Delivery
Delivery
Going into labour is exciting, but you may also feel apprehensive, so it helps to be prepared well in advance. Knowing all about the stages of labour and what to expect can help you to feel more in control when the time comes.
Hospital Bag
You should get a few things ready at least two weeks before your due date.
- Something loose and comfortable to wear during labour.
- Comfortable and supportive bras, including nursing bras
- Sanitary pads
- Basic toiletries like toothbrush, toothpaste, hairbrush.
- Towels
- Things that can help you pass the time and relax, e.g. books, magazines
- Front-opening nightdresses, which help to breastfeed.
- Slippers.
- A loose, comfortable outfit to wear after you have given birth and to come home in.
- Clothes soft material preferably cotton including a cap
- Warm clothes like vest, mittens, booties etc especially in winter
- Diapers
- A shawl or blanket to wrap the baby in
- Wet wipes
- Hand sanitizer
- Baby soap
- Baby oil
- Baby powder
- Regular uterine contractions: During a contraction, your uterus gets tight and then relaxes. You may have had these throughout your pregnancy – particularly towards the end. Before labour, these are called Braxton Hicks contractions. When you are having regular contractions that last more than 30 seconds and begin to feel stronger, labour may have started. You will feel tightness and hardening of the uterus for 20 to 30 seconds every10 to 15 minutes initially and gradually the contractions will become longer, stronger and more frequent.
- Backache or the aching, heavy feeling that some women get with their monthly period.
- The ‘show’. The plug of mucus in the cervix, which has helped to seal the uterus during pregnancy, comes away and comes out of the vagina. This small amount of sticky pink mucus is called the ‘show’. It usually comes away before or in early labour. There should only be a little blood mixed in with the mucus. If there is heavy vaginal bleeding, report to the hospital immediately.
- Bag of membranes rupture (bag of waters break). The bag of water surrounding your baby may break before labour starts. If your waters break before labour starts, you will notice either a slow trickle from your vagina or a sudden gush of water that you cannot control.
- Nausea or vomiting
- Diarrhoea
Pain relief in labour
1.Self-help
The following techniques can help you to be more relaxed in labour, and this can help you to cope with the pain.
- Learn about labour. This can make you feel more in control and less frightened about what is going to happen. Read books like this one, talk to your doctor and attend antenatal classes
- Learn how to relax and stay calm. Try breathing deeply.
- Keep moving. Your position can make a difference. Try kneeling, walking around or rocking back and forwards.
- Have a partner, friend or relative to support you during labour.
- Have a bath.
2. Intramuscular injections of pain- relieving drugs
Epidural is a special type of local anaesthetic. It numbs the nerves which carry pain from the birth canal to the brain. For most women, an epidural gives complete pain relief. An anaesthetist is the only person who can give an epidural.
How it works
A drip will run fluid into a vein in your arm.
While you lie on your side or sit up in a curled position, an anaesthetist will clean your back with antiseptic and numb a small area with some local anaesthetic.
A very small tube will be placed into your back near the nerves that carry pain from the uterus.
Drugs (usually a mixture of local anaesthetic and opioid) are then administered through this tube. It takes about 20 minutes to get the epidural set up and then another 10–15 minutes for it to work.
After it has been set up, the epidural can be ‘topped up’ by an anaesthetist or you may be given a machine, which will let you top up the epidural yourself.
Your contractions and the baby’s heart will need to be continuously monitored by a NST machine. This means having a belt round your abdomen and possibly a clip attached to your baby’s head.
Side effects
- Epidurals may make your legs heavy. It depends on the type of epidural that you have.
- An epidural should not make you feel drowsy or sick.
- Your blood pressure can drop. This is rare, as the drip in your arm will help you to maintain good blood pressure.
- Epidurals can prolong the second stage of labour. If you can no longer feel your contractions, the doctor/ nurse will have to tell you when to push. This may mean that instruments like forceps/ vacuum may be used to help you deliver your baby.
- About 1 in 100 women gets a headache after an epidural. If you develop headache afterwards, it can be treated.
- Your back might be a bit sore for a day or two, but epidurals do not cause long-term backache.
About 1 in 2,000 mothers gets a feeling of tingling or pins and needles down one leg after having a baby.
Some women want to avoid the above methods of pain relief and choose acupuncture, aromatherapy, homeopathy, hypnosis, massage and reflexology. Most of these techniques do not provide very effective pain relief.
What Happens In Labour?
There are four stages of labour. In the first stage the cervix gradually opens up (dilates). In the second stage, the baby is pushed down the vagina and is born. In the third stage the placenta comes away from the wall of the uterus and
is also pushed out of the vagina. Fourth stage is the stage of observation for 1 hour after the delivery.
The first stage of labour – The dilation of the cervix and effacement (softening) of the cervix
The cervix needs to open to about 10cm for a baby to pass through. This is called ‘fully dilated’. Contractions at the start of labour help to soften the cervix so that it gradually opens. Sometimes the process of softening can take many hours before what midwives refer to as ‘established labour’. This is when your cervix has dilated to at least 4cm.
Fetal heart monitoring
Your baby’s heart will be monitored throughout labour. There are different ways of monitoring the baby’s heartbeat.
- Baby’s heart will be heard intermittently, but for at least one minute every 15 minutes when you are in established labour, using a stethoscope or a hand-held doppler. This method allows you to be free to move around.
- Your baby’s heartbeat and your contractions may also be followed electronically through a monitor linked to a machine called a CTG. The monitor will be strapped to your abdomen on a belt.
Speeding up labour
- Your labour may be slower than expected if your contractions are not frequent or strong enough or because your baby is in an awkward position.
- Your bag of membranes will be artificially ruptured (if this has not already happened) during a vaginal examination. This is often enough to get things moving.
- If this doesn’t speed up labour, you may be given a drip containing oxytocin (Pitocin), which is fed into a vein into your arm to encourage contractions. You may want some pain relief before the drip is started.
- After the drip is attached, your contractions and your baby’s heartbeat will be continuously monitored.
In early labour, you can have liquids and maybe a light snack. You can walk around until you are comfortable. As the contractions start getting more frequent and stronger, deep breathing and relaxation technquies are helpful.
The second stage of labour – the baby’s birth
This stage begins when the cervix is fully dilated, and lasts until the birth of your baby.
Pushing
When your cervix is fully dilated, you can start to push when you feel you need to during contractions:
- Take two deep breaths as the contractions start, and push down.
- Take another breath when you need to.
- Give several pushes until the contraction ends.
- After each contraction, rest and get up strength for the next one.
- The skin of the perineum usually stretches well, but it may tear. Sometimes to avoid a tear or to speed up the delivery, the midwife or doctor will inject local anaesthetic and cut an episiotomy. Afterwards, the cut or tear is stitched up again and heals.
Once your baby’s head is born, most of the hard work is over. With one more gentle push the body is born quite quickly and easily.The cord is clamped and cut, and the baby is handed over to the paediatrician.
The third stage of labour – the placenta
After your baby is born, the uterus can contract to push out the placenta.
An injection contains a drug called oxytocin will be added to your drip or given intramuscularly in your thigh, which makes the uterus contract and helps to prevent the heavy bleeding which some women experience.
Let your baby breastfeed as soon after birth as possible.
Fourth stage
1 hour of observation of the mother’s vitals( pulse, blood pressure) and vaginal bleeding after delivery
Episiotomy
It is the deliberate cut given on the perineum during second stage of labour when the head is about to deliver in order to avoid vaginal tears. It is not essential in all women but those delivering for the 1st time may need it, big babies, and premature deliveries.
Once the placenta has delivered, the vagina is cleaned and the episiotiomy cut is sutured and stitched back completely with absorbable (dissolving) stitches. These stitches do not need to be removed later. The stitches do not require dressing. It is left open. It has to be kept clean and dry. The stitches will heal in 8 to 10 days. If the stitches are very painful, report to your doctor.
After a normal delivery
- Breast feed as soon as possible
- You can have water, coconut water, tea or coffee immediately.
- You can first sit up in bed and stand up and walk around with someone’s help , if needed within 2 to 3 hours after delivery.
- You will be encouraged to pass urine in the bathroom as soon as you can, ideally within 4 to 6 hours after delivery.
- You can start eating as soon as you feel like.
- You can eat all regular food (full diet). There are no restrictions.
- You may have constipation or passage of hard stools: a high fibre diet is recommended. If the problem persists, contact your doctor for laxatives but do not strain excessively.
- You will be discharged on the 2nd / 3rd day if everything is ok with you and the baby
Induction of labour
Labour can be induced if you have crossed your expected date of delivery and not gone into labour, or there is any sort of risk to you or your baby’s health – for example, if you have high blood pressure or if your baby is failing to grow and thrive. Induction is always planned in advance, so you will be able to talk over the benefits and disadvantages with your doctor and find out why they recommend your labour is induced.
Contractions are usually started by inserting a gel or tablet into the vagina or sometimes an oral tablet can also be given. Induction of labour may take a while (24 hours to 48 hours), particularly if the mouth of the uterus (the cervix) needs to be softened. Sometimes a hormone drip is needed to speed up the labour. Once labour starts it should proceed normally, but it can sometimes take 24–48 hours to get you into labour.
Assisted birth (forceps or ventouse delivery)
About one in eight women have an assisted birth, where forceps or a ventouse are used to help the baby out of the vagina. This can be because:
Your baby is distressed your baby is in an awkward
Position you are too exhausted.
Both ventouse and forceps are safe and are used only when necessary for you and your baby.
As the baby is being born, a cut (episiotomy) may be needed to enlarge the vaginal opening. Any tear or cut will be repaired with stitches
Ventouse/Vacuum (Delivery)
A ventouse (vacuum extractor) is an instrument that has a soft or hard plastic or metal cup, which is attached to your baby’s head by a tube that is fitted to a suction device. The cup fits firmly onto your baby’s head and, with a contraction and your pushing, the obstetrician or midwife gently pulls to help deliver your baby.
The suction cup (ventouse) can leave a small mark on your baby’s head called a chignon, however it will disappear after delivery. It may also cause a bruise on your baby’s head called a cephalhaematoma. A ventouse is less likely to cause vaginal tearing than forceps.
Forceps
Forceps are smooth metal instruments that look like large spoons or tongs. They are curved to fit around the baby’s head. The forceps are carefully positioned around your baby’s head and joined together at the handles. With a contraction and your pushing, an obstetrician gently pulls to help deliver your baby.
Forceps can leave small marks on your baby’s face. These will disappear quite quickly.
You may sometimes be fitted with a urinary catheter (a small tube that fits into your bladder) for up to 24 hours after instrumental delivery
Caesarean section
There are situations where the safest option for you or your baby is to have a caesarean section. As a caesarean section involves major surgery, it will only be performed where there is a real clinical need for this type of delivery.
Your baby is delivered by cutting through your abdomen and then into your uterus. The cut is made across your abdomen, just below your bikini line. The scar is usually hidden in your pubic hair.
Most caesarean sections are performed under spinal anaesthesia (injection in your back which makes everything from your umbilicus downwards numb but you are awake). It minimises risk and means that you are awake for the delivery of your baby. A general anaesthesia is required only in very few conditions.
If you have an epidural or spinal anaesthesia, you will not feel pain– just some tugging and pulling as your baby is delivered. A screen will be put up so that you cannot see what is being done. The doctors will talk to you and let you know what is happening.
Urgent (emergency) caesareans
Urgent (emergency) caesarean sections are necessary when complications develop and delivery needs to be quick. This may be before or during labour.
This maybe needed in certain conditions like fetal distress (baby’s heart beats are dropping), abruption (placenta suddenly gets prematurely separated), and prolonged 2nd stage of labour.
- An intravenous line will be secured, if not already done and and intravenous fluid will be connected.
- An injection to increase the emptying of stomach will be given (Reglan/ Rantac) as your stomach will not be empty, which is needed for spinal anesthesia
- An antibiotic injection will be given.
- A sample of blood will be collected and sent to the blood for cross matching to be kept reserved by your name if needed in emergency.
- A signature from you and one of your relative present will be taken on the consent form.
- You will be shifted to the operation theatre on a stretcher immediately.
Planned (elective) caesareans
A caesarean is ‘elective’ if it is planned in advance. This usually happens because your doctor or midwife thinks that labour will be dangerous for you or your baby. Some of these conditions are placenta praveia (placenta is low), big baby, breech, twins if the 1st baby is not cephalic (head down), severe growth restriction in the baby (IUGR), severe PIH (very high blood pressure).
In case of a planned caesarean section,
- You will have to be admitted in the evening one day prior to the surgery with all your reports.
- Anaesthetist check up will be done the night prior to the surgery for anaesthetic fitness
- You can have only one relative waiting with you at night in the hospital
- The surgery will be the next day in the morning. Exact timing will be told to you at night.
- You can have normal meals the whole day one day prior and preferably an early dinner by around 8-8.30 pm. Home cooked, regular food is advisable.
- You should not eat or drink anything not even water after 10 pm the night before the surgery. Intravenous fluid will be started at night. Any tablets to be taken in the morning will be given by the sister on duty.
- Shaving and preparing of parts (full abdomen, private parts and upto the mid thigh level) will be done by the sister on duty.
- Blood sample will be collected at the time of accessing IV line to be sent to be blood bank and if required some blood tests maybe repeated.
- A signature will be taken from you and your relative on the consent form.
- You should have a bath early in the morning (6 am) of the surgery and wear the hospital gown.
- You will be shifted to the operation theatre about 15- 20 minutes before the scheduled time of surgery.
Once a caesarean always a caesarean?
If you have your first baby by caesarean section, this does not necessarily mean that any future baby will have to be delivered in this way. Vaginal birth after a previous caesarean can and does happen. This will depend on your own particular circumstances.
- You will be kept in the recovery room for observation for about 45 minutes to 60 minutes and then shifted to your room.
- You will be uncomfortable and will be given painkillers. Injectable antibiotics will also be given.
- Breastfeeding must be initiated as soon as possible.
- You will not be allowed to eat or drink anything for at least 12 hours after the surgery.
- You will receive intravenous fluids.
- You will be started with clear liquids 1st (water, cocnut water, juice) followed by tea/coffee and then as per instructions of your doctor you will be graduated the 2nd day to soft diet (soft rice, dal, upma, khichadi, soup) and the 3rd day to full regular diet.
- You will usually be fitted with a urinary catheter (a small tube that fits into your bladder) for up to 24 hours. You will be encouraged to pass urine in the bathroom once the catheter is removed within 3 to 4 hours.
- You will be encouraged to do leg movements and side-to-side movements on the 1st day in bed. You may sit up in the bed. Feeding is best done in sitting position with the back supported.
- You will be encouraged to ambulate (walk around) from the 2nd day onwards.
- The dressing of the stitches will be removed on the 3rd day the stitches will be kept open; you will be given a powder to apply on it.
- You may have a bath from the 3rd day onwards but keep the area of the stitches completely dry. In case there are some different instructions as can be in some high risk patients, you will be told specifically.
- You will be discharged on the 3rd / 4th day if everything is normal with you and the baby.
- Stitches will heal in 10 to 14 days
Follow up
After normal delivery /caesarean section after 7 days and then after 11/2 months.