Birth Complications with Diabetes
The problems that can occur in labour may be a complication of childbirth or the result of a disorder in the pregnancy. The following are common causes of problems in labour.
High blood pressure (hypertension)
One in 20 of the women who experience high blood pressure during pregnancy has had long-term hypertension before the pregnancy started. This condition requires careful management because it increases the risk of preeclampsia and placental abrupt ion (see below).
A rise in blood pressure, combined with swollen face, hands, wrists, feet and ankles, and protein in the urine (when there is no urinary tract infection) indicate a pregnancy condition called preeclampsia. This usually occurs in the final three months of the pregnancy and is diagnosed when the lower figure in a blood pressure reading rises by 15-20 or goes above 90. Preeclampsia is more common in older women and first-time mothers, and is monitored closely since it increases the risk of placental abrupt ion and may develop into eclampsia. Bed rest is advised and a low dose of aspirin may be given.
Regular antenatal checks mean that preeclampsia turns into eclampsia in only one in 2000 pregnancies. This strikes quickly and causes convulsions (fits) and a coma. Apart from the risk of injury and even a heart attack, the mother and her unborn baby may be starved of oxygen. Warning signs include a sharp rise in blood pressure, increased protein in the urine, headache, drowsiness, visual disturbance and nausea. Anticonvulsant drugs are given and a Caesarean is usually performed if the baby isn’t yet born.
Pregnancy increases the body’s demand for insulin and this activates diabetes in two per cent of women. Gestational diabetes is treated by diet or insulin injections. It can accelerate fetal growth, and labour may need to be induced if the baby becomes too large.
Rupture of the amniotic sac
The waters usually break just before, or during, labour, but in one in 14 women this happens too soon. Immediate medical advice is needed as the rupture leaves the baby vulnerable to infection and may stimulate contractions. If labour does not begin within 24-48 hours, it is induced.
A baby born before 37 weeks is said to be preterm or premature. Babies born after 32 weeks generally do well, but before this infants may have difficulty breathing. Premature babies are at increased risk of jaundice and may have an infection if the early delivery was caused by rupture of the amniotic sac.
Abnormalities in the heart rate or the presence of fresh meconium are warnings that the baby may not be getting enough oxygen and is in distress. Diagnosis can be confirmed by taking a small blood sample from the scalp. Continued oxygen deprivation causes brain damage, so a decision is usually made to perform a Caesarean or to deliver the baby quickly using forceps or a ventouse.
One in three babies lies in the womb in a breech (bottom first) position at 30 weeks, but most of them turn spontaneously and only 4 per cent remain in it by the due date. It may be possible to turn the baby by manipulating the abdomen in the last few weeks, but this can be uncomfortable and one in ten babies returns to the breech position. Acupuncturists say they can sometimes turn a breech baby by burning moxa, a herb, on certain acupuncture points. Vaginal delivery of a breech baby is possible, but increasing Caesarean rates mean fewer midwives and doctors have experience in delivering breech babies in this way.
Occasionally a section of umbilical cord slips out of the uterus in front of the baby. This is more likely to occur in a breech presentation, premature labour or multiple pregnancy.
Prolapse is very dangerous since the cord may be compressed, cutting off the fetal oxygen supply. If this happens, the mother is given oxygen to maximize the baby’s supply.
If the prolapse occurs during the first stage of labour, an emergency Caesarean is usually performed. If it happens in the second stage, the baby’s position determines whether it will be delivered using forceps or by Caesarean.
Placenta praevia, a low-lying placenta, occurs in one in 200 pregnancies and is more common in older mothers. It can cause bleeding and there is an increased risk of haemorrhage. Depending on the position of the placenta, a vaginal delivery may be possible. However, if the placenta is blocking the cervix, a Caesarean is performed.
In one in 120 pregnancies, the placenta begins to break away from the wall of the uterus before the baby is born. Symptoms include vaginal bleeding, backache and reduced fetal movement. Abruption can cause poor fetal growth and stillbirth, and blood loss in the mother may mean she will need a blood transfusion. The labour may need to be induced or a Caesarean delivery carried out. If placental abruption occurs in the first six months of pregnancy, the death of the fetus is inevitable.
If you think the baby is coming too quickly, call the midwife, maternity unit or GP for guidance. If it appears that the baby may arrive before there is time to reach hospital, call 999 for an ambulance – do not drive yourself. If you are on the way to hospital, the driver should pull over at a safe point, make you comfortable and call 999, giving the exact location and car registration number. If you don’t have a mobile phone, flag down another motorist; the mother should never be left alone.
CARE FOR THE NEW BABY
Provided the baby is making some effort to breathe, it is cleaned, weighed and checked for any obvious signs of abnormality. Details of the delivery, time of birth and any drugs given to the mother are recorded, and, in hospital, name bands are placed on the baby’s hand and ankle.
Medical staff perform a range of physical checks on newborns, including measuring the skull. The baby’s condition is assessed a minute after birth, using the Apgar score so the baby can be given attention if needed. An injection or oral dose of vitamin K may be given. Vitamin K is essential for blood clotting and is given to babies at increased risk of bleeding, such as those born prematurely or with the help of instruments. Many paediatricians believe all babies benefit from vitamin K supplements so some hospitals offer it routinely. The parents are asked for their permission and are given a second oral dose to be administered to their baby four weeks later.
Newborn babies are vulnerable to cold. In the womb they enjoy a constant temperature of 37.7°C (99.9°F), while the average delivery-room temperature is 21°C (69.8°F). Evaporation of amniotic fluid (see above) on the baby’s skin contributes to heat loss. Because of this, the baby should be dried as quickly as possible and wrapped in a warmed sheet. The head should be covered to prevent further heat loss.
Most babies breathe within a minute of the birth; if this does not happen the midwife uses suction to clear the airways. A stream of oxygen over the baby’s face may prompt a reflex gasp; if this fails, the baby needs assisted ventilation.
CARE FOR THE MOTHER
After the birth a nurse or midwife will take the mother’s blood pressure at regular intervals. You will be asked about the amount and consistency of blood loss and have your abdomen palpated – felt firmly – to make sure that your womb is contracting. If you have been given any stitches they will be checked to ensure that they are healing properly. The mother is usually encouraged to put the child to her breast as early as possible, to encourage the early production of milk.