During Your Labour and Birth
How might labour start? : Your labour might start by your waters breaking and then contractions start – maybe straight away, maybe hours later. You might experience contractions without your waters breaking. These contractions may start 10 – 20 minutes apart or they may be 5 minutes apart. You may notice a mucous plug with some slight pink colouring, or blood streaking, that comes out of your vagina. This might be up to a week before labour starts or perhaps part way through your labour. Are you getting the idea? It’s different for each woman and can be different for each woman’s labour.
If your waters break while you are at home it’s a good idea to check that there’s no green or brown staining to the water. Do this by putting a big sanitary pad in your knickers and checking it when water has leaked onto it.
Note: If your waters break before 37 weeks you should contact your midwife immediately. If your waters break and you notice something ‘hanging out’ of your vagina you should also call her immediately, no matter how many weeks you are.
Fetal Heart Monitoring : I will regularly check your baby’s heart rate during labour. This is usually done with a hand-held Doppler or Sonicaid, much like the one used during antenatal visits. As your labour progresses the intervals will become closer together to ensure that baby is coping with the labour.
If baby does become distressed it would be recommended that ‘continuous electronic fetal heart monitoring’ (CTG) is carried out for a space of time. This is done by strapping a monitor to your abdomen and listening in continuously.
Vaginal Examination (VE) : This is done either at home or at the birthing suite – depends on where I first see you. It is invasive but I believe it is also very important. I will only do one where absolutely necessary, you don’t need anyone ‘fossicking’ around in there unless it is really needed!!
Artificial Rupture of Membranes (ARM) : Research does not support using ARM as a routine procedure for speeding up labour. If the labour is progressing there is no real advantage in carrying this out. However, it can sometimes be effective in certain circumstances. Your midwife will discuss the advantages and disadvantages of this procedure should it be necessary.
What a huge subject! This can be pretty much divided into natural methods and pharmacological (medical) methods.
The best thing you can do for yourself is to try and relax. Yes, it’s exciting that labour has started and yes, it’s painful but if you can ‘go with the flow’ and try not to panic you will be doing yourself the most good. Let’s look at some specific choices for pain management.
*** Breathing – sounds odd but this is one of the most effective things you can do. There is no ‘special way’ of breathing, just remember to do it and keep it relaxed and controlled, or gentle and rhythmic might be a different way to approach it. Relaxing through the shoulders, bottom and face is very effective. This helps your body release it’s own natural pain relieving hormones called endorphins. The ‘feel good’ hormone – it’s free and it’s natural!
*** Position – being active and upright during the later stages allows gravity to lend a helping hand. Walking, rocking and rotating your pelvis are all good.
*** Massage – some women love this and some prefer not to be touched. Everyone is different and you need to find your own preference here.
*** Warmth or cold – a wheat bag on tummy or back can work wonders in labour. Alternatively some women prefer a cold pack on the lower back & a cool cloth for the face. Try either to find your preference.
*** Swiss Ball/Birthing Ball – a fabulous place to sit. It is like a supported squatting position which can help line up your baby in the pelvis & potentially shorten your labour.
*** TENS – transcutaneous electronic nerve stimulation – non-invasive with small electrodes attached to your lower back. These electrodes send a low-voltage current through the nerves in your back which effectively ‘scramble’ the pain message going to your brain. Again, some women find them excellent right through their labour and others use them for only part of their labour.
*** Water – being in water, be it under the shower or submerged in the bath, helps many women cope with the intensity of contractions. (Please note that we fully support labouring in the water but if you would like a waterbirth we will help you find another midwife who will do this with you)
*** Homeopathic – you may already use things like rescue remedy or arnica, for example, and these are fine to continue with in labour.
*** Nitrous oxide (gas) – some women find this effectively reduces the intensity of the contractions and can be a great ‘carry through’ during the transition time leading up to being fully dilated. It can cause nausea and dizziness for some women either immediately or after using it for some time.
*** Epidural anaesthesia – a local anaesthetic is injected into the epidural space in the lower part of your spine. This is always administered by an anaesthetist with ongoing management by myself. If you have an epidural you may also need an intravenous (IV) infusion of artificial hormones, along with IV fluids, to stimulate your contractions. You may also need to have a catheter inserted into your bladder because you will have reduced sensation and not recognize the need to urinate. The anaesthetist will discuss the possible risks associated with epidural pain relief.
*** Pethidine – no longer recommended as a drug for pain relief in active labour as it does cross the placenta. It tends to work more as a sedative than as pain relief and can cause the baby to be very sleepy and require resuscitation at birth (the baby may need an antidote injection to reverse the effects if necessary). It has also been shown to have an adverse effect on breastfeeding.
Immediately Following the Birth
Tearing and Episiotomy : The external area between your vagina and anus is known as the perineum. As baby moves through the vagina his/her head puts pressure on the perineum allowing it to stretch and for baby’s head to come through without tearing. Sometimes tearing does occur and I will discuss with you whether this needs stitching or not.
If baby becomes distressed near the end of second stage of labour it may be necessary to cut the perineum to allow baby to birth more quickly. This is known as an episiotomy. There may also be very rare occasions when I may feel that tearing will cause more damage than an episiotomy.
Research shows there is no evidence to support the routine use of episiotomy; it will not always prevent more serious tearing, it is not easier to repair nor does it heal more rapidly, it does not prevent trauma to a baby’s head as it is being born and it does not prevent serious damage to women’s pelvic floor muscles.
The ideal outcome for you is to have an intact perineum or to have experienced minimal damage.
Cord Blood Collection : If you would like cord blood to be collected this needs to be decided well in advance of labour and birth. This is explained fully in the pamphlet by CordBank available by phoning 0800 cordbank or researching on the intenet.
Delivery of the Placenta : There are two different ways of managing this stage.
Physiological – let it be!! If you have had an intervention free labour there is no reason you should start introducing drugs into your system after baby is born unless it is necessary. With this management the cord would not usually be clamped and cut until
after it had stopped pulsating and can be left intact until the placenta has been delivered. Gravity will usually assist you to push your placenta down through the vagina. If there is excessive bleeding this would not be the best approach. Other reasons why a physiological approach may not be appropriate are low iron levels (Haemoglobin – Hb), very large baby, long drawn out labour – either first or second stage, previous postpartum haemorrhage or a medically induced labour.
Active Management – this involves giving an injection of an artificial hormone (known as an ecbolic) into your thigh as your baby is being born. The cord has usually stopped pulsating by the time the cord is clamped and cut, although this will be done reasonably soon after the injection. It means the placenta is delivered quickly, usually within 3 – 10 mins. Under certain circumstances active management is the recommended one – your midwife will discuss this in depth with you. Some research shows that the incidence and severity of post partum haemorrhage is reduced using this method. If an ecbolic has been given the placenta needs to be removed quickly as there is a risk that the contractions may cause your cervix to shut, trapping your placenta inside your uterus. A small number of women may experience nausea and/or a headache when this method is used, however this usually resolves within a few hours at most.
You might decide to keep your placenta – let me know if you’d like to. If you don’t want to keep it but would like to have a look at it I can explain how the placenta has been working for the past nine months.
Cutting the cord : You and/or your partner or support person may choose to cut the cord as a symbolic gesture. Everyone is different on this one. Some partners prefer not to, either choice is absolutely fine.
Skin to skin : Having your baby passed up onto your tummy/chest following birth is a great way to achieve skin to skin contact. This is such an important time, the first 2 hours or so following birth, to set yourself up for successful breastfeeding. Your baby will spend this time doing what nature intended which is to use its natural reflexes looking for the nipple, and, if left to do this, will usually find and attach him/herself to the breast.