Labor complications arise from problems with the powers, passage, passenger, or psyche, or from sudden obstetric emergencies. Many can be anticipated from risk factors; others (shoulder dystocia, uterine rupture, amniotic fluid embolism) occur suddenly and need a rehearsed team response.

Dysfunctional labor (dystocia)

Current arrest definitions (ACOG)

• First-stage arrest: at ≥ 6 cm with ruptured membranes and no cervical change for ≥ 4 hours despite adequate contractions, or ≥ 6 hours with inadequate contractions and oxytocin
• Second stage is prolonged at about 3 hours of pushing in nulliparas and 2 hours in multiparas; longer is acceptable when progress continues and maternal and fetal status are reassuring

Preterm labor: regular contractions with cervical change between 20 0/7 and 36 6/7 weeks. Risk factors: previous preterm birth, short cervix, multiple gestation, infection, bleeding, smoking, substance use.

Post-term pregnancy: 42 0/7 weeks or more. Risks: placental insufficiency, oligohydramnios, meconium aspiration, macrosomia, stillbirth. Induction is commonly offered at 41 weeks.

• Shoulder dystocia: the head delivers and then retracts against the perineum ("turtle sign"); the shoulders do not follow with gentle traction
• Uterine rupture: the most common first sign is an abnormal FHR (prolonged deceleration or bradycardia); also sudden severe or tearing pain, loss of station, change in uterine contour, vaginal bleeding, hypotension and tachycardia. Main risk: previous uterine scar (especially classical incision), induction or augmentation in TOLAC
• Amniotic fluid embolism (AFE): sudden hypoxia, hypotension or cardiac arrest, and coagulopathy (DIC) during labor or shortly after birth; may start with agitation or a sense of doom
• Preterm labor: menstrual-like cramps, low backache, pelvic pressure, change in vaginal discharge, regular contractions (often painless)
• Intraamniotic infection: maternal fever, fetal tachycardia, uterine tenderness, foul fluid
• Hypertonic labor: severe pain out of proportion to progress, high resting tone

• Cervical exams over time and labor curve evaluation
• Leopold maneuvers and ultrasound for presentation and position; estimated fetal weight (macrosomia estimates are imprecise)
• Continuous EFM and IUPC (Montevideo units ≥ 200 suggest adequate contractions)
• Preterm labor: cervical length by transvaginal ultrasound; fetal fibronectin (a negative result has high value for ruling out birth within 7–14 days; valid only at 22–34 weeks with intact membranes and cervix < 3 cm, and invalid after intercourse, vaginal exam, lubricant, or bleeding in the previous 24 hours); urinalysis and cultures
• AFE: clinical diagnosis; coagulation studies, fibrinogen, CBC, blood gases

Shoulder dystocia — call for help, note the time, no fundal pressure

1. McRoberts maneuver — sharply flex the client's thighs onto the abdomen (straightens the sacrum)
2. Suprapubic pressure — applied by a nurse just above the pubic bone toward the fetal face (never fundal pressure, which worsens impaction)
3. Delivery of the posterior arm, internal rotational maneuvers, hands-and-knees (all-fours) position
4. Episiotomy only to create room for internal maneuvers
5. Newborn risks: brachial plexus injury (Erb palsy), clavicle or humerus fracture, hypoxia. Maternal: hemorrhage, severe lacerations

Uterine rupture: emergency laparotomy and delivery, blood products, possible hysterectomy.

Amniotic fluid embolism: immediate high-quality CPR with left lateral uterine displacement, airway and oxygen, early blood products and massive transfusion for coagulopathy; avoid excessive crystalloid (acute right heart failure); if no return of circulation, resuscitative (perimortem) cesarean is recommended within about 4–5 minutes of arrest when the uterus is at or above the umbilicus.

Preterm labor

• Antenatal corticosteroids (betamethasone 12 mg IM, two doses 24 hours apart) between 24 0/7 and 33 6/7 weeks if birth within 7 days is likely; may be considered at 22–23 weeks and in selected late-preterm clients
• Magnesium sulfate for fetal neuroprotection when birth is expected before 32 weeks (reduces cerebral palsy)
• Tocolytics for up to 48 hours to allow steroids to act or transfer:

• Magnesium sulfate safety: monitor deep tendon reflexes, respiratory rate (≥ 12/min), urine output (≥ 30 mL/h), level of consciousness, and serum magnesium if toxicity is suspected. Therapeutic about 4–8 mEq/L (4.8–9.6 mg/dL; 2–4 mmol/L); loss of reflexes about 7 mEq/L; respiratory depression about 10 mEq/L; cardiac arrest about 25 mEq/L (see Hypertensive Disorders of Pregnancy). Loss of reflexes appears before respiratory depression. Antidote: calcium gluconate 10%, 10 mL (1 g) IV over about 3 minutes. Caution with renal impairment and myasthenia gravis
• GBS prophylaxis if birth appears imminent and status is positive or unknown
• 17-alpha hydroxyprogesterone caproate injections are no longer used (FDA withdrew approval in 2023); vaginal progesterone is used for a short cervix

Listed in priority order.

1. Emergencies — call for help and act
   • Shoulder dystocia: call for help, position for McRoberts, apply suprapubic pressure, record the time; never apply fundal pressure
   • Suspected uterine rupture or AFE: activate the emergency response, begin resuscitation, lateral uterine displacement, two large-bore IVs, prepare for surgery and massive transfusion
   • Sudden fetal bradycardia after membrane rupture: check for cord prolapse
2. Oxytocin augmentation safety
   • Continuous FHR monitoring is the priority assessment
   • Stop or decrease oxytocin for tachysystole (> 5 contractions in 10 minutes averaged over 30 minutes), contractions lasting > 2 minutes, elevated resting tone, or abnormal FHR; reposition, give IV fluid, notify
3. Monitor for infection — after prolonged rupture of membranes, check temperature every 2 hours after membranes rupture (hourly if elevated), per facility policy, and FHR (fetal tachycardia is an early sign)
4. Support hypertonic and prolonged labor — rest, analgesia, hydration, and position changes; void every 2 hours
5. Back labor — sacral counterpressure, heat, hands-and-knees or side-lying; encourage position changes
6. Precipitous birth — do not leave the client; support the head with gentle pressure to prevent rapid expulsion, check for a nuchal cord, dry and warm the newborn, watch for hemorrhage
7. Anxiety — stay with the client, coach breathing, explain events; anxiety increases pain and catecholamines

• Preterm labor warning signs: regular contractions (e.g., 4–6 or more in an hour, as instructed) even if painless, pelvic pressure, low backache, leaking fluid, bleeding — go to the hospital
• Explain procedures such as ECV (risks: FHR changes, rarely abruption; Rh immune globulin if Rh-negative)
• After shoulder dystocia: explain newborn assessments for arm movement and fractures
• Before TOLAC: the risk of uterine rupture and the need for a hospital ready for emergency cesarean

• Hypotonic labor → oxytocin; hypertonic labor → rest and analgesia, no oxytocin
• First-stage arrest is diagnosed only at ≥ 6 cm with adequate contractions for 4 hours
• Oxytocin: continuous FHR monitoring; stop for tachysystole or abnormal FHR
• Shoulder dystocia: McRoberts + suprapubic pressure; never fundal pressure
• Uterine rupture: first sign is usually abnormal FHR
• OP position → back labor → counterpressure, hands-and-knees
• Preterm labor: betamethasone 24–34 weeks; magnesium for neuroprotection < 32 weeks
• Magnesium toxicity → calcium gluconate
• Indomethacin: < 32 weeks, ≤ 48 hours (ductus, oligohydramnios)
• AFE: sudden cardiorespiratory collapse + DIC