, the mother may be placed in a kneeling position, with her head down on the bed and her bottom in the air. Drugs may be given to stop labor as well.
Labor may be prolonged for several reasons. The muscles of the uterus may not produce sufficiently strong contractions (a 'lazy' uterus), or may not contract regularly. Some women have incoordinate contractions, which cause different parts of the uterine muscle to contract at different times. This can result in significant discomfort but minimal progress in labor. Injections may help the contractions, but sometimes a cesarean section is necessary.
There may also be an obstruction to the passage of the baby through the birth canal. This can be caused by the baby having a large head, having the head twisted in an awkward position, or having an abnormal part of the baby presenting (e.g. shoulder instead of head); or the mother may have a narrow pelvis that does not allow sufficient room for the baby to pass. Sometimes these situations can be assisted by forceps, but often a cesarean section is necessary for the well-being of the baby.
In some women, the cervix fails to dilate and remains as a thick fibrous ring that resists any progress of the baby down the birth canal. In an emergency the cervix may be cut, but in most cases doctors would again prefer to perform a cesarean section.
A miscarriage is always most upsetting to the parents, particularly if there has been difficulty in achieving the pregnancy in the first place. A miscarriage usually starts with a slight vaginal bleed, then period-type cramps low in the abdomen. The bleeding becomes heavier, and eventually clots and tissue may pass.
The most common cause of a miscarriage is a 'blighted ovum'. This is best thought of as a growing placenta without the presence of a baby. The abnormal growth is detected, and then rejected, by the woman's body. A 'blighted ovum' is purely bad luck, and no blame can be placed on the parents for its development. A subsequent pregnancy has a normal chance of success. Other causes include abnormalities of the fetus, death of the fetus, severe infections in the mother (e.g. hepatitis), abnormalities of the womb, hormonal problems, emotional stress and a violent injury to the mother.
At least one quarter of all pregnancies end as a miscarriage, but many of these occur at a very early stage and are merely passed off as an abnormal period by the woman. Up to 15% of diagnosed pregnancies end as a miscarriage.
There is no treatment for a threatened miscarriage except bed rest. If a miscarriage occurs, it may be necessary to have a minor operation (curettage) to clean out the womb. If this operation is not performed, there may be prolonged bleeding, continued pelvic pain, and difficulty in falling pregnant again. The operation also gives the doctor an opportunity to detect any problem that may have caused the miscarriage.
Women who have repeated miscarriages will be investigated further, and may be given additional hormonal or surgical treatment by a gynecologist.
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