Labor Complications and Interventions

What is a labor complication or intervention?

Woman in Labor
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There are times when things do not go as nature intended and complications arise. This is to say that either mom or baby is having a problem with the pregnancy or labor/birth. At that point intervention, be it a medication, a procedure, or surgery, might be employed to make pregnancy/birth easier, less complicated or safer for both mom and baby.

While no one really plans on needing intervention or having complications, there are times and places where problems arise, even when you've take really good care of your body and had supreme care. The good news is that much of what might go wrong in labor is predictable in early pregnancy.

Interventions are sometimes necessary because of complications, however, they are more likely to be used as a matter of policy, either from your place of birth or your practitioner. For example, the use of an IV or fetal monitoring typically falls into this category. Intervention is not always a bad thing, despite the negative connotation it may have.

In fact, you may be willing to accept certain interventions in exchange for things like an epidural. The IV, continuous fetal monitoring, and extra maternal monitoring are done to help monitor you and the baby for potential negative reactions to the epidural.

We will address some of the more common complications and interventions that can arise later in this class.

IV, Enema, Catheter

Pregnant women in hospital with IV
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IV/Saline Lock

The IV line is designed to admit a small catheter into a vein, usually in your arm. This allows for the rapid introduction of medications or fluids, should it be needed in an emergency situation. A saline lock (or Heparin lock) is the start of this catheter with no tubing attached so that only the first portion of the IV is in place. This allows more freedom of movement and mobility.

These may be routine at your hospital or birth center. Ask. You may have the ability to choose the lock over a standard IV line, or if you're low risk you may have the option to forgo this all together. This should be addressed in your birth plan.

An IV line will be required for those who are high risk or request medication. You do have the right to ask about the placement and choose a site that is better for you comfort. For example, having it placed in the arm rather than the back of the hand may allow you a bit more flexibility in the wrists.


Catheters are inserted into the bladder to help drain urine. A full bladder can prevent the descent of the baby, so it is important to be able to have an empty bladder.

If you choose to have epidural anesthesia or require a cesarean birth, a urinary catheter will be used because you will not be able to have the sensation of a full bladder. The catheter will allow your bladder to remain empty without effort on your part.


The shaving of the pubic hair was once thought to prevent infection, this is untrue. If you're concerned you can trim the hairs towards the perineum or shave yourself prior to having the baby.

The enema was to help you pass all the stool in your bowel. Since we know that labor tends to start out with loose bowels, this is generally not needed. It can also be quite uncomfortable and lead to dehydration.

Fetal Monitoring

Woman on the electronic fetal monitor in labor
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Fetal Monitoring

Fetal monitoring usually calls to mind a woman in bed with monitoring straps around her waist and several people staring at a machine that prints out the numbers of the contractions and the baby's heartbeat. However, that is but one way to monitor baby during labor.

The American College of OB/GYNs states that low-risk women do not need constant fetal monitoring. They also say that monitoring can just as effectively be done by a human being as a machine. They suggest a reactive strip upon arrival at the birth place or arrival of the attendant. This means that the baby is doing well and responding to the contractions with the appropriate accelerations in heart rate. Then they suggest that the baby be "checked" 15 minutes out of every hour during the first stage of labor and 5 minutes out of every 15 minutes during the second stage (pushing).

Types of Monitoring:

It is critical that you discuss monitoring with your practitioner and address the issue in your birth plan. If you prefer to maintain your mobility then continuous monitoring will make that harder to achieve. You may not have even known that you had options.

For those who have a high-risk situation or who develop complications during the monitoring period, a form of continuous monitoring will be implemented. The external monitor works by ultrasound and is less accurate than an internal monitor. There are increased risks with using the internal monitors, but they are more accurate. The increased risks include increased risk of infection, fetal laceration from probe, etc. It is also important to note that the bag of waters must be broken to allow internal monitoring.

Amniotomy and Episiotomy

Amniohook - Induction Breaking Water
Amnihook. Photo © Robin Elise Weiss


This is the artificial rupture of membranes. It is supposedly done to "speed up" labor, though most studies say that this is not true for most women. Much of the time your water will break past nine centimeters. Amniotomy may also be used to assess if the baby has passed meconium or to allow the insertion of internal monitoring.

It is done by placing an amnihook (looks very similar to a long crochet hook) inside the vaginal during a vagina exam and scratching the bag until it ruptures.

Drawbacks to this can include:

  • Increased risk of infection
  • Lack of cushion for the baby's head
  • Slim risk of cord prolapse (life threatening emergency)
  • Increased intervention, and limited mobility

There are other ways to speed labor, including walking, nipple stimulation, position changes, etc. Amniotomy may also be used as an induction technique.


This is the surgical cut in the perineum to enlarge the area to allow the baby to pass. Recent studies have shown that this is usually not necessary and can actually cause more problems than it prevented.

Most studies agree that rates of episiotomy above about 10 re excessive. Many state that times small cuts that are made actually lead to an increase in larger tears (3rd and 4th degree), greater risk of infection, and a longer and more painful recovery.

Episiotomies should be saved for complications such as fetal distress, to angle a cut or tear, etc. Talking to your practitioner about your feelings and theirs will help you in finding the path that is right for you.

There are many things that can be done to prevent the need for an episiotomy and tearing, including positioning, massage of the perineum (both prenatally and during the birth), a slow, controlled pushing stage, and practitioner manipulations.

Hospital Policy, Interventions and Medications for Birth

Couple in hospital hall on tour
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Other Hospital Policies

There maybe other interventions or policies that are specific to your practitioner or place of birth. Be sure to take a tour and inquire about any such policies. Knowing about these policies ahead of time can help you make changes to your plans or encourage them to make changes for you. Examples might be:

Dealing with Interventions

While an intervention may not be what you had envisioned, remember to get informed consent. Always ask specific questions about the proposed intervention, including why it is being done, alternatives, risks, benefits, and what happens if you choose to not do anything. Satisfaction with birth is not about it going according to plan, but rather that you felt in control of the decisions being made.

What types of medications are used in labor?

  • Analgesia: This describes a medication that is used to alter your perception of the pain or remove the pain without causing numbness. Examples would be Nubain, Demerol, Stadol, Tylenol, etc.
  • Anesthesia: This describes a medication used to remove feeling. This can be a regional anesthetic like an epidural or spinal, or a local anesthetic like an injection of Lidocaine in your perineum for a repair of a laceration or episiotomy. This can also include general anesthesia which will also result in the loss of consciousness. Though use of general anesthesia for childbirth is fairly rare, it does occasionally occur in extreme cases mostly emergencies.

IV Medications

Woman in Labor
Photo © Charles Gullung/Getty Images

IV medications are usually given via the intravenous line, but can also be given by regular injection, depending on the medication.

These medications have been used for a long period of time for labor and birth. However, timing of these medications are critical because you want there to be a time interval between when these medications are given and when the baby is born to help prevent breathing difficulties at birth.

IV pain medications take effect more quickly that medications like the epidural, but do not remove pain, rather they alter your perception of the pain. They can help promote relaxation or even sleep. Their use can also be combined with epidural anesthesia for the very anxious mother.

Common Medications Used

  • Stadol
  • Demerol
  • Nubain

Pain relief for childbirth has run the gamut over the ages. And the battle is still being fought today. Should a woman have medications or not during birth is not a question that I anticipate an answer for anytime soon. However, some women will choose medication and some will require it for surgical deliveries and complications. Let's just all be thankful that we are no longer buried alive for accepting pain relief in labor as was done in the middle ages.

Forceps and Vacuum Extraction

Vacuum Extractor
Vacuum Extractor. Photo © Robin Elise Weiss

Using something like forceps and vacuum extraction is a fear of nearly every parent. Certain positions or medicines may make it more likely to be needed.


There are several shapes and sizes of forceps, but they do look remarkably similar to salad tongs. These are slipped, one at a time, inside the mother's body and then locked around the baby's skull. The practitioner will then pull with the mother's pushes.

Forceps are used in a graded system: high, mid, and low or outlet forceps. When you hear of the forceps horror stories it was usually from the high forceps, which has now nearly universally been replaced by cesarean section.

Mid forceps has mostly been replaced by the use of vacuum extraction and cesarean, leaving only low or outlet forceps to be used.

Forceps have different properties than the vacuum extractor:

  • Can be used to turn a baby in a different position (i.e. posterior, etc.)
  • Can cause more trauma to mother's tissues
  • Can cause less trauma to baby

Vacuum Extraction

Vacuum extraction is a cup-like device that is either attached to a suction device on the wall or by a manual suction pump. It is placed on the back of the baby's head and the suction is increased so that the practitioner pulls with the mother's pushes.

Vacuum extractors have different properties than the forceps:

  • Can be used higher than forceps
  • Can cause less trauma to mother's tissues
  • Can cause more trauma to baby

Medications for Forceps & Vacuums

If you do not have an epidural in place your practitioner will probably use either a pudendal block. This is given by injecting medication through the vagina near the pudendal nerves. This takes effect quickly and is very effective at blocking the pain of the procedure, while still allowing the mother to push.

Epidural Anesthesia and The Walking Epidural

Nurse holds a laboring woman during epidural procedure
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This article will actually focus on a particular aspect of pain relief in labor, the ultra low dose epidural, frequently called the walking epidural.

Q. What is the difference between the walking epidural and the regular epidural?

A. The differences lie in both the procedure and the medications used. The walking epidural is a combination of spinal and epidural analgesia. While the medications, often referred to as a cocktail, are a narcotic, a local anesthetic and epinephrine, used in smaller amounts than the regular Epidurals. (See Procedure.)

Q. If I can walk, what can I feel?

A. The walking epidural is not designed to make you feel deadened. It is designed to provide enough pain relief that you are comfortable and yet still aware of the contractions.

Q. Can I really walk?

A. This really depends, women receiving the walking epidural will not be able to walk for the following reasons: woman refuses (15-25%), leg weakness (often described as not feeling normal), and maternal hypotension (low blood pressure). Some facilities do not allow you to walk.

Q. Why would I want to walk in labor?

A. Ambulation and mobility promote contractions and therefore labor, decrease pain, shorten labor, and increase the vaginal delivery rate. This type of medication will actually give her more control over her body as opposed to the classic epidural.

Q. What about extra interventions or complications from the walking epidural?

A. Every medication that you take will reach the baby and have potential side effects on you, labor and your baby. These are comparable to the classic epidural.

Q. What if I need more medication or a cesarean birth?

A. The catheter is left in place in your back so that additional medication could be administered for either additional pain relief or a surgical birth.

Cesarean Section

Cesarean section being performed
Photo © Steve Debenport/Getty Images

Reasons for a Cesarean Birth

With more than 32% of women giving birth in the United States via cesarean section, it's important to cover this topic.

The most common reasons for cesarean section are listed below, some are absolute and others are not.

The Procedures:

Some of these may go in a different order but these are the basics of a cesarean section:

  • Pre-operative medications like an antacid
  • Monitoring leads (yours and baby's)
  • Anesthesia
  • A catheter inserted
  • Wash and Clip hair
  • Skin Incision
  • Uterine Incision
  • Breaking the Bag of Waters
  • Disengage the baby from the pelvis
  • Birth!
  • Cord Clamping and cutting
  • Placenta removed & uterus repaired
  • Skin Sutured
  • Recovery Room

Pain Relief for the Surgery

You have a few options here: spinal anesthesia, epidural anesthesia (both regional blocks) or general anesthesia. Epidurals and spinals are the most common form of anesthesia for the cesarean delivery. Typically the epidural is used if it is already in place. However, in the planned cesarean, many women are given spinal anesthesia. General anesthesia is used mostly in emergency situations.

Pain Relief After the Surgery

Duramorph is often placed through the spinal or epidural catheter, right before it is removed and is generally good pain relief for 16-24 after delivery.

Other options include: Patient controlled analgesia (PCA), where your IV is attached to a machine that will alert you when you can have more IV medications and you can then take it at will. You have the option of oral pain medications, usually at 4-hour intervals. And, less frequently used, are intramuscular injections.

Emotional Relaxation in Labor

Yoga Class While Pregnant
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We've talked about a lot of different possibilities this week. Some you may find frightening or prefer not to think about at all. However, you've learned that education is a key to overcoming fear.

Doing a relaxation exercise that focuses on the emotional aspects of labor can be very beneficial, particularly if you're feeling tense. This week is the perfect time to introduce this topic.

By helping your partner into a relaxed state using the previously learned techniques, you can begin to help her emotionally relax by using verbal and physical cues. Be reassuring of her choices, the decisions she has made up until this point. Remind her that her flexibility in times of change is a good thing.

Remember that how she feels about labor emotionally can and will affect her body's ability to give birth. A fearful woman will not dilate.

By utilizing touch to ensure your constant presence she never feels alone. By using your voice, she can always hear you. There is also some pretty convincing evidence that smells are very important because our olfactory senses are in over drive. So a favorite lotion or scent might be very familiar feeling as well.

Protecting her environment is an absolute must. The key to doing this in labor is to model the behavior you want others to do. Be quiet. Keep the lights low. Be respectful of her at all times, and not allowing distraction when she needs to focus (like during a contraction).

During your practice sessions use this exercise to discuss the worries that you both have and how you can overcome them. By allowing yourselves time to have these feelings they can lessen the fearful intensity. Reminding her that her hard work and planning will pay off and she will have the positive birth that she needs, even when things might not go as planned.

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