Pregnancy and Birth Sourcebook Part 42

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Chapter 67.Problems during Childbirth Chapter Contents.Section 67.1-Cephalopelvic Disproportion .............................. 540 Section 67.2-Episiotomy ............................................................ 541 Section 67.3-Birth Injuries ....................................................... 543 539.

Pregnancy and Birth Sourcebook, Third Edition Section 67.1 Cephalopelvic Disproportion "Cephalopelvic Disproportion," 2007 American Pregnancy a.s.sociation (www.americanpregnancy.org). Reprinted with permission.

The accurate definition of cephalopelvic disproportion (CPD) is when a baby's head or body is too large to fit through the mother's pelvis. It is believed that true CPD is rare, but many cases of "failure to progress" during labor are given a diagnosis of CPD. When an accurate diagnosis of CPD has been made, the safest type of delivery for mother and baby is a cesarean delivery.

What causes cephalopelvic disproportion (CPD)?

The possible causes of cephalopelvic disproportion (CPD) include: * large baby due to: * hereditary factors; * diabetes; * postmaturity (still pregnant after due date has pa.s.sed); * multiparity (not the first pregnancy); * abnormal fetal positions; * small pelvis; * abnormally shaped pelvis.

How is cephalopelvic disproportion diagnosed (CPD)?

The diagnosis of cephalopelvic disproportion is often used when labor progress is not sufficient and medical therapy such as use of oxytocin is not successful or attempted. CPD can rarely be diagnosed before labor begins even if the baby is thought to be large or the mom's pelvis is known to be small. During labor, the baby's head molds and the pelvis joints spread, creating more room for the baby to pa.s.s through the pelvis. Ultrasounds are used to estimate fetal size, however they are 540 Problems during Childbirth not 100% accurate in determining fetal weight. A physical examination that measures pelvic size can often be the most accurate at determining a diagnosis of CPD. If a true diagnosis of CPD cannot be made, the use of oxytocin is often administered to see if this aides in labor progression or change in fetal positioning.

What about future pregnancies?

Cephalopelvic disproportion is a rare occurrence. According to the American College of Nurse Midwives (ACNM), CPD occurs in 1 out of 250 pregnancies. If you have been diagnosed with CPD, this does not automatically mean that you will have this problem in future deliveries. According to a study published by the American Journal of American Journal of Public Health, Public Health, over 65% of women who had been diagnosed with CPD over 65% of women who had been diagnosed with CPD in previous pregnancies were able to deliver v.a.g.i.n.ally in subsequent pregnancies.

Section 67.2 Episiotomy From "What You Need To Know About Episiotomy," by the Agency for Healthcare Research and Quality (AHRQ, www.ahrq.gov), AHRQ Publication No. 06-0005, December 2005.

Research shows that routine use of episiotomies (surgical cuts in the area between the v.a.g.i.n.a and a.n.u.s) does not keep the mother's skin from tearing during birth. It does not speed up a normal birth.

It does not help avoid the bladder control problems women sometimes get after having a baby.

What do I need to know?

An episiotomy is a surgical cut in the perineum. (That is the area between the v.a.g.i.n.a and the a.n.u.s.) When a woman has a baby, the doctor, nurse-midwife, or midwife may make this cut.

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Pregnancy and Birth Sourcebook, Third Edition If you are pregnant, you should talk to your doctor, nurse-midwife, or midwife about episiotomies, just as you talk about whether you want pain medicine during childbirth. Do it before you get to the delivery room.

Should I have or not have an episiotomy?

Some doctors perform episiotomies for every birth. Researchers looked at the evidence for this routine use of episiotomies. They did not look at special cases, such as when a baby's shoulders get stuck during birth.

The research shows that routine use of episiotomies does not keep the mother's skin from tearing during birth. It does not speed up a normal birth. It does not help avoid the bladder control problems women sometimes get after having a baby.

You should know that: * Both episiotomies and tears that occur when giving birth may be painful. They may be slow to heal. They can become infected.

* If you do not have an episiotomy, your skin may tear during delivery. But the tear is likely to be smaller than an episiotomy and to heal with less pain.

Women who do not have episiotomies: * are likely to start having s.e.x sooner after childbirth than women who have them.

* have less pain the first time they have s.e.xual intercourse after childbirth.

What should I do?

* Talk with your doctor, nurse-midwife, or midwife. Ask the reasons they might perform an episiotomy. Ask how often they perform them.

* Tell your doctor, nurse-midwife, or midwife any questions or concerns you have about having an episiotomy.

* Tell them what you prefer. Your voice counts.

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Problems during Childbirth Section 67.3 Birth Injuries "Birth Injuries," 2008 Children's Hospital of Pittsburgh (www.chp.edu). Reprinted with permission.

What is a birth injury?

Occasionally during the birth process, the baby may suffer a physical injury that is simply the result of being born. This is sometimes called birth trauma or birth injury.

What causes birth injury?

A difficult birth or injury to the baby can occur because of the baby's size or the position of the baby during labor and delivery. Conditions that may be a.s.sociated with a difficult birth include, but are not limited to, the following: * Large babies-birthweight over about 4,000 grams (8 pounds, 13 ounces) * Prematurity-babies born before 37 weeks (premature babies have more fragile bodies and may be more easily injured) * Cephalopelvic disproportion-the size and shape of the mother's pelvis is not adequate for the baby to be born v.a.g.i.n.ally * Dystocia-difficult labor or childbirth * Prolonged labor * Abnormal birthing presentation-such as breech (b.u.t.tocks first) delivery What are some of the more common birth injuries?

The following are common birth injuries: * Caput succedaneum: Caput succedaneum: Caput is a severe swelling of the soft tissues of the baby's scalp that develops as the baby travels 543 Caput is a severe swelling of the soft tissues of the baby's scalp that develops as the baby travels 543 Pregnancy and Birth Sourcebook, Third Edition through the birth ca.n.a.l. Some babies have some bruising of the area. The swelling usually disappears in a few days without problems. Babies delivered by vacuum extraction are more likely to have this condition.

* Cephalohematoma: Cephalohematoma: Cephalohematoma is an area of bleeding between the bone and its fibrous covering. It often appears several hours after birth as a raised lump on the baby's head. The body reabsorbs the blood. Depending on the size, most cephalohematomas take two weeks to three months to disappear com- Cephalohematoma is an area of bleeding between the bone and its fibrous covering. It often appears several hours after birth as a raised lump on the baby's head. The body reabsorbs the blood. Depending on the size, most cephalohematomas take two weeks to three months to disappear com- pletely. If the area of bleeding is large, some babies may develop jaundice as the red blood cells break down.

* Bruising/forceps marks: Bruising/forceps marks: Some babies may show signs of bruising on the face or head simply as a result of the trauma of pa.s.sing though the birth ca.n.a.l and contact with the mother's pelvic bones and tissues. Forceps used with delivery can leave temporary marks or bruises on the baby's face and head. Babies delivered by vacuum extraction may have some scalp bruising or a scalp laceration (cut). Some babies may show signs of bruising on the face or head simply as a result of the trauma of pa.s.sing though the birth ca.n.a.l and contact with the mother's pelvic bones and tissues. Forceps used with delivery can leave temporary marks or bruises on the baby's face and head. Babies delivered by vacuum extraction may have some scalp bruising or a scalp laceration (cut).

* Subconjunctival hemorrhage: Subconjunctival hemorrhage: Subconjunctival hemorrhage is the breakage of small blood vessels in the eyes of a baby. One or both of the eyes may have a bright red band around the iris. Subconjunctival hemorrhage is the breakage of small blood vessels in the eyes of a baby. One or both of the eyes may have a bright red band around the iris.

This is very common and does not cause damage to the eyes. The redness is usually absorbed in a week to 10 days.

* Facial paralysis: Facial paralysis: During labor or birth, pressure on a baby's face may cause the facial nerve to be injured. This may also occur with the use of forceps for delivery. The injury is often seen when the baby cries. There is no movement on the side of the face with the injury and the eye cannot be closed. If the nerve was only bruised, the paralysis usually improves in a few weeks. If the nerve was torn, surgery may be needed. During labor or birth, pressure on a baby's face may cause the facial nerve to be injured. This may also occur with the use of forceps for delivery. The injury is often seen when the baby cries. There is no movement on the side of the face with the injury and the eye cannot be closed. If the nerve was only bruised, the paralysis usually improves in a few weeks. If the nerve was torn, surgery may be needed.

* brachial palsy: brachial palsy: Brachial palsy occurs when the brachial plexus (the group of nerves that supplies the arms and hands) is injured. It is most common when there is difficulty delivering the baby's shoulder, called shoulder dystocia. The baby loses the ability to flex and rotate the arm. If the injury caused bruising and swelling around the nerves, movement should return within a few months. Tearing of the nerve may result in permanent nerve damage. Special exercises are used to help maintain the range of motion of the arm while healing occurs. Brachial palsy occurs when the brachial plexus (the group of nerves that supplies the arms and hands) is injured. It is most common when there is difficulty delivering the baby's shoulder, called shoulder dystocia. The baby loses the ability to flex and rotate the arm. If the injury caused bruising and swelling around the nerves, movement should return within a few months. Tearing of the nerve may result in permanent nerve damage. Special exercises are used to help maintain the range of motion of the arm while healing occurs.

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Problems during Childbirth * Fractures: Fractures: Fracture of the clavicle or collarbone is the most common fracture during labor and delivery. The clavicle may break when there is difficulty delivering the baby's shoulder or during a breech delivery. The baby with a fractured clavicle rarely moves the arm on the side of the break. However, healing occurs quickly. As new bone forms, a firm lump on the clavicle often develops in the first 10 days. If the fracture is painful, limiting movement of the arm and shoulder with a soft bandage or splint may be helpful. Fracture of the clavicle or collarbone is the most common fracture during labor and delivery. The clavicle may break when there is difficulty delivering the baby's shoulder or during a breech delivery. The baby with a fractured clavicle rarely moves the arm on the side of the break. However, healing occurs quickly. As new bone forms, a firm lump on the clavicle often develops in the first 10 days. If the fracture is painful, limiting movement of the arm and shoulder with a soft bandage or splint may be helpful.

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Chapter 68.How to Perform an Emergency Delivery Although most women do not go into labor during emergencies and most of those who do can get to a hospital or birth center, recent events have raised concerns about what to do if travel is not possible. Being prepared can help. The information here includes a list of supplies and directions for managing a normal labor and delivery while taking shelter in place.

This is not a "do-it-yourself " guide for a planned home birth, nor is it all the information you need for every emergency. It is not meant to replace the knowledge and skills of a doctor or midwife. The information is a basic guide for parents-to-be who want to be ready in case they have to give birth before they can get to a hospital or birth center.

Supplies for Giving Birth in Place The following list is not a "do-it-yourself " list of supplies for a planned home birth, nor is it all the information you need for every emergency.

The following supplies can be found at most drugstores, cost about $70, and should be kept in a waterproof bag away from children and pets. Keep them in a tote bag in case you leave home.

"Giving Birth 'In Place': A Guide to Emergency Preparedness for Childbirth,"

Journal of Midwifery and Women's Health, July/August 2004. 2004 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. July/August 2004. 2004 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission.

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Pregnancy and Birth Sourcebook, Third Edition * Baby size bulb syringe (made of soft plastic, often called an ear syringe; should not be a nasal syringe as the plastic tip does not fit into a baby-sized nose) * A bag of large-sized under pads with plastic backing to protect sheets from messy fluids * Small bottle of isopropyl alcohol * Package of large cotton b.a.l.l.s * Box of disposable plastic or latex gloves * White shoe laces (to tie umbilical cord) * Sharp scissors (to cut umbilical cord) * 12 large sanitary pads * Chemical cold pack (the kind you squeeze to get it cold) * Hot water bottle (to help keep baby warm) * Six disposable diapers * Pain pills such as Tylenol or Advil * Small bar of antibacterial soap or liquid antibacterial hand sanitizer Additional items you will use: * Shower curtain * Four cotton baby blankets * Newborn cap * Medium-sized mixing bowl * Four towels * Wash cloth * Blankets to keep mom warm * Pillows * Five large trash bags for dirty laundry * Two medium-sized trash bags for the placenta * Instructions for CPR [cardiopulmonary resuscitation] for adults and babies * Emergency contact information 548.

How to Perform an Emergency Delivery If you think you are going to have to give birth at home, put the scissors and shoe laces in a pan of boiling water for 20 minutes.

When done, pour off the water but do not touch the items until needed. If there is no way to boil water, wash the scissors and laces with soap and water and soak them in alcohol during the labor.

Call for Help If you think you are in labor, try to get to a hospital, birth center, or clinic. If you are alone or travel seems unwise, call the emergency number in your community and ask for help. After you have called for help, keep your front door unlocked so that rescue workers can get in if you are unable to come to the door. Call a neighbor to come and help the family. If the phones are working, keep talking to emergency services or your health care provider who can "talk you through" a labor and birth.

If your labor is going fast and birth seems near, stay at home and have your baby in a safe place rather than in the back seat of the car.

Fast labors are usually very normal, and the mothers and babies can both do well. Slow labors will give you time to get to a hospital or birth center, or for a health care provider to get to you. Get out your supply kit and put the supplies where you can easily reach them.

As the helper, your job is to: * Keep mom comfortable. It is good for her to walk, take a shower, get a ma.s.sage, and move even if she is in bed.

* Be sure she drinks lots of fluids. Water, tea, and juice are the best.

* Be sure she goes to the bathroom every hour.

* Say and do things that create a calm feeling, even if you are very nervous.

* Wear gloves if you are going to be touching blood.

* Wash your hands or gloves often.

* Do not let pets into the labor and birth room.

* Talk to mom about the sounds of childbirth. Making groaning or crying noise during labor is okay and can help the mom-to-be.

It can scare the helpers. So mom has to try to not scream and lose control, and the helpers have to let mom make the noise that helps her cope.

* Decide how to help other members of the family. Will they be present for the birth? What do they need to feel safe?

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Pregnancy and Birth Sourcebook, Third Edition Prepare the Bed To keep the mattress from getting wet, cover it and the sheets with a shower curtain and then cover the shower curtain with another clean sheet, plastic-backed under pads and lots of pillows for comfort.

The mother may want to spend a lot of time in bed, or she may prefer to be on her feet or in a chair. Whatever feels best is okay.

When the Baby's Head Is Coming First If you know your baby has been head down during the last weeks of pregnancy, chances are good that the baby will be head first at birth.

This is the most common position for a baby. First labors can last for 12 hours or more, whereas the next babies can come much faster.

The Urge to Push The longest part of labor is the time it takes for the cervix to open wide enough for the baby to pa.s.s into the birth ca.n.a.l or v.a.g.i.n.a (first stage). You can tell the cervix has opened all the way (fully dilated) when the mother has a very strong need to push (second stage). She cannot hold back that urge and may make sounds like she is going to the bathroom. Once she starts pushing, the baby can be born in a few minutes or a couple of hours. As birth gets closer, the area around the v.a.g.i.n.a begins to bulge out until the top of the baby's head can be seen at the v.a.g.i.n.al opening. The mother should be encouraged to push the baby's head out gently in any position that is comfortable for her. She does not have to lie on her back in bed, but you will feel safer if she is lying down or squatting so the baby can slip gently onto a soft surface.

Put on your gloves and get in a place where you can see the baby come out. Remind mom to push gently even when she wants to push hard. As the baby comes out, mom will feel a lot of burning around the v.a.g.i.n.a and this is when she may make a lot of noise. After the head is born, look and feel with your fingers to find out if the cord is around the baby's neck. If you find a cord around the neck, this is not an emergency. Gently lift the cord over the baby's head, or loosen it so there is room for the body to slip through the loop of cord.

The baby's head will turn to one side and with the next contraction the mother should push to deliver the body. If the body does not come out, push on the side of the baby's head to move the head toward the mother's back. The shoulder will be born. The rest of the body slips out easily followed by a lot of blood-colored water.

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How to Perform an Emergency Delivery If the Head Is Born But the Body Does Not Come out after Three Pushes The mom must lie down on her back, put two pillows under her bottom, bring her knees up to her chest, grab her knees, and push hard with each contraction. After the baby is born, place her or him on the mother's chest and tummy, skin to skin, and cover both with towels. If the baby is not crying, rub her back firmly. If she still does not cry, lay her down so that she is looking up at the ceiling, tilt her head back to straighten her airway, and keep rubbing. Not every baby has to cry, but this is the best way to be sure the baby is getting the air she needs.

If the Baby Is Gagging on Fluids in Her Mouth and Turn- ing Blue Use the baby blanket to wipe the fluids out of her mouth and nose.

If this does not help, use the bulb syringe to help clear things out. Just squeeze the bulb, place the tip in the nose or mouth, and release the squeeze. This will suck fluid into the bulb. Move the bulb away from the baby and squeeze again to empty the bulb. Repeat until the fluid is removed.

If the baby is still not breathing, follow the CPR directions.

The Umbilical Cord There is no rush to cut the cord. All you have to do is keep the baby close to the mom so the cord is not pulled tight. If you pick the cord up between your fingers, you can feel the baby's pulse. Within about 10 minutes the pulse will stop. At that time you can tie and cut the cord. Remember the cord is connected to the placenta (afterbirth) which is still inside the mother.

The Baby At the time of birth, most babies are blue or dusky. Some cry right away and others do not. Do not spank the baby, but rub up and down her back until you know she is taking deep breaths. Once the baby starts to cry, her color will be more like her mom, but her hands and feet will still be blue. Now is the time to keep the baby warm. Remove the wet towel that is over the baby and put another dry towel and blanket over the mother and baby. Put a hat on the baby. The mother can help keep the baby warm with her body heat.

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Pregnancy and Birth Sourcebook, Third Edition Put the baby to breast. Even if you did not plan to breastfeed, one of the safest things you can do for mom and baby is put the baby to breast. A breastfeeding baby helps keep the mother from bleeding too much and gets the food it needs right away. If the cord is too short to allow the baby to reach the breast, it is okay to wait until you cut the cord.

Cutting the Cord There are no nerve endings in the cord so it does not hurt either the baby or the mother when it is cut. It is very slippery so take your time because there is no rush. Wash your hands, put on gloves, and then get the container with the scissors and shoelace. Tie one of the laces around the cord very tightly with a double knot about 3 inches from the baby's tummy. The baby will cry when she is uncovered because she is cold, not because it hurts. Tie the other shoelace around the cord about 2 inches from the first knot.

Pick up the scissors by the handle without touching the blades. Cut between the knots you have tied. It is rubbery and tough to cut especially if you have dull scissors. After it is cut, place the end of the cord that is still connected to the mother's placenta into the mixing bowl.

Cover the baby again to keep her warm.

The Placenta or Afterbirth (Third Stage) The placenta looks like a big piece of raw meat with a shiny film on one side. On the other side it has membranes that are attached to the placenta (the membranes look like skin that has been peeled off). When the placenta is ready to come, you will see a gush of blood from the v.a.g.i.n.a and the cord will get a little longer. Put the bowl close to the mother's v.a.g.i.n.a and put more waterproof pads under her bottom. Ask the mother to sit up and push out the placenta into the bowl.

There will be a lot of blood and water coming after the placenta.

Firmly rub the mother's stomach below her belly b.u.t.ton until most of the bleeding stops. This will hurt but needs to be done. The heavi-est bleeding should stop in a minute and then the bleeding will be more like a heavy period. If the bleeding increases again, very firmly rub the mother's lower belly until the bleeding slows. When it is firm, you will be able to feel the uterus (womb), which is the size of a large grapefruit, in the lower belly. A firm uterus is a good thing because it will stop the mom from bleeding too much.

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How to Perform an Emergency Delivery Mom's bottom and her uterus may be sore. You may see places where the mother's skin has torn around her v.a.g.i.n.a. Most of these tears will heal without any problems. Mom will feel better when you put an ice pack on her bottom where the baby came out and then put the sanitary pad on top of the ice pack. She may want to take a couple of pain pills at this time.

Put the placenta in a medium-sized trash bag and wipe off any blood on the outside of the bag. Put this bag into a second trash bag.

Take the placenta with you to the hospital or birth center. If you cannot leave the house for more than 4 hours, put the bagged placenta in a container with a lid and put it in the freezer.

Clean Up After the mother has delivered the placenta and the bleeding has slowed down, give her a drink of juice, soup, or milk and something to eat like crackers and cheese or a peanut b.u.t.ter and jelly sand-wich. Put on gloves to clean up the bed. Roll up the sheet and pads inside the shower curtain and put in a large plastic bag. Have clean under pads ready to cover the sheets and a sanitary pad for the mother.

The dirty sheets and towels can be washed in cold water with bleach or ammonia added. Wear gloves when touching items that are b.l.o.o.d.y. Put a diaper on the baby or you will be sorry.

Breastfeeding It is important for the mother to breastfeed the baby in the first hour after birth and at least every 2 hours until her milk comes in.

* Breastfeeding will keep the uterus firm and decrease bleeding.

* Colostrum, the liquid that is in the b.r.e.a.s.t.s right after birth until the milk comes in, will give the baby all of the food she needs and it will help prevent infection.

* Even if the emergency situation continues for days, weeks, or months, there will always be a ready supply of safe and perfect food for the baby.