Written by:

Dr Tom Pettinger

MBChB, MRCOG

Dr. Pettinger is a specialist registrar in obstetrics and gynaecology, working in hospitals throughout West Yorkshire. He is currently completing advanced training in benign gynaecological surgery and obstetrics, and is particularly interested in improving communication in maternity care.

Emergencies in labour

In this article:

  • Slow fetal heart rate (bradycardia)
  • Issues with the umbilical cord
  • Bleeding after delivery
  • Shoulder dystocia
  • Retained placenta
  • Main Points
  • References

Emergencies in labour

Only a few situations during labour and delivery need immediate medical attention, but when they do arise, your maternity team will likely need to act so quickly that there are only minutes to explain what needs to happen. Some of those complications are described on this page.

Maternity staff are trained repeatedly in the skills they need to keep you and your baby as safe as possible during any complication. Do remember that while any of the situations below are likely to be the only childbirth emergency you experience, responding to these situations is a routine part of working on a labour ward, and your team will have dealt smoothly with these situations many times before. If you would like to learn about other possible complications that are not emergencies, please see our page on Complications In Labour.

Slow fetal heart rate (bradycardia)

Whether your baby’s heart rate is being monitored continuously on a CTG or intermittently with a doppler device or Pinard, a sudden and persistent slowing of the heart rate is a cause for concern. Dips in the heart rate (“decelerations”) are common during a contraction, but usually recover to the baby’s normal rate soon afterwards. Dips lasting beyond one minute should be noted by your midwife; dips lasting more than 3 minutes require action. This could be as simple as changing your body position, but your midwife will also call for extra assistance.

The vast majority of prolonged dips in fetal heart rate return to normal within 10 minutes, particularly if there had been no concerns beforehand. If your cervix is fully dilated, it can indicate that your baby is about to be born. However, if your cervix is not fully dilated, rapid arrangements need to be made to deliver your baby by caesarean section if their heart rate has not returned to normal by 10 minutes.

Issues with the umbilical cord

By 36 weeks, your baby should have its head pointing downwards into the pelvis. When the head can no longer float away it is referred to as “fixed”, and the head neatly fills the gap, preventing a loop of cord from dropping down through the cervix. Unfortunately, this still happens for a small number of babies. It may occur because you needed to be induced but the head was still high when your waters were broken by the doctor or midwife, or because your baby was not actually head down at the beginning of labour or turned unexpectedly. When the umbilical cord comes down through the cervix or into the vagina, it is called a cord prolapse and your baby will need to be delivered immediately by emergency caesarean.

Bleeding after delivery

Some blood loss is expected immediately after the birth of the baby, but as your womb rapidly shrinks down after delivering your baby and placenta, bleeding usually stops quickly. Losing over 500mls of blood (around a pint) is called a “postpartum haemorrhage”, and the number of women who suffer from this varies significantly across the globe. In Europe, it is approximately 15-20%.1 The most common cause is when the womb does not contract quickly after labour. Having an injection immediately after the birth of your baby significantly reduces the chance of bleeding heavily afterwards.

Shoulder dystocia

If your baby’s head is delivered and outside of the vagina but its body seems to be stuck, this is called a “shoulder dystocia.” If you’re delivering in a hospital, the midwife will pull an emergency cord to quickly summon help because this is an emergency; the oxygen supply to the baby has stopped but it cannot yet fill its lungs, and the team must act quickly. All maternity staff are regularly trained in the manoeuvres that must take place. These are a set of positions and actions that are performed in sequence to release the front shoulder of the baby stuck behind the pubic bone. Thankfully, the vast majority of instances of shoulder dystocia are rapidly dealt with by just the first manoeuvre, which involves bending your legs up at the hips as far as they will go.

It is difficult to predict who might experience a shoulder dystocia, but there are risk factors that make it more likely, most of which are related to the size of the baby. It is a complication seen after approximately 0.5-1% of vaginal births.2

Retained placenta

Once your baby has been born, the placenta that has nourished your baby during pregnancy also needs to be delivered. This only takes a moment and does not hurt, because the placenta is soft, and usually happens 5-15 minutes after the birth of your baby. If it has not happened by 30 minutes (or 60 minutes if you chose not to have an active third stage) it is classed as a “retained placenta“, and it happens after around 3% of deliveries.3 Having a retained placenta is not necessarily an emergency situation, but it needs to be dealt with quickly and comes with a high risk of heavy bleeding; the longer the placenta stays inside, the higher the risk. If you have birthed at home, you will be transferred into a hospital urgently. A doctor will come to see you and usually perform an examination to confirm that the placenta truly is stuck within the uterus; if so, they will discuss a procedure called a “manual removal of the placenta”. This happens under anaesthetic (usually a spinal injection) in an operating theatre.

Main Points

  • Some complications in labour are emergencies and require your medical team to act quickly.
  • An umbilical cord prolapse happens when a loop of cord falls down below your baby’s head. If this happens, your baby will need to be delivered immediately by an emergency caesarean.
  • Bleeding usually stops quickly after the delivery of your baby and placenta. If it does not, you might have suffered from postpartum haemorrhage. Having an injection immediately after birth reduces the chances of you bleeding after birth.
  • Shoulder Dystocia occurs when your baby’s head is delivered but their shoulder becomes stuck behind the bones of the pelvis. Your obstetric team will perform some emergency manoeuvres to help get your baby unstuck.
  • After your baby is delivered, the placenta should follow. If it doesn’t after 30 minutes, then it is classed as a retained placenta, and may need to be manually removed, which is a procedure that happens under local anaesthetic in an operating theatre.

References

  1. Calvert C. et al. Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis. PLoS ONE 2012