Class 5: Complications and Intervention

• Class 5 focuses on complications and interventions during doula training and mentorship.

Interventions Overview

• Interventions usually happen because of risk or complication management, induction, augmentation, or pain management.
• Interventions typically occur only in hospitals.

About Pregnancy Complications

• Certain conditions or diagnoses can make a pregnant woman high risk.
• High-risk pregnancies require monitoring by an MD, such as an OB/GYN or MFM.
• Seek a certified nurse midwife (CNM) for a vaginal delivery, as they can collaborate with an MD if needed.

Common Complications

• Hyperemesis Gravidarum (HG) is extreme nausea and vomiting that lasts past the 14th week of pregnancy until delivery.
  • It is caused by hormones and increases the likelihood of dehydration, perinatal depression and nutritional imbalances. Traditional nausea remedies are ineffective, and symptoms usually disappear after pregnancy.
• Placenta Previa is a condition where the placenta covers the cervix, appearing early in pregnancy and usually detected by 20 weeks.
  • It occurs randomly when the placenta implants on any uterine wall and can be caused by past cesareans, scar tissue, or uterine lining issues.
  • It increases the likelihood of hemorrhage or cesarean.
  • If the placenta is low-lying, it may move as the uterus expands, but severe cases may require a cesarean.
• Placental Abruption is when the placenta separates from the uterine wall, causing bleeding and risking the fetus, usually in the third trimester.
  • It increases the likelihood of hemorrhage, preterm delivery, cesarean or NICU.
  • Common causes are severe trauma, high blood pressure, and uterine infection.
  • Partial separations may progress with supervision, but full separations often require urgent delivery.
• Intrauterine Growth Restriction (IUGR) is limited fetal growth during pregnancy; fetuses in the 10th percentile or lower need more monitoring and imaging.
  • It increases the likelihood of low birth weight, preterm delivery or NICU.
  • It is caused by placental issues and requires early delivery to address nutrition via breast milk or formula.
• Gestational Diabetes develops during pregnancy in mothers without prior diabetes.
  • It increases the likelihood of macrosomia, cesarean or NICU.
  • It is caused by insulin resistance, with risk factors like lack of exercise, obesity, poor diet, and family history. -It is managed through glucose testing and diet, but sometimes requires medication.
• Preeclampsia is a condition with high blood pressure, fluid retention, and protein in the urine.
  • It increases the likelihood of preterm delivery, cesarean or NICU.
  • Risk factors include chronic hypertension, obesity, and family history; more common in the black community.
  • Delivery is the only cure, often via induction and low-dose aspirin with risk factors.

Additional Pregnancy Complications

• Rh incompatibility
• Insufficient cervix
• Recurrent UTIs or kidney infections
• Low amniotic fluid, which may also occur during labor.

Additional Labor Complications

• Hemorrhage is the most common labor complication.
• Communicable diseases like genital herpes or HIV.
• Chorioamnionitis
• Cord prolapse
• Shoulder dystocia
• Stillbirth.

Clinical Induction Methods

• Dinoprostone (cervidil) "the tampon"
  • Softens the cervix; Topical and does not affect the baby, but can cause pain and bleeding.
• Misoprostol (Cytotec) "the abortion pill"
  • Softens the cervix; Given in the outpatient setting and causes contractions, but may cause fetal heart decelerations.
• Foley bulb "the balloon"
  • Opens the cervix; Manual and does not affect baby, can be administered in outpatient setting, but is typically painful.
• Pitocin "synthetic oxytocin"
  • Starts or augments contractions; Causes strong, consistent contractions, but contractions are more painful and can cause fetal distress.
• Manual rupture of membranes "breaking the water"
  • Augments contractions/engagement; Relieves uterine pressure and helps the baby descend, but puts the client on a time clock and increases infection risk.

Less-Invasive Induction (Scientifically Proven)

• Nipple stimulation.
• Sex.
• Membrane sweep or cervical checks.
• Castor oil/midwives brew only under midwife direction.

Less-Invasive Induction (Not Scientifically Proven)

• Pineapple.
• Spicy food.
• Eggplant.

Medication During Interventions

• Antibiotics treat infections like GBS or chorio by ridding the birth canal of bacteria, allowing vaginal birth, but requires monitoring and may cause infant digestive issues.
• IV NSAIDs reduce pain in early labor, are safe for the baby, may not be effective in reducing pain and are ineffective in later labor stages.
• IV narcotics reduce contraction pain and pressure temporarily, but cross the placenta so the baby needs to be monitored postpartum.
• Epidurals minimize contractions, making the client comfortable and able to sleep, but can stall labor, reduce mobility and not reduce pressure.
• General anesthesia is used during cesareans only and puts the patient in full sedation in emergency situations, ensuring patient tolerance, but causes aspiration risk and blocks the patient's birth experience.

Standard Interventions During Labor

• Many hospital recommendations during labor are interventions in disguise that can lead to additional interventions called "the cascade of interventions."
• Starting an IV requires knowing if the client is dehydrated or requested it, because it can lead to pushing fluids, narcotic pain meds, and epidural use.
• Fetal monitoring requires knowing if the fetus shows signs of stress, because it can lead to too much information, provider anxiety, maternal anxiety, stationary labor, lack of maternal mobility, and lack of progress.
• Cervical exams should only occur if the client requests it, as it can lead to membrane rupture, being rushed, and augmentation.
• Pitocin may be used to deliver placenta/early postpartum if the client has hemorrhage risks.

Assisted Deliveries

• Assisted deliveries use tools or maneuvers to help deliver the baby, including forceps, vacuum extraction, excessive force and episiotomy.
• It is recommended in order to prevent a cesarean delivery if it is needed.

Avoiding Intervention: Labor Preparation

• Throughout pregnancy, do stretching/prenatal yoga and maintain regular care with the prenatal care network, including chiropractic care, pelvic floor therapy, and acupuncture.
• Beginning at 36 weeks, there are Miles Circuit, curb walking, prostaglandins/cervical ripeners, 6 dates a day, semen, and evening primrose oil use (oral and suppository).

Things to Consider

• How your own biases might show up when educating clients about interventions.
• Review and memorize the Miles Circuit at www.milescircuit.com
• Research shoulder dystocia and the doula role in this type of delivery.