The Hospital

Giving birth is a natural process but it is still associated with certain risks to you and your baby. Your doctors and nurses will work together with you to provide the least invasive and safest environment possible for you and your baby. Please read the following information regarding the labor and delivery process and certain risks and benefits associated with procedures sometimes used during labor; then, discuss any questions you may have with your doctor.

Spontaneous vaginal delivery. This term refers to normal, natural childbirth. This is our goal for you during your labor. If you desire, we can provide you with different options for pain control including pain medications in your IV, local anesthetic in your perineum or near the pudendal nerves in your vagina, epidural anesthesia, or, in many hospitals, inhaled nitrous oxide. Your anesthesia provider will discuss the risks and benefits of an epidural with you before proceeding if you choose that option. If you do not want any of these things, that is totally fine! Just know that you have options.

Augmentation. In some cases, your labor may become slowed or stop altogether, and it may be necessary to use a medicine called oxytocin (Pitocin). This will make your contractions stronger and closer together. Rarely, this medicine can cause your contractions to become too strong or too close together, which may stress your baby. In almost all cases, this risk is easily manageable and we can decrease the contractions by turning down or turning off the medicine or by using another medicine called terbutaline (Brethine) to stop the contractions in emergencies.

In rare cases, it is necessary to perform an emergency Cesarean section for the safety of the baby. The risks of not using oxytocin to augment a stalled or slowed labor, however, include an increased risk of Cesarean delivery for arrest of labor, an increased risk of an infection in your uterus or your baby, a longer labor, and a risk of maternal exhaustion that leads to more Cesareans or operative deliveries.

Amniotomy. Another method of augmenting your labor is called amniotomy or breaking water. This is done during a vaginal exam with a small plastic hook and benefits include a decreased risk of Cesarean delivery, shorter labors, less need for oxytocin, and the ability to monitor the baby’s heartbeat and your contractions with internal monitors if needed. Risks are very small, but not absent, and include an increased risk of infection, a very small risk of the umbilical cord falling through the cervix requiring emergency Cesarean delivery, and sometimes the plastic hook can leave a small scratch on the baby’s head.

Induction of labor. Sometimes, if labor has not started on its own, it may be necessary to induce labor for the well-being of the baby and/or mother. Induction can be carried out many different ways and depends on several factors, including the reason for induction, your obstetrical history, and your cervical exam. In many cases, induction can be carried out only with oxytocin and/or amniotomy, as discussed above. However, in some cases, the cervix needs to be ripened. Cervical ripening is usually accomplished with medications called prostaglandins, including misoprostol (Cytotec) or dinoprostone (Cervidil), or with balloons placed in the cervix. Like oxytocin, these medications can occasionally make contractions too strong or too frequent, and emergent Cesarean delivery may rarely be necessary because of fetal distress. Overall, however, your risk of Cesarean delivery is higher if these drugs are not used when they are necessary. Some women who might have had a vaginal delivery if her labor started on its own will need a Cesarean delivery after a failed induction attempt, so it is important to discuss with your doctor the specific reasons for induction.

Monitoring. Normally during labor, a nurse will place monitors on your abdomen to measure the frequency of your contractions and to monitor the fetal heartbeat. Occasionally, it is necessary to use monitors placed in the vagina. An intrauterine pressure catheter (IUPC) can be placed through the vagina into a space between the wall of your uterus and the fetal head to measure how strong your contractions are. Insertion of an IUPC is very safe but rarely may cause an infection in your uterus and very rarely may cause bleeding from the placenta or an early separation of the placenta, called an abruption. This can cause stress for the baby and might require a Cesarean delivery. Sometimes a monitor called a fetal scalp electrode (FSE) is placed through the vagina onto the baby’s head in order to more accurately record the baby’s heartbeat. Occasionally, this can cause a small scab on the baby’s head after birth and it may rarely cause a superficial infection on the baby’s head. Fetal monitoring, whether externally or internally, does not prevent cerebral palsy or birth defects. If you are low-risk and in spontaneous labor, you may be a candidate for intermittent monitoring, where the fetal heart rate is listened to every 15 minutes while in labor and every five minutes while pushing, instead of continuous monitoring.

Amnioinfusion. Sometimes, a non-reassuring pattern in the fetal heart tracing can be corrected with a technique called amnioinfusion, where sterile saline is infused through an IUPC into your uterus, relieving pressure off of the umbilical cord. This is associated with an increased risk of infection in your uterus, but may prevent some Cesarean deliveries.

Tears/episiotomy. During birth, many women (reported to be upwards of 80%) get small tears around the vaginal opening and some will get larger tears in the perineum that, in rare cases, may extend into the rectum. Rarely, it is necessary to cut an episiotomy during some emergencies to help you deliver your baby, and cutting an episiotomy carries a greater risk of tears extending into the rectum. Sometimes tears happen in the walls of the vagina or in the cervix. Most of these tears are unavoidable. Some of them will require dissolvable stitches. The areas torn may be swollen and painful for a few days and very rarely these areas may become infected. You may have burning with urination. More severe tears and tears that extend into the rectum are associated with an increased risk of fecal incontinence and pain during intercourse later in life, but most women do not have these problems.

Local anesthetics/pudendal block. Sometimes, if you do not have an epidural or if your epidural does not provide adequate pain relief, it will be necessary to inject a local anesthetic into the area around your vaginal opening in order to repair tears or lacerations. Occasionally, a special injection of local anesthetic near the pudendal nerves just inside your vagina can provide pain relief at the end of your labor. Injection of local anesthetics are associated with rare allergic reactions or injection into large blood vessels could rarely cause an abnormal maternal heartbeat. Very rarely, a serious infection can occur with the placement of a pudendal nerve block. The benefits of local anesthetics or pudendal nerve block include pain relief, and sometimes a pudendal nerve block can allow delivery with a vacuum or forceps that would prevent a Cesarean delivery.

Operative vaginal delivery. About 10% of women require some assistance by the doctor to deliver the baby through the birth canal. This is done either by means of a vacuum-assisted vaginal delivery (VAVD) or forceps-assisted vaginal delivery (FAVD). These types of deliveries may be necessary because of problems with the baby’s heartbeat or because you are unable to push because of a medical problem, fatigue, or if pushing alone has not been enough to deliver the baby. Forceps and vacuums may cause tears in the vagina, cervix, or perineum, including severe tears into the rectum. Both can cause bleeding under the baby’s scalp and very rarely this bleeding can be serious. Forceps can also cause a temporary paralysis of the baby’s facial muscles. Very rarely, this can become permanent, though often this type of facial nerve palsy is due to a developmental abnormality. Vacuums usually cause a bruise and bump on the baby’s head where the plastic suction cup was applied called a chignon. This usually disappears in about a week. Very rarely, a vacuum can cause a tear in the baby’s scalp. Benefits of both types of operative vaginal delivery include a decreased need for Cesarean delivery and the ability to speed up delivery when the baby may be distressed. If, however, a forceps or vacuum delivery is unsuccessful, an emergent Cesarean delivery will be necessary.

Shoulder dystocia. In about 1% of births, the baby’s shoulders do not deliver easily after the head has passed through the birth canal. This is called shoulder dystocia. Your doctor may have to perform several different maneuvers designed to deliver your baby as safely as possible. Shoulder dystocia is associated with a risk of a broken collarbone or arm and sometimes damage to the nerves of the baby’s shoulder can occur either during pushing or during maneuvers to free your baby’s shoulders. This nerve injury, called a brachial plexus injury, is usually temporary and will get better either on its own or with physical therapy. Rarely, the injury is permanent, leading to permanent dysfunction of the affected arm. The baby may also be at risk for brain damage due to a lack of oxygen while the baby is stuck. When injuries to the arm or collarbone occur, it is often because your doctor is trying to prevent permanent injury to your baby’s brain or death. Unfortunately, we cannot predict which babies will have a shoulder dystocia. Risk factors include large babies, mothers who are diabetic or obese, and slow labors combined with the use of forceps or a vacuum. However, in most cases where these factors exist, no shoulder dystocia occurs. What’s more, most shoulder dystocias happen with either only one risk factor or no risk factors present, so we have no reliable way of predicting who will experience this complication. If your baby is very large, your doctor may recommend Cesarean delivery to prevent shoulder dystocia (more than 5,000 grams for most women or more than 4,500 grams for diabetic women).

Placenta. After delivery of your baby, the placenta, or afterbirth, must also be delivered. This usually happens just a few minutes after the delivery of your baby and is rarely associated with problems. The nurse will start oxytocin during this time to help your uterus contract down and prevent unnecessary bleeding after delivery. However, sometimes excessive bleeding does occur, called postpartum hemorrhage. If this happens, your doctors may order additional oxytocin or other medications called uterotonics to help stop the bleeding. Rarely, a blood transfusion is necessary, and this can be associated with an allergic reaction or about a 1 in 2,000,000 chance of serious infections such as Hepatitis C or HIV. You need to tell your doctor if you are unwilling to accept a blood transfusion in order to save your life. In very rare cases of postpartum hemorrhage, as a live-saving measure, it is necessary for your doctor to perform emergency surgery to control the bleeding, and very rarely, this may include performing an emergency hysterectomy.

Sometimes, the placenta does not deliver on its own and your doctor may have to perform manual extraction of the placenta. In this procedure, your doctor will deliver the placenta with her hand placed in your uterus. This increases your risk of an infection in the uterus but decreases the risk of serious bleeding. Very rarely, because the placenta cannot be delivered, it is necessary to perform a D&C (dilation and curettage), where instruments are used, under anesthesia, to detach and remove the placenta from your uterus. This increases your risk of a blood transfusion, as well as your risk of infection, and occasionally the instruments used can perforate your uterus causing damage to the organs around your uterus, such as the bowel or bladder, and your doctor may need to perform emergency surgery to repair these organs.

Infections. Occasionally, an infection may occur while you are in labor, or before labor, particularly if your water has broken. This infection is called chorioamnionitis. Your doctor will start antibiotics if this happens and treat your fever. However, your baby may be born with a serious infection if this occurs. Sometimes, Cesarean delivery is necessary because of stress to your baby. Also, an infection may occur after your delivery called endometritis. This also may require antibiotics. Your doctor will try to limit factors that may put you at risk for infection, but not all infections are preventable.

All of these risks we’ve been discussing are fortunately relatively rare and we are typically good at preventing and treating them when they do occur. The bottom line is, birth is the scariest and happiest thing you’ll ever do. We try everything in our power to make the birth experience a smooth one for you. That being said, we want you to be informed every step of the way.