Childbirth: Labour and Delivery

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The new guide to women’s health

Childbirth – Labour and Delivery

Labour: Towards the end of pregnancy, every so often you will put a hand on your abdomen and find that the whole area is rock-hard. This is the painless rehearsal for labour and it is a good idea when you are sitting down watching television or laying in bed to put a hand flat across the middle of your stomach and observe the gradual tightening. Then slackening of the uterus.

Usually, the day going into labour proper you will feel these sensations frequently, and, in between these contractions, you will also feel lots of fetal activity as your baby prepares for its birth.

When you are in true labour you become very aware of these contractions. For the first three to four hours, contractions are between 15 to 20 minutes apart and last for about one to two minutes or so. Throughout labour the contractions get closer and closer together and more and more intense. Time them, because with your first baby it is sensible to go to the hospital when they are about ten minutes apart.

Before going into hospital, have something to eat – you will need all your energy. But do not have a heavy meal, particularly anything rich. Your stomach will not be able to cope with digesting a large amount of food at this point. Eat light foods: yoghurt, fruit, some wholemeal toast or biscuits, perhaps with fruit juice.

The duration of labour: Some 50 per cent of labours start with a slight bleeding or pinkish discharge, then during labour the ‘bag’ of membrane in which the baby has lived so far finally ruptures, and a flood of amniotic fluid is released. Some labours actually initiate like this, and if this ‘breaking of the waters’ happens while you are out or during the night, it is sensible to go straight to hospital.

The uterus contracts to push the baby out in a natural, rhythmic movement that occurs spontaneously during the birth process. However, babies vary greatly in how much effort it takes to push them out. The process can involve as few as 50 to 60 contractions or as many as 200.

Modern labours should not last longer than between six to twelve hours because, at the end of that time, maternal fatigue may well be compounded by fetal distress. If labour has reached this point, your midwife and obstetrician will decide on the best course of action, which may (for example), be a Caesarian section.

There are, however, some women who have a somewhat desultory or intermittent labour process that can last for one to two days before enough ‘work’ is done to ensure the safe arrival of the baby.

Most midwives, and some obstetricians, by the time they have completed their training, can detect quite early on abnormal patterns of labour.

Birth positions: Each pregnant woman finds ways of sitting and lying that are comfortable for her. Being in labour is no different. Some women prefer to lie down, some prefer to crouch – the downward pull of gravity in this position helps the contractions, and you can be supported by a birthing chair or stool.

(Some medical museums exhibit examples of what they label ‘birthing stools’. In fact, these are so near to the ground that were they indeed to be used by the pregnant woman she would have a very bad time. They were intended for, and used by, the attendants at the birth!).

Delivery

Pregnancy - Pregnant Woman and natural Childbirth
Pregnancy – Pregnant Woman and natural Childbirth labour and delivery

The first and most important rule of giving birth is that every woman should have someone with her from her the moment that she enters the birth room. This may sound an obvious point, but it is worthwhile to stress it – remembering that the doctors, midwives and obstetricians may all be evidently concerned principally for the baby’s safety and well-being. It is all too easy for the mother to come to feel forgotten, ignored or just a machine for giving birth.

Many women report feeling terrible depression and fear, in large part due to the sheer exhaustion of giving birth. So it is crucial to have your partner, or husband, by your side caring for your needs – if he is not available, make sure a friend or relative is with you.

But your partner’s presence is rally ideal – he can describe for you what is happening and give you loving encouragement and support. He will also share with you that triumphant and tender moment when your newly-born child is first handed to you.

Episiotomy

Natural Childbirth - Pregnant woman
Natural Childbirth – Pregnant woman labour and delivery

It is a tradition in some hospitals that, just as the head is about to emerge (crowning), the nurse or obstetrician cuts into the vaginal tissues (called an episiotomy), through the muscle tissue around the opening of the vagina to assist delivery.

In recent years this automatic enlarging of the vaginal opening has been increasingly questioned, for the grounds on which an episiotomy was originally performed – among others, to prevent a prolapsed in the mother – are actually indefensible.

If a prolapsed (that is, the collapsing of the uterus is going to happen, it will have happened before this stage. In any case, the perineal muscles are not involved in supporting the uterus.

Another factor against automatic episiotomy is that scar tissue resulting from hasty sewing up of the cut can cause trouble later. Contrary to popular belief, torn tissues heal naturally and smoothly. However, there is no reason for the perineum to tear if the right preventive techniques are employed: depending on the training of the midwife present, a perineal massage is more effective than a routine episiotomy in the majority of cases.

Perineal massage involves the midwife inserting her hand into the vagina sometime before the baby begins the descent into the birth canal, to massage the pelvic muscles with her fingers. This relaxes the vagina and causes it to be so well lubricated that the baby slides out almost always without tearing, removing any need for episiotomy.

An episiotomy becomes essential, however, if there is to be a forceps delivery or any other need for manipulation of the baby. It is carried out under these circumstances to prevent a tear into the rectum. Before the introduction of antibiotics, such a tear commonly resulted in a fistula (tiny opening between the rectum and vagina) and chronic ill-health for years.

Forceps

The delivery of babies by forceps is constantly controversial. Without a doubt, forceps deliveries have achieved as much good as they have harmed. The commonest indication for a straightforward forceps delivery in modern obstetrics is maternal fatigue or exhaustion.

This type of delivery is most usually carried out at the end of the second stage of labour. There should be no force used – the forceps are designed to make it impossible to crush the baby’s head and the procedure should be a gentle lifting out of the head and body from the vaginal passage.

Much more controversial are the forceps used in higher extraction techniques; these should always be carried out by the most experienced obstetrician available after an explanation and effective anaesthesia have been given to the mother.

Breech Births

Childbirth - Pregnant woman
Childbirth – Pregnant woman labour and delivery

A breech birth is when the baby is facing bottom first or down, rather than head down. The baby can be delivered either with special extraction techniques or by Caesarian section. It can be a great disappointment to a young, healthy mother who has trained for an active birth to be told at 36 weeks that her baby is a ‘breech’ and it will be safer therefore to have a Caesarian.

Whether or not she is thus advised will depend on the training and experience of her obstetrics team, and until the safety rates for breech deliveries in various hospitals are made available to us it is sensible for each mother to accept – after due explanation and reassurance – the method that works best in that particular hospital.

Caesarian Section

It is a tradition in some hospitals that, just as the head is about to emerge (crowning), the nurse or obstetrician cuts into the vaginal tissues (called an episiotomy), through the muscle tissue around the opening of the vagina to assist delivery.

In recent years this automatic enlarge of the vaginal opening has been increasingly questioned, for the grounds on which an episiotomy was originally performed – among others, to prevent a prolapsed in the mother – are actually indefensible. If a prolapsed (that is, the collapsing of the uterus is going to happen, it will have happened before this stage. In any case, the perineal muscles are not involved in supporting the uterus.

For the last ten years, since the advent of safe epidural anaesthesia, having a baby by Caesarian has become a much less frightening prospect for both mother and father. If you know in advance that it is to take place, you will go into hospital at the appointed time and, once in the operating theatre, will be painted with an antiseptic from armpits to thighs (many women comment on the coldness of the solution – so be warned!).

However, the epidural inserted then at the base of your spine should cause little discomfort. Some hospital still favour a general anaesthetic, regarding it as better for both mother and baby. An incision is then made into your abdomen and, if you wish, you can watch the whole procedure without fear of feeling any pain.

At the moment of delivery, you will feel a tremendous pressure under your rib cage rather than in the abdomen, as the uterus is pulled down and the baby scooped out.

The baby will be given to you immediately for a brief greeting, then you can relax and sleep while the incision is stitched and you are taken back to your ward.

Some obstetricians allow the father to take a home video of the proceeding, thus providing a positive memory of a happy and satisfying event. Remember, as long as you are delivered of a healthy baby, you don’t have to give birth ‘naturally’ to experience the momentous occasion of birth.

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Induction

This is when labour is triggered artificially by the obstetrician. After a discussion with her, you will probably be asked to come into the hospital the night before or very early on the morning of the planned birth.

Labour is induced by one of two methods: by synthetic pituitary extract, or by prostaglandins (natural hormones that make the uterine muscles relax). In the first method, synthetic oxytocin is injected into a vein via a drip. In the second, prostaglandins are introduced in the form of vaginal pessaries.

Some obstetricians explain the process in detail to the mother-to-be and then give her the pessaries to insert at home, usually at around 6 am, after which she goes into the hospital at a prearranged time, say around 1 or 2 pm, following the pattern of a non-induced labour.

Babies may be induced to suit hospital timetables, but there are two types of medical reasons for a baby to be born in advance of natural labour.

Baby reason: When the pregnancy has progressed well but the baby is not growing. This means that the placenta is not providing adequate nourishment and, even though the baby will be born underweight, it would do better in the hospital’s nursery than waiting for the mother to give birth.

In multiple pregnancies, that is, if you are expecting twins or more, the placenta may sometimes not keep up with feeding and so an induced birth become advisable. Multiple births should always take place in the hospital, and the delivery should be supervised by an obstetrician.

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Mother reasons: If the mother is very short or small-framed, and particularly if her partner happens to be tall, once the baby has reached 5 or 6 lbs (which can be accurately measured through ultrasound, the obstetrician is likely to suggest induction.

Because of her small size, her birth canal and pelvis will be very shallow and, if the baby gets too big, she would be likely to have an obstructed labour and/or a Caesarean section.

The baby will be constantly monitored, and an induction or Caesarian section discussed if you have any of the following conditions: rhesus blood group incompatibility; high blood pressure; heart or kidney disease; diabetes; history of previous stillbirths.

Next article: Special Care After the Birth

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