Emergency interventions: management of labor complications

Birth complications include

premature rupture of membranes,

steep work,

preterm labor

secondary arrest of work,


abnormal lying (position of the fetus) and

rupture of the uterus.


The rupture of the membranes (ROM) is sometimes referred to in layman’s terms as the rupture of the “water bag”. Premature rupture of membranes (PROM) is a term used when the rupture occurs before labor begins.

The tensile strength of the amniotic membranes (membranes of the placenta that form the “water sac” or amniotic sac) varies from pregnancy to pregnancy. Some contractions strain this sac so much that it ruptures, others don’t. It commonly occurs before and during labor, but should not occur before 37 weeks gestation.

If it occurs before labor begins, there is a suspicion that infection has weakened the membranes enough to rupture spontaneously before the stresses of labor can affect them.

Once these membranes rupture, they won’t reseal (except rarely, when it happens in the 2nd trimester).

So if fluid is allowed to leak out, bacteria can get in, and there is a high risk of infection of the non-delivered fetus and placenta (“amnionitis”) if infection is not already present.

Amnionitis is a serious infection that endangers the life of the unborn child and the health and reproductive organs of the mother.

The earlier the PROM occurs before 37 weeks (date considered 37-41 weeks), the more likely spontaneous preterm labor will occur (or the need to induce preterm labor if infection is suspected).

PROM is treated strictly according to obstetric management flowcharts, so transport is always required whenever membranes rupture.

Because ROM typically occurs at or near term, transport is also indicated because of upcoming labor and/or risk of infection; Even if it happens during labour, which is normal, transport is necessary as this is a process that only ends with delivery.

ROM during labor is quite normal

It should be a clear, flaky liquid that has a distinctive sweet odor (once you smell it, it’s recognizable forever).

However, a ruptured membrane that reveals blood or pus indicates a detached placenta (placental abruption) or a serious infection (amnionitis). The odor should never be foul (indicative of infection).


Preterm labor, with or without PROM, carries all of the complications that a preterm baby can experience after birth:

  • hypoxia from undeveloped lungs or persistent fetal circulation,
  • Developmental and mental delays in childhood due to intracranial hemorrhage,
  • Jaundice from immature liver and
  • Blindness from oxygen poisoning from use of artificial respirators.
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Therefore, any contractions or pain before 37 weeks should not be treated as normal labor and constitute an obstetric emergency requiring transport.

This again underscores the need to ask the patient about her due date.


“Braxton Hicks” contractions — disorganized tightening of the uterine muscle that doesn’t dilate the cervix — can occur anytime after 20 weeks of pregnancy and can be quite normal.

They usually don’t last more than a few hours – nothing like every 2-4 minutes seen in active labour.

When in doubt – since active labor is defined as active dilatation of the cervix and not a contraction pattern, labor safety can only be determined by medical evaluation: transport is always the safest option.


The journey of the fetal head through the maternal birth canal is a journey of compression and decompression of the fetal skull.

Because the skull bones are not yet fused like they are in adults, the openings between them (called “sutures”) allow them to give and adjust during this process.

Labor is safest for the fetal skull (and brain) when labor delivers the baby in a controlled, gradual manner.

A steep birth is one in which the descent of the fetus is precipitous.

How fast is too fast? There is no one size fits all answer as the fetal skull is very flexible (as discussed above).

However, any rushed delivery that is so rapid that it exceeds the elasticity of the vaginal tissue and ruptures it is “rushed.”

This is an important detail to be documented so that neurological assessment can be emphasized in the pediatric evaluation of the newborn.

The telltale signs of vaginal tears are visible on a non-invasive (external) examination of the vagina, which reveals bleeding that is distinct from the stage III blood that comes from higher up in the uterus.

(Stage I of labor extends to the time of full dilatation of the cervix; Stage II from full dilation to delivery of the infant; Stage III from delivery of the infant to delivery of the placenta.)


Secondary arrest is birth that has started and then stalled.

It usually occurs with home deliveries where the work has been going on for days.

Some home birth enthusiasts stubbornly follow an agenda of natural processes, even to the point where they refuse medical intervention when abnormalities of labor are evident, such as: B. a secondary birth arrest.

In this situation, the woman’s uterus has exhausted its ability to contract.

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Even in a woman who has had multiple babies (when labor is usually rapid), the cervix typically dilates about 1 cm/hour, so delivery is expected within 12 to 15 hours.

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Longer than this may constitute a secondary arrest and a warrant transport.

Babies are tough, but even they can deplete their energy reserves and cause fetal distress.


MECONIUM is a green-black tarry stool composed of vernix (oily skin), lanugo (fine fetal hair), and other fetal waste structures normally ingested by the fetus during pregnancy.

When a fetus experiences hypoxia, that stress can provoke an attempt to breathe while in the uterus, depressing its diaphragm and pushing stool along its colon through the rectum.

This meconium is very irritating to a baby’s lungs, and if the baby ‘breathes’ it in the womb, it can cause a serious infection of the lungs (called ‘pneumonitis’) at birth.

Rupture of membranes exposing meconium is also an obstetric emergency because it implies fetal distress.

Of course, ROM justifies the transport itself, but meconium is important to be documented so that the baby’s airway can be carefully examined after birth to ensure that the meconium has not entered the lungs, which can cause pneumonia.

Also, such documentation prepares the delivery attendant to aggressively aspirate residual meconium from the nasopharynx before the baby takes his first breath, which would send the meconium deep into the lungs.

Closely related to the topic of meconium is ‘fetal distress’, a term that has been replaced by more specific terms such as ‘fetal bradycardia’, ‘fetal acidosis’ and so on.

(Fetal bradycardia will result in acidosis if left uncorrected.) Fetal bradycardia is a baseline rate < 110 bpm, although the normal variation can sometimes include a transient drop below 110 (no baseline).

There are two ways fetal bradycardia can occur:

  • The unborn child does not have the resilience (reserve) to endure the stress of labor (e.g. small for gestational age infants, placental abnormalities affecting nutrition and oxygenation, placental calcifications – aging of the placenta after birth, and other reasons. As such, meconium is a common co-finding with fetal bradycardia. The bradycardia due to the baby’s inability to tolerate labor will be most pronounced after labor begins when the blood supply is reduced.
  • Maternal hypoxia. The mother is the incubator, and if the incubator is hypoxic, so is her baby.


Any assessment of labor should include a cursory glance to ensure that a coronation is not occurring (the baby’s head is pushing through the vagina).

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However, instead of the fetal head, you can sometimes see a foot or hand protruding from the vagina.

This is called an abnormal “lying” and can show up in all variations of breech presentation.

Many, if not most, cases of abnormal lying are incompatible with a vaginal delivery and can result in a baby becoming stuck in the birth canal, resulting in injury and death; therefore, the sooner the patient is transported, the better.

rupture of the uterus

Rupture of the uterus is the most life-threatening labor-related event that can occur.

If the contractions are too strong and rapid, the thin lower segment of the uterus, which is also distorted by the fetus, can tear.

Tissue scarred from a previous cesarean section is particularly at risk. Ask about a history of a previous cesarean section.

The uterus is a highly vascular organ and rupture represents a hemorrhagic crisis that typically has a high maternal and infant mortality rate.

Pain between contractions can occur with it (as with placental abruption), so any constant pain requires appropriate transport and large-bore IVs, preferably two, to prevent possible massive bleeding.

Alternatively, sometimes with a rupture, the entire uterus becomes slack and visible fetal movement under the mother’s skin becomes evident (the fetus is outside the uterus).

►Call to Action: TRANSPORT

Any contractions in a woman who has had a previous cesarean warrant immediate transport.

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