Labour and Birth
The process of coming into labour and giving birth has become an increasingly medicalised event as new technologies and procedures invented for use in high risk situations have then become routinely used during normal labour and birth. Some of these procedures have been part of maternity care for decades despite a lack of evidence that they offer any benefits to either the mother or the baby.
The following provides you with information on what these interventions are and the benefits and risks of having them. None of the procedures described are compulsory. It is important that you ask your midwife or doctor to explain what each intervention involves before you agree to any of them.
Place of birth
Induction of labour
IV fluids
Foetal monitoring
Vaginal examinations
Monitoring maternal wellbeing
Pain relief
Augmenting labour
Labouring and/or birthing in Water
Forceps Ventouse
Casarean Section
Oxytocin and sking-to-skin contact
Waiting for the placenta
Cord blood banking
In New Zealand you are able to choose where you want to give birth. Your choices include having your baby at home, or in a primary birthing unit or a small maternity hospital, or in a large maternity hospital. In some areas of New Zealand not all of these options may be available.
It is important that you make the decision on where you would like to give birth, and then choose a maternity caregiver or Lead Maternity Carer (LMC) who will support and care for you at the place you have chosen.
Giving birth at home or in a primary birthing unit increases your chances of having a normal birth without unnecessary interventions. Healthy pregnant women who give birth in a secondary or tertiary hospital are more likely to experience interventions in the birth process that are not medically indicated
and to end up with a caesarean section.
Environments for giving birth
A great deal is now known about the impact that the birthing environment has on women during labour. An intimate setting for labour and birth will allow the release of birthing hormones such as oxytocin that help with the progress of labour. Many things about the hospital birthing environment can be stressful. If youare giving birth in hospital remember you can change the layout of the room, push the bed to one side, ask people to knock before entering your room, and alter the lighting and the amount of noise you are exposed to. Many women are not comfortable labouring on a bed and prefer to move freely around. Labouring in water has also been found to be helpful during active labour, and to reduce the need for intervention.
Carefully choosing the people you want with you during your labour and birth is also an important aspect of creating the supportive birthing environment you need for birth. Most hospitals are reasonably flexible as to the number of support people youcan have in the room with you.
The decision to induce labour rather than wait for the spontaneous onset of contractions is one of the most drastic ways of intervening in the natural process of pregnancy and birth. While inducing labour can be a life-saving intervention in complicated pregnancies, the current rates of induction are extreme. When powerful drugs are used on healthy pregnant women the risks start to outweigh
the benefits.
There are a variety of ways of inducing labour. They include mechanical methods such as “sweeping of the membranes,” the use of a prostaglandin gel, artificial rupture of the membranes (amniotomy); or oxytocic drugs such as syntocinon (a synthetic form of oxytocin). The success or failure of these methods usually
depends on whether the cervix is favourable or ripe, meaning that the softening that signals the cervix is ready for labour has already begun. Induction is the procedure that is responsible for initiating a cascade of interventions that often leads to a caesarean section, usually because your baby is not ready to be born.
If your midwife or doctor is suggesting that labour be induced it is important that you are given sufficient information about the risks and benefits of the proposed procedures and how likely they are to succeed, so you can make an informed decision.
Eating and drinking during labour is the natural way of making sure your nutritional needs are met so you don’t become dehydrated. While most women do not want to eat once labour is well established, you may want to eat and drink during the early phase of labour. There are no published data about the nutritional needs of women during labour, but it can be safely be assumed
that these are likely to be similar to those of a woman undertaking some form of strenuous athletic activity.
There is some evidence that shows the use of saline fluids has an effect on labour and can reduce the strength of contractions in active labour.
Listening to the baby’s heart and checking the amniotic fluid for the presence of meconium (baby’s first bowel movement) once your waters have broken are two ways of monitoring your baby’s wellbeing during labour. There are several different ways of listening to the baby’s heart and some are more intrusive than
others. Checking the baby’s heart rate regularly throughout labour can be done with a handheld stethoscope or sonicaid. Most hospitals now use electronic foetal monitors (EFM) to record the baby’s heart rate as well as the mother’s contractions. These devices were intended for use in high risk pregnancies but they have since become the norm. There is no evidence to support the routine use of continuous electronic foetal monitoring on all women, as it has not been shown to improve the outcome for babies and mothers. It does however restrict your ability to freely move around, and increases the rates of inappropriate
interventions.
There is no evidence to support the practice of doing an EFM trace on admission to hospital although a few hospitals still do this. While it is important that the wellbeing of both you and your baby is carefully monitored during labour, this monitoring does not necessarily require the use of special equipment.
Remember, the choice of how you and your baby are monitored during labour is yours.
Vaginal examinations during labour are performed to check how soft and how dilated your cervix is, how far down in the pelvis your baby is (station of the baby), and sometimes the position of your baby. Both the station and position of the baby can also be felt by palpating your baby through your tummy. If you have a vaginal examination it is important that an abdominal examination is performed as well.
The use of vaginal examinations to monitor the progress of labour is not a reliable method on its own because labour is not just a physical process but is also an emotional one. Watching how a woman is responding to her contractions and listening to the noises she makes can often convey just as much information
about the progress of labour. As vaginal examinations increase the risk of infection as well as being uncomfortable, talk to your midwife about what you want or don’t want with regards to vaginal examinations.
Recording your blood pressure throughout labour is an important aspect of monitoring your overall wellbeing. It is recommended that your blood pressure is measured four-hourly, although this may need to be done more frequently if there are medical interventions in place, eg. an epidural or a syntocinon IV drip.
Your temperature may also be monitored, particularly if you have other medical interventions.
Pain is a physically normal part of labour and birth. It is also involved in the vitally important hormonal processes that occur in you during labour and birth and in your baby during the critical transition from womb to world. Your ability to deal with the pain of labour can be enhanced by creating an intimate and private
birthing environment that is sensitive to your needs, and by having plenty of support and encouragement from your midwife and the support people you have chosen to be with you.
There are many ways of coping with the range of pain in labour that do not involve the use of drugs. They include being able to move freely around, adopting positions that feel more comfortable to you, having access to a large bath or a birth pool, using counterpressure to alleviate back pain, being touched or massaged, having access to acupuncture and acupressure, and using
aromatherapy, visualization, music and various forms of hypnosis.
While epidural analgesia offers the most effective form of pain relief during labour, having an epidural has major undesirable effects on all of the hormones of labour. These include interfering with the release of oxytocin which causes your uterus to contract, and beta-endorphin which helps you cope with contractions.
Studies have shown that the adverse effects of epidurals include increased length of first and second stage labour, increased use of oxytocin to augment labour, greater likelihood of the baby adopting an unfavourable position, an increased chance of needing a forceps or ventouse delivery, and an increased risk of pelvic floor problems. Other common side effects of epidurals include a drop in maternal blood pressure, the inability to pass or hold urine, itching, shivering, a rise in temperature, postpartum bleeding or haemorrhage, and unexpected breathing difficulties for the mother which can occur hours after the birth and may progress to respiratory distress.
There are also significant and well-documented side effects on the baby. Many of these are caused by the effects of the epidural on the mother, eg. maternal fever. They include changes in the baby’s heart rate, low oxygen and low blood pressure. There are also reports of newborn toxicity from the use of epidurals due to the fact that the opiate drugs enter the baby’s circulation within minutes.
Whatever methods of pain relief you choose, it is important that you find out as much as possible about their benefits and side effects – for both you and your baby – and discuss your preferences with your LMC.
The NZ College of Midwives has a booklet Pain in Labour which we also recommend that you read.
When labour is thought to be progressing slowly your LMC may suggest strengthening your uterine contractions by the use of an intravenous administration of syntocinon. As noted in the section on induction there are always risks attached to the use of these powerful drugs, especially when you are making some progress. Each labour is unique and you should be encouraged to let your labour progress naturally.
As labour is as much an emotional and psychological process as it is a physical one it is essential that you are able to create the environment you need for labour and birth. When women in labour are free to move around as much or as little as they wish, to eat and drink when they want, and to adopt the positions they feel most comfortable in, they are less likely to need to have their labour augmented by the use of syntocinon. Encouraging women to labour undisturbed by unwanted noise, bright light, and feeling observed and monitored, thus avoiding situations likely to trigger the release of hormones of the adrenaline family, means they will have the privacy, safety and security they need for their labour
to progress normally.
Labouring and/or birthing in water
The healing, pain-relieving and relaxing properties of water have been known for centuries. Most maternity hospitals now have labour and birthing pools for women to use during labour as a result of the widespread demand by women for access to this method of comfort and pain relief during labour. Water also helps women to relax, tune into their body and retreat into another world.
If you want to be able to spend part of your labour in a birthing pool then find out if the hospital you have chosen has enough pools to ensure that you will have access to one when you arrive at the hospital. You will also need to talk to your LMC about your wish to use a labour and birthing pool.
Positions for labour and birth
Labour is not considered to have started until your cervix is 3-4cms dilated and is completely thin or effaced. Evidence shows that prior to reaching this stage it is best if you stay at home in your own environment. If you go to the hospital too early, before your cervix has begun to dilate properly, you are likely to be sent home.
Once labour is well established it is important that you are free to adopt the positions that are most comfortable for you. Changing positions alters the relationships between gravity, your uterine contractions, your baby, and your pelvis, and this helps with the progress of labour. It may also reduce the amount of pain you feel.
These are two methods of instrumental delivery that involve assisting the baby to be born vaginally during the second stage of labour.
A forceps delivery involves inserting each blade into the vagina and placing them on either side of the baby’s head and then pulling the baby out. The use of forceps has decreased over the past decade due to the greater risks of injuring the mother and the baby compared to the use of a ventouse, and the increasing
preference to resort to a caesarean section.
The ventouse is a metal or silastic/soft cup which is applied to the baby’s scalp. While the mother pushes during a contraction the doctor helps to pull the baby out. The use of ventouse has increased as it is easier to use and has the potential to cause less harm than forceps to both mother and baby.
There has been considerable disagreement about which method is preferable with English-speaking countries having a greater tendency to use forceps and European countries preferring the ventouse also known as vacuum extraction. The success or failure of each instrument is largely dependent on the skill and
experience of the doctor in using either of them. As there are potentially significant complications to both mothers and babies associated with the use of either instrument, it is important that you find out about these and discuss them with your LMC and/or doctor prior to labour.
Caesarean section is now the most commonly performed surgical procedure in the western world. As caesarean section rates continue to rise, there is mounting evidence of the short- and longterm harms that having a caesarean poses for mothers and babies. A caesarean section can be a life-saving operation for a mother and/or her baby in a small number of situations. However, many of
the caesarean sections performed these days are not necessary and there is now good evidence that for most women the overall risks and long-term harms of such surgery outweigh the benefits.
There are important differences for you and your baby between a caesarean section that is performed prior to labour, known as an elective caesarean, and one that is performed after you have spontaneously gone into labour, usually referred to as an emergency caesarean. The experience of going into labour
spontaneously ensures that your baby’s lungs are mature and she/he is ready to be born. An elective caesarean reduces your chances of being able to give birth vaginally to your next baby.
If your doctor or midwife suggests or recommends that you have a caesarean section then it is important that they explain the risks and benefits of the operation so that you can make an informed decision. The MSCC has produced a leaflet Caesarean Section: The Facts which we also recommend you read.
Oxytocin and skin-to-skin contact
Oxytocin, along with a number of other hormones, plays an important role in both labour and birth, in breastfeeding and in maternal behaviour. This particular hormone is known as the hormone of love. According to obstetrician Michel Odent, there are good reasons to believe that in humans, brain receptors to
oxytocin also develop during labour and birth. This is one of the important ways a woman develops her capacity to love while giving birth.
The most appropriate place for your healthy newborn baby to be immediately after birth is in close body contact with you. You may choose to delay the health checks on newborn baby for several hours. This holds true whether your baby is born vaginally or by caesarean section, and whether you plan to breastfeed or bottlefeed. Undisturbed early skin-to-skin contact meets all of your baby’s physical needs, provides your baby with a very effective way of regulating its temperature, and enables easy access to your breast. The touch of your nipple by your baby’s lips increases oxytocin in both your brain and your baby’s brain. This then causes the increase in output of the very important gastrointestinal hormones that help your baby absorb nutrients.
For both you and your baby, the peak hormone levels that occur after birth when you are in skin-to-skin contact with your baby reduce stress by increasing the levels of stress-reducing hormones such as oxytocin and beta-endorphin. It also increases the level of prolactin, the main hormone responsible for the production
of breastmilk.
There is now good evidence to support a natural third stage that respects the emotional and hormonal processes of both you and your baby as you meet for the first time. This involves delaying clamping your baby’s cord until after it has stopped pulsating or you have birthed the placenta, delaying or forgoing the routine injection of syntocinon, and having skin-to-skin contact with your
baby. This level of non-interference requires a caregiver or LMC who has the confidence, skill and experience to adopt a hands-off approach at this profound moment.
The increasingly medical management of the third stage of labour has seen the process of actively managing this third stage become routine. Much of the anxiety around this stage concerns the possibility of postpartum haemorrhage (PPH). However, medical interference in the birth process often serves to create some of the problems it aims to address.
Active management of the third stage can result in your baby being deprived of up to one-third of its expected blood volume, and the drugs and procedures may pose extra risks for you.
It is important that you discuss with your LMC what you want or don’t want at this extremely sensitive time following birth.
There is no published evidence that storing a baby’s cord blood will offer the benefits claimed by the private, for-profit umbilical cord blood bank that was established in New Zealand in 2003. It costs $2,500 to have a baby’s cord blood stored, plus the annual $200 storage fee. According to one New Zealand cancer specialist new stem cell technology developed over the past two years will
most likely make storing umbilical cord blood stem cell redundant.
Cord blood storage involves early clamping of the baby’s cord and the taking of a significant amount of blood at birth, blood that the baby needs for both making the transition to the outside world and for its iron stores. According to one source, clamping of the baby’s cord should not occur prior to 30 seconds after the birth
as it could lead to the baby being deprived of up to a third of its normal circulating blood volume.
Further information on the issues surrounding cord blood banking can be accessed from the MSCC’s website – www.maternity.org.nz
“Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine – nil nocere (do no harm).”
G.J. Kloosterman, Professor of obstetrics, The Netherland
References available on request