Baby stuck during birth – causes and solutions
As I watched the 22-year-old first-time mum go through the motions of delivery, it dawned on me that the baby’s passage was not clear. My suspicion? Baby stuck during birth.
The pregnant mum had arrived at the hospital at around seven in the evening, in labour. I was on night duty. After admitting her immediately, I called the doctor.
A vaginal examination showed that she had dilated about three centimetres. I examined her pelvis which is the large bony structure at the bottom of the spine to which legs are attached. It contains the ovaries, uterus, fallopian tubes, urinary bladder and rectum. A baby born naturally, passes through the bony canal of the pelvis (known as the true pelvis). The foetal head becomes engaged — that is, it is positioned within the pelvis — during the final weeks of pregnancy (from week 36). A vaginal examination will determine whether this has occurred.
To assess the adequacy of the pelvis, one considers the mother’s height, size of the palm or the hand and the size of her foot. A mother wearing a size two shoe and above, generally has an adequate pelvis. Short mothers or those with small palms and feet are more likely to have an inadequate pelvis. If the pelvis is inadequate, it leads to obstructed labour. Other causes of obstruction include malpresentation. For instance where the baby has not turned. Or a case of congenital abnormality like hydrocephalus (excess water in the head causing an abnormal head size).
She could not bear down
It was now one in the morning. The night had been a tough one for both the mother-to-be and I. Throughout the night I had the task of wiping stool from her bed. During delivery, as the baby’s head descends it presses on the rectum—the lower part of the large intestine leading to the anus. If a mother has not passed stool before progressing to labour, she will find it hard to control the passage of stool held in the rectum as the baby comes down through the birth canal. After assessing her situation. I ruled that it was not safe for the mother to go to the toilet at this stage, and therefore I had to regularly monitor and clean her.
Exhaustion was kicking in and I wished the delivery was faster. It was a lone work environment, considering that I was only one month old in my new job. I joined the hospital immediately after finishing college just weeks earlier. Carefully, I observed the patient and administered a drug to induce labour. She achieved full dilation at 10 centimetres, come two in the morning. At about three, I called the doctor and explained the situation.
An hour later, I noticed that she was losing strength. She could not bear down (exert pressure to push the baby). Soon it was five in the morning. I carried out another vaginal examination, and noted that I could touch the baby’s head and even feel the hair. The doctor arrived and decided to deliver the baby by Caesarean section.
The baby’s head had mal-presented in the pelvis
We commenced procedures to deliver the baby, and I wheeled the mother-to-be into theatre. She looked nervous and somewhat surprised. The doctor explained to her why an operation would be necessary. He counselled her, and she agreed to have surgery to save both her baby’s and her life. It was obvious that she had hoped to have a natural birth.
The operation went smoothly, without any complications at all. The doctor found that the baby’s head had mal-presented in the pelvis. The baby’s head position was not ideal, and the baby could not advance within the birth canal.
The baby boy — weighing a whopping four kilograms — was delivered in the morning hours. He looked very tired. I took him to the nursery for normal post-delivery procedures, and a check-up for signs of distress or injury. There were none. He picked up quite well, and after a few days mother and child were discharged from hospital.
What causes obstructed labour?
By Dr. David Kiragu
Obstructed labour means baby stuck during birth. The foetus has been unable to successfully work its way out of the birth canal, after a considerable duration of time despite optimum uterine contractions.
Size of the baby may cause obstruction
♦ One of the common causes of baby stuck during birth, is disproportion between the presenting part of the foetus and the maternal passage (vagina). In a typical normal delivery, the presenting part of the foetus (emerging first) should be the head. So if that presenting part (or its diameter) is bigger than the passageway, then one has a scenario referred to in medical language as Cephalopelvic disproportion (CPD). Cephalo refers to the head of the baby, while pelvis is the bony outlet through which the baby passes to be born.
♦ A large-sized baby, or as a result of some congenital disorders (abnormalities existing at birth) like hydrocephalus, a condition in which the head becomes enlarged by excess water retention.
♦ Some rare cases of disproportion include a baby with a tumour on the spine, which renders it impossible for the baby to pass through birth canal.
Pelvic deformities and malpositioning of baby may cause obstruction
♦ Maternal pelvic deformities, either inherited or acquired from diseases like polio, can also lead to obstruction. Accidents which result in pelvic injuries can also cause obstruction during delivery. In such cases the shape of the pelvis prevents the baby’s access to the birth canal, despite the proper position of the baby.
♦ In a normal delivery, for a baby to exit the womb naturally, the head of the baby not only comes out first, but must also present itself within the birth canal in a certain position, referred to as vertex. Malposition means the orientation of the baby’s head in relation to the pelvis is not ideal. While the mother is lying on her back, the baby may abnormally present facing upwards instead of facing the ground.
Sometimes babies with smaller heads can come out facing up and may not need any assistance. Imagine a scenario where you have a narrow window and you want to pass through it. How you place your head into the window frame will determine your passage.
♦ Sometimes a baby may present other body parts first, instead of the head. This is known as malpresentation and includes breech (buttocks or feet first) or shoulder. Such a baby can easily stall in the birth canal, become distressed, injured and could even die.
How can one know that labour has been obstructed?
Prolonged labour is not necessarily obstructed labour. There are many reasons why labour does not progress successfully, for example inadequacy of contractions. Normally the doctor would consider other clinical aspects and indications before concluding obstruction in labour has occured. The doctor or midwife observes the advancement of the baby after regular examination. If the presenting part of the foetus is not making much progress or is stagnant at some point within the vaginal canal, then there is a high likelihood of obstruction.
The head of the baby feels swollen under examination. It is inevitable that when the head of the baby is trying to pass through a limited opening a swelling will gradually occur on the area of friction with the birth canal.
The bones of the skull of a newborn tend to overlap during delivery (lie on top of each other). If you examine your baby after delivery you will notice that the bones of the skull appear to be separated from each other. The bones get joined together later. During obstructed labour, the skull becomes squeezed within the passage as the mother bears down. A vaginal examination can reveal if the bones of the skull are markedly overlapping.
How is the situation rectified?
The solution for obstructed labour is a Caesarean section. One should ideally not try other manipulations once it is confirmed that the foetus is immobile and obstructed. That could easily result in either maternal and foetal injury or death.
It is important to determine the status of the foetus in order to make a decision on the most appropriate kind of operation. If the baby is already dead the doctor will perform destructive surgery. The obstructed part of the baby may be fragmented to allow removal of the dead foetus. For example, in the case of an abnormal head (hydrocephalus), the doctor can perforate the head to let out the water and make it easier and faster to remove the dead foetus. The doctor has to examine both mother and foetus critically to make the right decision within the limited time lest the life or wellbeing of either or both becomes threatened. In the majority of cases the most appropriate and safest action is a Caesarean section.
Risks if baby stuck during birth — if unmanaged
The most obvious result of unattended obstructed labour is foetal death.
It may also result in brain injury, from which the baby cannot recover, leading to cerebral palsy. This is a serious condition in which the growing baby has difficulty initiating, controlling and coordinating muscular movements as well as permanent mental disability.
Forcing out the baby may lead to injury of other parts of the body. For instance the baby’s limbs may fracture or dislocate.
Besides harming the foetus, maternal injury can result such as the destruction of the urinary system. The mother’s bladder can get destroyed and vesicovaginal fistula (which means an opening between the bladder and vagina) can occur. Mothers with this condition develop urine incontinence (inability to control the passage of urine). This will necessitate surgery after the mother recovers from the effects of pregnancy and birth.
Injury can also happen to the nerves that serve the mother’s legs. This can lead to temporary paralysis or weakness.
The uterus can also rapture, with dire consequences.
Does a woman’s foot size determine the risk of having baby stuck during birth?
Extremely short mothers are at higher risk of having Cephalopelvic disproportion (CPD). Normally these are mothers who are less than five feet and four inches (5’4″) tall.
In some regions of the world the shoe size is used as an approximate measure with the adult shoe size number 2 as the critical limit. In East Africa that parameter is not in general use; the more commonly applied measure is the height of the mother.
These are predictive measures and do not necessarily mean that only short women or those with small feet are at risk. The size of the baby, for example, is among many other relevant factors. A tall woman may have an oversize baby and this can lead to obstruction. Likewise, any woman irrespective of her height or shoe size can have a malposition or malpresentation of the foetus. A short woman can have a small pelvis but still deliver successfully if the baby is relatively small.
END: PG 05/14-15