7.4: Delivery Complications

7.4.1 Labor Dystocia

Labor dystocia, defined as slower than expected or arrested progress in labor, is the most common indication for cesarean delivery. Barber and colleagues demonstrated that abnormalities of labor progress substantially contribute to the rising cesarean delivery rate. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate.73

Dystocia can result from inadequate uterine contractions, fetal macrosomia, cephalopelvic disproportion, or fetal malposition. These scenarios increase the risk of intrauterine infection, fetal compromise, and maternal pelvic floor injury, all of which contribute to maternal and neonatal morbidity. Standardized criteria for abnormal labor progress help ensure that intervention occurs when necessary while avoiding unnecessary procedures.

7.4.1.1 Failed Induction

Failed induction refers to unsuccessful efforts to initiate active labor. Updated criteria for failed induction are intended to reduce primary cesarean rates. Current guidance suggests that if a patient has received oxytocin (Pitocin) for at least 12 to 18 hours after artificial rupture of membranes without adequate progress, cesarean delivery should be considered.

7.4.1.2 Failure to Progress in Labor

Once active labor is established, cervical dilation should generally follow an expected pattern of change. (Figure 7.50 forthcoming)  If the labor curve begins to deviate significantly, augmentation strategies such as oxytocin administration or artificial rupture of membranes may be undertaken.

If these measures fail, operative vaginal delivery or cesarean delivery is recommended.

• Active phase arrest: The active phase of the first stage begins at 6 cm dilation. Lack of cervical change over 4 to 6 hours in the presence of ruptured membranes and adequate contractions is consistent with active phase arrest and warrants consideration of cesarean delivery.  
• Prolonged second stage: The second stage begins at complete dilation (10 cm) and encompasses the pushing phase. A prolonged second stage is defined as more than 3 hours of pushing in nulliparous individuals or more than 2 hours in multiparous individuals. An additional hour may be allowed in the presence of regional anesthesia. Operative vaginal delivery or cesarean section should be considered in prolonged second stage.

7.4.2 Cesarean Section

Although cesarean birth is not inherently a complication of labor, it is a common intervention for complicated or high-risk deliveries. Approximately one third of births in the United States occur via cesarean section, making it one of the most frequently performed surgical procedures.

7.4.2.1 Indications

Beyond labor dystocia, common indications include nonreassuring fetal status, fetal malpresentation, and placenta previa. Individuals with one or two prior low transverse cesarean deliveries may be candidates for trial of labor after cesarean (TOLAC). Because uterine rupture risk rises with the number of prior uterine scars, patients with more than two prior cesarean sections are generally advised to undergo repeat cesarean delivery.

7.4.2.2 Procedure

Source for this section content:

Sung, Sharon, Veverly A. Mikes, Daniel J. Martingano and Heba Mahdy. Cesarean Delivery. [Updated 2024 Dec 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546707/. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/).⁷⁴ 

• Consent: Thorough informed consent should address risks, benefits, and alternatives.
• Anesthesia: Most planned cesarean births are performed under spinal anesthesia. Epidural or general anesthesia may be required in specific situations. A functioning labor epidural can often be used. General anesthesia is reserved for emergencies or contraindications to neuraxial anesthesia.
• Antibiotic Prophylaxis: Because cervical dilation creates communication between the uterus and vagina, cesarean section is considered a contaminated procedure. Prophylactic antibiotics should be administered before incision when possible.

Abdominal Incision

Most cesarean sections utilize a Pfannenstiel (low transverse) skin incision. (Figure 7.51 forthcoming)

Layers traversed include:

• Skin
• Subcutaneous fat, including Camper fascia and Scarpa fascia
• Rectus fascia, which includes contributions from the external oblique, internal oblique, and transversus abdominis aponeuroses
• Rectus abdominis muscles, separated in the midline at the linea alba
• Parietyal peritoneum

A bladder flap may be created by incising the vesicouterine peritoneum and dissecting the bladder inferiorly to protect it from injury.

 

Uterine Incision
  

The hysterotomy is typically a low transverse incision in the lower uterine segment. This approach is associated with less blood loss than vertical incisions and involves less contractile myometrium, thereby decreasing the risk of rupture in subsequent labors. A vertical or classical incision is reserved for circumstances such as extremely preterm gestations when the lower uterine segment is inadequately developed. Patients with classical uterine incisions should not labor in future pregnancies. 

All uterine layers (serosa, myometrium, and endometrium) are incised.

 

Delivery of the Infant

If membranes remain intact, they are ruptured. The surgeon then elevates the fetal head through the hysterotomy while an assistant applies fundal pressure to facilitate delivery. For breech presentations, the feet or sacrum are delivered first, followed by the body, arms, and head. The neonate is stimulated, and oropharyngeal suction may be performed. When feasible, delayed cord clamping is recommended before the infant is transferred to the pediatric team.

Placental Delivery

The placenta is removed using controlled cord traction and uterine massage or manual extraction. Unlike vaginal delivery, where the third stage may last up to 30 minutes, placental delivery at cesarean should be prompt to reduce blood loss from the open hysterotomy.

Closure

The uterus is closed in a running fashion. Debate exists regarding single versus double layer closure and suture technique, which is beyond the scope of this resource. The rectus fascia is closed with continuous suture, followed by closure of the skin. Subcutaneous tissue may be reapproximated in cases of significant adiposity.

7.3.2.3 Complications

 

Intrapartum

• Hemorrhage: Blood loss is greater with cesarean surgery than with vaginal birth, and the risk of postpartum hemorrhage increases. The uterine arteries course along the lateral uterus and can deliver up to 500 mL of blood per minute. Injury to these vessels can result in rapid exsanguination.
• Injury to surrounding organs: Bowel, bladder, ureters, and major vessels may be injured, particularly in the presence of dense adhesions from prior surgeries, infections, or endometriosis.

Postpartum

• Infection: Cesarean delivery is associated with endometritis, wound infection, pelvic abscess, and higher rates of urinary tract infection due to bladder catheterization.
• Thrombosis: The combination of pregnancy-associated hypercoagulability, major pelvic surgery, and decreased mobility increases the risk of deep vein thrombosis and thromboembolism.

Future Pregnancies

Multiple cesarean deliveries increase the risk of placenta accreta spectrum and may limit future options for TOLAC.

 

7.4.3 Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide and remains a major contributor to morbidity despite advances in prevention and treatment.75

7.4.3.1 Definition

PPH is defined as blood loss greater than 1000 mL during birth or within 24 hours postpartum, or any blood loss associated with signs or symptoms of hypovolemia.

7.4.3.2 Etiologies and Risk Factors

The “four Ts” summarize major causes: tone, trauma, tissue, and thrombin.

• Tone (uterine atony): The most common cause of PPH. Risk factors include conditions that weaken the myometrium (prolonged labor, intrauterine infection, general anesthesia with muscle relaxants, magnesium sulfate exposure, grand multiparity) or overdistend the uterus (multifetal gestation, polyhydramnios, macrosomia). Uterine fibroids also increase risk.
• Trauma (lacerations): Vaginal, perineal, or cervical lacerations can result in brisk bleeding after vaginal birth. Risk factors include nulliparity, operative vaginal delivery, and precipitous labor. During cesarean birth, injury to uterine or pelvic vessels can cause significant hemorrhage.
• Tissue (retained placenta): Retained placental fragments, including placenta accreta spectrum, prevent adequate uterine contraction and lead to persistent bleeding.
• Thrombin (coagulopathy): Less common but important causes include disseminated intravascular coagulation, inherited bleeding disorders such as von Willebrand disease, and therapeutic anticoagulation.

7.4.3.3 Prevention

• Risk stratification: Hemorrhage risk is assessed at admission and updated throughout labor as new risk factors develop. High risk patients are typed and crossmatched for blood products.
• Active management of the third stage: Universal administration of oxytocin (Pitocin) during the third stage of labor reduces PPH risk. Uterine massage and controlled cord traction are low risk interventions that may further limit blood loss.

7.4.3.4 Treatment  

Management is guided by the underlying cause, but initial therapies focus on uterine atony. 

Evaluation

• Assess uterine tone with bimanual examination. A firm, contracted uterus is expected postpartum; a boggy uterus suggests atony.
• Inspect the cervix, vagina, and perineum using retractors to identify lacerations.
• Examine the placenta for completeness and use ultrasound to evaluate for retained tissue if indicated. A bimanual examination of the uterine cavity can remove clots or fragments.
• Screen for coagulopathy by assessing for bleeding at intravenous sites, petechiae, or oozing from wounds.
• Closely monitor vital signs, mental status, urine output, and overall perfusion.

Laboratory Testing

Obtain hemoglobin, platelet count, fibrinogen level, prothrombin time (PT/INR), and partial thromboplastin time (PTT). A second intravenous line should be established if not already present.

Medications

• Methylergonovine (Methergine): Intramuscular ergot derivative that promotes strong uterine contractions. It may increase blood pressure and should be avoided in hypertensive disorders.
• Carboprost (Hemabate): Intramuscular prostaglandin F2 alpha analog that induces uterine contraction. Gastrointestinal side effects are common; antidiarrheal medications are often co-administered. It is contraindicated in patients with significant pulmonary disease such as asthma due to risk of bronchospasm.
• Misoprostol (Cytotec): High dose oral, sublingual, or rectal misoprostol can augment uterine tone. Onset is slower than injectable agents, so it is typically used as an adjunct. Low grade fever and chills are common side effects.
• Tranexamic acid (TXA): An antifibrinolytic agent that reduces ongoing blood loss but does not treat atony directly. TXA has been shown to decrease mortality in severe PPH and is increasingly incorporated into treatment algorithms.76

Tamponade Methods

• Uterine packing:  In resource-limited settings, packing the uterus with gauze provides temporary tamponade. 
• Bakri balloon: A balloon catheter placed into the uterine cavity and filled with saline to exert outward pressure and control bleeding. (Figure 7.52 forthcoming)
• Jada system: A silicone loop connected to low level wall suction that collapses the uterine cavity, stimulating myometrial contraction and controlling hemorrhage. Clinical studies report approximately 94 percent success in treating PPH. (Figure 7.53 forthcoming)

Surgical Management

If conservative measures fail, surgical options include dilation and curettage for retained products, uterine compression sutures (for example B-Lynch), and ligation of uterine or internal iliac (hypogastric) arteries. Familiarity with pelvic vascular anatomy, particularly branches of the internal iliac artery, is essential. (Figure 7.54 forthcoming)  When bleeding remains uncontrolled, hysterectomy is the definitive treatment.

7.4.4 Shoulder Dystocia

Shoulder dystocia occurs when the fetal shoulders fail to deliver after the head, usually due to impaction of the anterior shoulder on the pubic symphysis or, less commonly, impaction of the posterior shoulder on the sacrum. Because the umbilical cord may be compressed once the head is delivered, rapid resolution is essential to prevent hypoxic injury. Shoulder dystocia is therefore considered an obstetric emergency.

7.4.4.1 Risk Factors and Prevention

Most events are unpredictable and occur in patients without identifiable risk factors. However, fetal macrosomia, prior shoulder dystocia, and maternal diabetes are associated with higher risk. In selected cases with substantial risk, primary cesarean section may be offered as a preventive strategy.

7.4.4.2 Diagnosis

Failure of the shoulders to deliver with gentle downward traction after head delivery raises concern for shoulder dystocia. Retraction of the fetal head against the perineum, known as the “turtle sign,” may be observed.

7.4.4.3 Treatment

Shoulder dystocia requires immediate, coordinated maneuvers:

• McRoberts maneuver: Hyperflexion of the maternal hips by two assistants rotates the pelvis and can free the impacted shoulder.
• Suprpubic pressure: Applied to the maternal suprapubic area to dislodge and rotate the anterior shoulder. Often combined with McRoberts and successful in most cases.
• Delivery of the posterior arm: The clinician inserts a hand into the vagina, locates the posterior arm, and gently sweeps it across the chest and out of the vagina, reducing the bisacromial diameter.
• Rotational maneuvers: Internal rotation of the fetal shoulders (for example Woods screw or Rubin maneuvers) may be used when the above steps fail.
• Intentional fracture of fetal bones: If necessary, deliberate fracture of the clavicle or humerus may be performed to reduce shoulder diameter.
• Zavanelli maneuver: As a last resort, the fetal head is flexed and gently returned to the vagina and uterus, followed by emergent cesarean delivery. This maneuver carries high risk of severe neonatal morbidity and mortality due to prolonged hypoxia.

7.4.4.4 Complications

• Maternal: Severe perineal lacerations, pelvic floor dysfunction, and increased risk of postpartum hemorrhage.
• Fetal/Neonatal: Prolonged hypoxia can lead to neurologic injury, including cerebral palsy, or death. Fractures of the clavicle or humerus may occur. Brachial plexus injury is a well-recognized complication.
  • Damage to nerve roots C5–C6 produces Erb palsy, characterized by shoulder adduction, internal rotation of the upper arm, forearm pronation, and wrist flexion, giving the “waiter’s tip” posture.77 (Figure 7.55 forthcoming)
  • Damage to nerve roots C8–T1 results in Klumpke palsy with weakness of hand and wrist flexors and a “claw hand” appearance.78 (Figure 7.56 forthcoming)

Most brachial plexus injuries resolve with time and physical therapy, although some may be permanent.

7.4.5 Intra-amniotic Infection

Intra-amniotic infection (IAI), also known as chorioamnionitis, is an infection of the amniotic fluid, membranes, placenta, or decidua that most often arises during labor. Ascending vaginal flora, including Group B Streptococcus, are typical pathogens. IAI is associated with dysfunctional labor, postpartum hemorrhage, and both maternal and neonatal sepsis.

Management includes broad spectrum intravenous antibiotics, typically ampicillin and gentamicin, antipyretics such as acetaminophen, and delivery.79

Footnotes 

73. Barber, Emma L., Lisbet S. Lundsbert, Kathleen Belanger, Christian M. Prettker, Edmund F. Funai and Jessica L. Illuzzi. Indications Contributing to the Increasing Cesarean Delivery Rate. Obstetrics & Gynecology, 118, No. 1:(July 2011):29-38. | DOI: 10.1097/AOG.0b013e31821e5f65.
74. Sung, Sharon, Veverly A. Mikes, Daniel J. Martingano and Heba Mahdy. Cesarean Delivery. [Updated 2024 Dec 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546707/. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/)
75. ACOG. Postpartum Hemorrhage. Practice Bulletin, No. 183 (October 2017). Restricted access, https://www.acog.org/clinical/clinic...tum-hemorrhage.  
76. D'Alton, Mary E. et al. Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage. Obstet Gynecol. 136, No. 5 (Nov 2020) :882-891. doi: 10.1097/AOG.0000000000004138. PMID: 32909970; PMCID: PMC7575019. Lippincott Open Access, available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7575019/.
77. Basit, Hajira, Ali, Citra Dewi M. and Neal B. Madhani. Basit H, Ali CDM, Madhani NB. Erb Palsy. [Updated 2023 Apr 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513260/. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).
78. Merryman, Justin and Matthew A. Varacallo. Klumpke Palsy. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531500/. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).
79. ACOG. Intrapartum Management of Intraamniotic Infection. Committee Opinion, No. 712 (August 2017). Available from: https://www.acog.org/clinical/clinic...otic-infection.