Childbirth, labour, delivery, birth, partus, or parturition is the culmination of a pregnancy period with the expulsion of one or more newborn infants from a woman's uterus.
The process of normal childbirth is categorized in three stages of labour: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta.
In many cases and with increasing frequency, childbirth is achieved through induction of labor or caesarean section, which is the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.
Childbirth by C-Sections increased 50% in the U.S. from 1996 to 2006, and comprise nearly 32% of births in the U.S. and Canada. With respect to induced labor, more than 22% of women undergo induction of labour in the United States.
Medical professional policy makers find that induced births and elective cesarean can be harmful to the fetus and neonate as well as harmful or without benefit to the mother, and have established strict guidelines for non-medically indicated induced births and elective cesarean before 39 weeks.
One small study found that middle-eastern women, especially those with a low educational background, had more painful experiences during childbirth.
Pain is only one factor of many influencing women's experience with the process of childbirth. A systematic review of 137 studies found that personal expectations, the amount of support from caregivers, quality of the caregiver-patient relationship, and involvement in decision making are more important in women's overall satisfaction with the experience of childbirth than are other factors such as age, socioeconomic status, ethnicity, preparation, physical environment, pain, immobility, or medical interventions.
The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the rectum. The infant's head and shoulders must go through a specific sequence of maneuvers in order to pass through the ring of the mother's pelvis.
Six phases of a typical vertex (head-first presentation) delivery:
The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.
There are several factors that midwives and physicians use to assess the labouring mother's progress, and these are defined by the Bishop Score.
The Bishop score is also used as a means to predict whether the mother is likely to spontaneously progress into second stage (delivery).
Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. The presenting fetal part then is permitted to descend.
Full dilation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.
The duration of labour varies widely, but active phase averages some 8 hours for women giving birth to their first child ("primiparae") and shorter for women who have already given birth ("multiparae").
Active phase arrest is defined as in a primigravid woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, which plots the typical rate of cervical dilation and fetal descent during active labour. Some practitioners
may diagnose "Failure to Progress", and consequently, perform a Cesarean.
At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the pelvic inlet. The fetal head then continues descent into the pelvis, below the pubic arch and out through the vaginal introitus (opening). This is assisted by the additional maternal efforts of "bearing down" or pushing. The appearance of the fetal head at the vaginal orifice is termed the "crowning". At this point, the woman may feel a burning or stinging sensation.
Complete expulsion of the baby signals the successful completion of the second stage of labour.
The second stage of birth will vary by factors including parity,
fetal size, anesthesia, the presence of infection. Longer labours are
associated with declining rates of spontaneous vaginal delivery and
increasing rates of infection, perineal laceration, obstetric
hemorrhage, as well as need for intensive care of the neonate.
The umbilical cord is routinely clamped and cut in this stage. General hospital-based obstetric practice introduces artificial clamping as early as 1 minute after the birth of the child. In birthing centers, this may be delayed by 5 minutes or more, or omitted entirely. Clamping is followed by cutting of the cord, which is painless due to the absence of nerves.
Placental expulsion begins as a physiological separation from the wall of the uterus. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10–12 minutes dependent on whether active or expectant management is employed In as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta.
Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance. Active management is described as the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, and performance of uterine massage every 15 minutes for two hours afterward.
In a joint statement, World Health Organization, the International Federation of Gynaecologists and Obstetricians and the International Confederations of Midwives recommend active management of the third stage of labour in all vaginal deliveries to help to prevent postpartum hemorrhage.
When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact. This is referred to as "delivery en caul." The caul is harmless and its membranes are easily broken and wiped away. With the advent of modern obstetrics, artificial rupture of the membranes has become common, so babies are rarely born in the caul.
Mothers are often allowed a period where they are relieved of their normal duties to recover from childbirth. The length of this period varies. In many countries, taking time off from work to care for a newborn is called "maternity leave" or "parental leave" and can vary from a few days to several months.
Health conditions that may warrant induced labour or C-sections include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and post-term pregnancy. Cesarean section too may be of benefit to both the mother and baby for certain indications including maternal HIV/AIDS, Foetal abnormality, breech position, foetal distress, multiple gestations, and maternal medical conditions which would be worsened by labour or vaginal birth.
Oxytocin is the most commonly used agent for induction in the United States, and is used to induce uterine contractions. Other methods of inducing labour include stripping of the amniotic membrane, artificial rupturing of the amniotic sac (called amniotomy), or stimulation of the nipples of one breast. Ripening of the cervix can be accomplished with the placement of a Foley catheter or the use of synthetic prostaglandins such as misoprostol. A large review of methods of induction was published in 2011.
The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks (full term) of gestation for optimal health of the newborn when considering elective induction of labour. Per these guidelines, the following conditions may be an indication for induction, including:
The ACOG also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including vasa previa, complete placenta praevia, umbilical cord prolapse or active genital herpes simplex infection.
Water birth is an option chosen by some women for pain relief during labour and childbirth, and some studies have shown waterbirth in an uncomplicated pregnancy to reduce the need for analgesia, without evidence of increased risk to mother or newborn. Hot water tubs are available in many hospitals and birthing centres.
Meditation and mind medicine techniques are also used for pain control during labour and delivery. These techniques are used in conjunction with progressive muscle relaxation and many other forms of relaxation for the mind and body to aid in pain control for women during childbirth. One such technique is the use of hypnosis in childbirth. There are a number of organizations that teach women and their partners to use a variety of techniques to assist with labour comfort, without the use of pharmaceuticals.
A new mode of analgesia is sterile water injection placed just underneath the skin in the most painful spots during labour. A control trial in Iran of 0.5mL injections was conducted with normal saline which revealed a statistical superiority with water over saline.
Popular medical pain control in hospitals include the regional anesthetics epidural blocks, and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. Generally, pain and cortisol increased throughout labour in women without EDA. Pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but may rise again later. Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.
There is increasing evidence to show that the participation of the
child's father in the birth leads to better birth and also post-birth
outcomes, providing the father does not exhibit excessive anxiety. Research also shows that when a labouring woman was supported by a female helper such as a family member or doula
during labour, she had less need for chemical pain relief, the
likelihood of caesarean section was reduced, use of forceps and other
instrumental deliveries were reduced, there was a reduction in the
length of labour, and the baby had a higher Apgar score
(Dellman 2004, Vernon 2006). However, little research has been
conducted to date about the conflicts between partners, professionals,
and the mother.
Shoulder dystocia is a dystocia in which the anterior shoulder of the infant cannot pass below the pubic symphysis or requires significant manipulation to pass below it. It can also be described as delivery requiring additional manoeuvres after gentle downward traction on the head has failed to deliver the shoulders.
A prolonged second stage of labour is another type of dystocia whereby the fetus has not been delivered within three hours in a nulliparous woman, or two hours in multiparous woman, after her cervix has become fully dilated.
Synonyms for dystocia include difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, and dysfunctional labour.
Infection remains a major cause of maternal mortality and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of puerperal fever and saved many lives.
Hemorrhage, or heavy blood loss, is still the leading cause of death of birthing mothers in the world today, especially in the developing world. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated. Blood transfusion may be life saving. Rare sequelae include Hypopituitarism Sheehan's syndrome.
The maternal mortality rate (MMR) varies from 9 per 100,000 live births in the US and Europe to 900 per 100,000 live births in Sub-Saharan Africa. Every year, more than half a million women die in pregnancy or childbirth.
The process of normal childbirth is categorized in three stages of labour: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta.
In many cases and with increasing frequency, childbirth is achieved through induction of labor or caesarean section, which is the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.
Childbirth by C-Sections increased 50% in the U.S. from 1996 to 2006, and comprise nearly 32% of births in the U.S. and Canada. With respect to induced labor, more than 22% of women undergo induction of labour in the United States.
Medical professional policy makers find that induced births and elective cesarean can be harmful to the fetus and neonate as well as harmful or without benefit to the mother, and have established strict guidelines for non-medically indicated induced births and elective cesarean before 39 weeks.
Signs and symptoms
Pain levels reported by labouring women vary widely. They appear to be influenced by fear and anxiety levels, experience with prior childbirth, cultural ideas of childbirth and pain, mobility during labour and the support given during labour.One small study found that middle-eastern women, especially those with a low educational background, had more painful experiences during childbirth.
Pain is only one factor of many influencing women's experience with the process of childbirth. A systematic review of 137 studies found that personal expectations, the amount of support from caregivers, quality of the caregiver-patient relationship, and involvement in decision making are more important in women's overall satisfaction with the experience of childbirth than are other factors such as age, socioeconomic status, ethnicity, preparation, physical environment, pain, immobility, or medical interventions.
Descriptions
Pain in contractions has been described as feeling like a very strong menstrual cramp. Midwives often encourage refraining from screaming but recommend moaning and grunting to relieve some pain. Crowning will feel like intense stretching and burning. Even women who show little reaction to labour pains often show a reaction to crowning.Vaginal birth
Because humans are bipedal with an erect stance and have, in relation to the size of the pelvis, the biggest head of any mammalian species, human fetuses and human female pelvises are adapted to make birth possible.The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the rectum. The infant's head and shoulders must go through a specific sequence of maneuvers in order to pass through the ring of the mother's pelvis.
Six phases of a typical vertex (head-first presentation) delivery:
- Engagement of the fetal head in the transverse position. The baby's head is facing across the pelvis at one or other of the mother's hips.
- Descent and flexion of the fetal head.
- Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby's face is towards the mother's rectum.
- Delivery by extension. The fetal head passes out of the birth canal. Its head is tilted forwards so that the crown of its head leads the way through the vagina.
- Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.
- External rotation. The shoulders repeat the corkscrew movements of the head, which can be seen in the final movements of the fetal head.
The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.
First stage: dilation
The first stage of labour (or "active phase of first stage" if previous phase is termed "latent phase of first stage") is generally defined as starting when the effaced (thinned) cervix is 3 cm or 4 cm dilated. Women may or may not have active contractions before reaching this point. Rupture of the membranes or a bloody show may or may not occur at or around this stage.There are several factors that midwives and physicians use to assess the labouring mother's progress, and these are defined by the Bishop Score.
The Bishop score is also used as a means to predict whether the mother is likely to spontaneously progress into second stage (delivery).
Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. The presenting fetal part then is permitted to descend.
Full dilation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.
The duration of labour varies widely, but active phase averages some 8 hours for women giving birth to their first child ("primiparae") and shorter for women who have already given birth ("multiparae").
Active phase arrest is defined as in a primigravid woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, which plots the typical rate of cervical dilation and fetal descent during active labour. Some practitioners
may diagnose "Failure to Progress", and consequently, perform a Cesarean.
Second stage: fetal expulsion
This stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead.At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the pelvic inlet. The fetal head then continues descent into the pelvis, below the pubic arch and out through the vaginal introitus (opening). This is assisted by the additional maternal efforts of "bearing down" or pushing. The appearance of the fetal head at the vaginal orifice is termed the "crowning". At this point, the woman may feel a burning or stinging sensation.
Complete expulsion of the baby signals the successful completion of the second stage of labour.
Third stage: delivery of the placenta
The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour.The umbilical cord is routinely clamped and cut in this stage. General hospital-based obstetric practice introduces artificial clamping as early as 1 minute after the birth of the child. In birthing centers, this may be delayed by 5 minutes or more, or omitted entirely. Clamping is followed by cutting of the cord, which is painless due to the absence of nerves.
Placental expulsion begins as a physiological separation from the wall of the uterus. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10–12 minutes dependent on whether active or expectant management is employed In as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta.
Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance. Active management is described as the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, and performance of uterine massage every 15 minutes for two hours afterward.
In a joint statement, World Health Organization, the International Federation of Gynaecologists and Obstetricians and the International Confederations of Midwives recommend active management of the third stage of labour in all vaginal deliveries to help to prevent postpartum hemorrhage.
When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact. This is referred to as "delivery en caul." The caul is harmless and its membranes are easily broken and wiped away. With the advent of modern obstetrics, artificial rupture of the membranes has become common, so babies are rarely born in the caul.
Fourth stage
The "fourth stage of labour" is the period beginning immediately after the birth of a child and extending for about six weeks. Another term would be postpartum period, as it refers to the mother (whereas postnatal refers to the infant). Less frequently used is puerperium.Afterwards
Further information: Postnatal
Many cultures feature initiation rites for newborns, such as circumcision, naming ceremonies, baptism, and others.Mothers are often allowed a period where they are relieved of their normal duties to recover from childbirth. The length of this period varies. In many countries, taking time off from work to care for a newborn is called "maternity leave" or "parental leave" and can vary from a few days to several months.
Management
Eating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes, others continue to have concern regarding the increased possibility of an aspiration event (choking on recently eaten foods) in the event of an emergency delivery due to the increased relaxation of the esophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anesthetic in the event of an emergency cesarean.Labour induction and elective cesarean
More than 22% of women undergo labour induction the United States, and more than doubled the rate from 1990 to 2006. Induced labour is indicated when either the fetus or woman will benefit compared to continuation of pregnancy, but procedures are often elective. Childbirth by C-Sections increased 50% in the U.S. from 1996 to 2006, and comprise nearly 32% of births in the U.S. and Canada. Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective induction and C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%.[5] The researchers found many benefits but “no adverse effects” in the health of the mothers and babies at those hospitals.[5][35]Health conditions that may warrant induced labour or C-sections include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and post-term pregnancy. Cesarean section too may be of benefit to both the mother and baby for certain indications including maternal HIV/AIDS, Foetal abnormality, breech position, foetal distress, multiple gestations, and maternal medical conditions which would be worsened by labour or vaginal birth.
Oxytocin is the most commonly used agent for induction in the United States, and is used to induce uterine contractions. Other methods of inducing labour include stripping of the amniotic membrane, artificial rupturing of the amniotic sac (called amniotomy), or stimulation of the nipples of one breast. Ripening of the cervix can be accomplished with the placement of a Foley catheter or the use of synthetic prostaglandins such as misoprostol. A large review of methods of induction was published in 2011.
The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks (full term) of gestation for optimal health of the newborn when considering elective induction of labour. Per these guidelines, the following conditions may be an indication for induction, including:
- Abruptio placentae
- Chorioamnionitis
- Fetal demise
- Gestational hypertension
- Preeclampsia or eclampsia
- Premature rupture of membranes
- Postterm pregnancy
- Maternal conditions such as gestational diabetes or chronic kidney disease
- Fetal compromise such as isoimmunization leading to hemolytic disease of the newborn or oligohydramnios
The ACOG also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including vasa previa, complete placenta praevia, umbilical cord prolapse or active genital herpes simplex infection.
Pain control
- Non pharmaceutical
Water birth is an option chosen by some women for pain relief during labour and childbirth, and some studies have shown waterbirth in an uncomplicated pregnancy to reduce the need for analgesia, without evidence of increased risk to mother or newborn. Hot water tubs are available in many hospitals and birthing centres.
Meditation and mind medicine techniques are also used for pain control during labour and delivery. These techniques are used in conjunction with progressive muscle relaxation and many other forms of relaxation for the mind and body to aid in pain control for women during childbirth. One such technique is the use of hypnosis in childbirth. There are a number of organizations that teach women and their partners to use a variety of techniques to assist with labour comfort, without the use of pharmaceuticals.
A new mode of analgesia is sterile water injection placed just underneath the skin in the most painful spots during labour. A control trial in Iran of 0.5mL injections was conducted with normal saline which revealed a statistical superiority with water over saline.
- Pharmaceutical
Popular medical pain control in hospitals include the regional anesthetics epidural blocks, and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. Generally, pain and cortisol increased throughout labour in women without EDA. Pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but may rise again later. Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.
Augmentation
Augmentation is the process of facilitating further labour. Oxytocin has been used to increase the rate of vaginal delivery in those with a slow progress of labour.Instrumental delivery
Obstetric forceps or ventouse may be used to facilitate childbirth.Multiple births
In cases of a cephalic presenting twin (first baby head down), twins can often be delivered vaginally. In some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e.g.- Both twins born vaginally - this can occur both presented head first or where one comes head first and the other is breech and/or helped by a forceps/ventouse delivery
- One twin born vaginally and the other by caesarean section.
- If the twins are joined at any part of the body - called conjoined twins, delivery is mostly by caesarean section.
Support
Monitoring
For the Fetus
External Monitoring
For monitoring of the fetus during childbirth, a simple pinard stethoscope or doppler fetal monitor ("doptone") can be used. A method of external foetal monitoring (EFM) during childbirth is cardiotocography, using a cardiotocograph that consists of two sensors: The heart (cardio) sensor is an ultrasonic sensor, similar to a Doppler fetal monitor, that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound. The pressure-sensitive contraction transducer, called a tocodynamometer (toco) has a flat area that is fixated to the skin by a band around the belly. The pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction. Monitoring with a cardiotocograph can either be intermittent or continuous.Complications
Dystocia (obstructed labour)
Dystocia is an abnormal or difficult childbirth or labour. Approximately one fifth of human labours have dystocia. Dystocia may arise due to incoordinate uterine activity, abnormal fetal lie or presentation, absolute or relative cephalopelvic disproportion, or (rarely) a massive fetal tumor such as a sacrococcygeal teratoma. Oxytocin is commonly used to treat incoordinate uterine activity, but pregnancies complicated by dystocia often end with assisted deliveries, including forceps, ventouse or, commonly, caesarean section. Recognized complications of dystocia include fetal death, respiratory depression, hypoxic ischaemic encephalopathy (HIE), and brachial nerve damage. A prolonged interval between pregnancies, primigravid birth, and multiple birth have also been associated with increased risk for labor dystocia.Shoulder dystocia is a dystocia in which the anterior shoulder of the infant cannot pass below the pubic symphysis or requires significant manipulation to pass below it. It can also be described as delivery requiring additional manoeuvres after gentle downward traction on the head has failed to deliver the shoulders.
A prolonged second stage of labour is another type of dystocia whereby the fetus has not been delivered within three hours in a nulliparous woman, or two hours in multiparous woman, after her cervix has become fully dilated.
Synonyms for dystocia include difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, and dysfunctional labour.
Maternal complications
Vaginal birth injury with visible tears or episiotomies are common. Internal tissue tearing as well as nerve damage to the pelvic structures lead in a proportion of women to problems with prolapse, incontinence of stool or urine and sexual dysfunction. Fifteen percent of women become incontinent, to some degree, of stool or urine after normal delivery, this number rising considerably after these women reach menopause. Vaginal birth injury is a necessary, but not sufficient, cause of all non hysterectomy related prolapse in later life. Risk factors for significant vaginal birth injury include:- A baby weighing more than 9 pounds.
- The use of forceps or vacuum for delivery. These markers are more likely to be signals for other abnormalities as forceps or vacuum are not used in normal deliveries.
- The need to repair large tears after delivery.
Infection remains a major cause of maternal mortality and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of puerperal fever and saved many lives.
Hemorrhage, or heavy blood loss, is still the leading cause of death of birthing mothers in the world today, especially in the developing world. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated. Blood transfusion may be life saving. Rare sequelae include Hypopituitarism Sheehan's syndrome.
The maternal mortality rate (MMR) varies from 9 per 100,000 live births in the US and Europe to 900 per 100,000 live births in Sub-Saharan Africa. Every year, more than half a million women die in pregnancy or childbirth.
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