October 31, 2024 Vaginal delivery In a vaginal delivery, the following are among the assisting doctor objectives: Reduce the risk of trauma to the mother perineum ; Reduce the risk of fetal injur y. To achieve it is necessary in some case to help the fetus descend into the birth canal and the obstetrician can use specific instruments that adapt to the fetal head - the vacuum extractor and the forceps. Common indications for an assisted vaginal delivery are : Maternal indications: heart disease, situations in which straining should be avoided; Protracted expulsion period; Suspected fetal distress; Maternal exhaustion. The safety of these methods is demonstrated, and they do not contribute in any way to changes in children neurological development. Around 5% of pregnant women who had an assisted vaginal birth will have another one. Complications associated with vaginal delivery Maternal complications The more complex the procedure, the greater the maternal morbidity. Thus, normal vaginal delivery is associated with the lowest morbidity, followed by assisted vaginal delivery with vacuum extractor or forceps and cesarean sections. Lacerations : Between 40%-85% of women with a vaginal delivery will have some type of tear. However, severe lacerations (with anal sphincter involvement) are very rare, occurring in 2% of vaginal delivery, 10% of vacuum extractor deliveries, and 17%-20% of forceps deliveries. Episiotomy . Vulvar and vaginal bruises . Postpartum bleeding , which occurs in 5%-10% of births. Pelvic organ prolapse , due to weakening of the pelvic muscles, which can affect up to 20% of women with vaginal births. Urinary or fecal incontinence , due to damage to the muscles, sphincter and nerves during childbirth, which can be temporary (15%-30%) or permanent (5%-10%). Infection of the uterus, perineum or bladder , which affects 1%-3% of postpartum women. Baby complications Trauma , such as scalp wounds, eye trauma, cephalohematoma (1%-2%), intracranial hemorrhage, facial nerve damage, skull fracture, and fetal death. Shoulder dystocia : in 1% of births, the baby's shoulders can become trapped after the head comes out, which can cause clavicle fractures (0.5%-1%) and injuries to the brachial plexus nerves (0.1 %-0.2%). Aspiration of meconium (2%-5%), which can cause respiratory problems. Cesarean section In a cesarean section, the fetus is extracted through an abdominal incision . The most common obstetric indications for cesarean section are : Non-progression of dilation or descent of the fetus into the birth canal; Suspected fetal distress; Anomalous presentations such as fetuses sitting or in a transverse position. Other clinical indications include : Placental anomalies, such as placenta previa, placenta accreta, vasa previa; Maternal infection with high risk of fetal transmission during a vaginal birth; Umbilical cord prolapse; Fetal macrosomia suspicion; Mechanical obstruction, for example, due to myoma or history of trauma to the pelvis; History of uterine rupture or uterine surgery; Cervical or vaginal carcinoma; Diseases of the anal region such as fistula or fecal incontinence; Risk of retinal detachment, for example, in pregnant women with low vision. There are no absolute contraindications to a cesarean section. However, the risks and benefits for the mother and fetus and the timing of an elective cesarean section (without labor) must be considered. Cesarean sections performed before 39 complete weeks are associated with higher rates of respiratory distress syndrome and a higher rate of adverse events in the newborn. Complications associated with cesarean section The main non-anesthetic maternal complications of a cesarean section are: Surgical site infection ; Bleeding ; Pelvic organ injury ; Thromboembolism . Cesarean sections during labor are associated with higher complication rates than elective cesarean sections. Surgical wound complications ( infection, hematoma, seroma, dehiscence): complicate 1%-2% of cesarean sections. Scar infections appear 4-7 days after surgery. Bleeding : On average, a pregnant woman loses around 1 liter of blood during a cesarean section. Routine use of oxytocin reduces postpartum losses and the risk of bleeding, but 2%-4% of pregnant women will require a blood transfusion. Pelvic organ injury (eg, bladder, intestine, ureter): the risk is almost 0.5% in a first cesarean section. Venous thromboembolism : the probability at any time in the 6 months after a cesarean section is 2 to 3 times higher than that of a vaginal birth and is around 240 cases per 100 thousand births. Maternal mortality is rare in developed countries (13 out of 100 thousand births in the USA and 22 out of 100 thousand births in the Netherlands) and is associated in a third of cases with postpartum hemorrhage. Other complications include ileus, thrombophlebitis of the pelvic vessels, increased risk of postpartum depression, but also neonatal complications, such as trauma associated with difficult extractions or emergent cesarean sections (1%-3%). Having a cesarean section in the past increases the risk, in a new pregnancy, of: Placenta disorder (placenta accreta, placenta previa); Premature placental abruption; Uterine rupture. It also increases the risk of isthmocele (a defect in the uterine wall that can cause blood loss), lack of sensitivity around the cesarean scar, endometriosis of the scar, incisional hernia, pelvic adhesions and intestinal obstruction. This content was prepared by the Gynecology-Obstetrics team at Hospital da Luz. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
