Delivery / Post Delivery

Summary: Childbirth through labouring and vaginal delivery is the most common way in which your child is born. There are multiple stages and can take many hours.

Childbirth through labouring and vaginal delivery is divided into stages.

The First Stage (the "onset of labour") is generally considered to have commenced when you start having regular uterine contractions (as opposed to Braxton Hicks contractions or "false labour") less than 10 minutes apart. The purpose of this stage is for your body to prepare itself for the actual birth. Primarily, the cervix (which is the opening into the uterus) will progressively thin, stretch and widen which is called cervical dilation. During this stage you should not try to "push" or "bear down". The first stage of labour can last many hours, however it tends to be shorter or quicker in subsequent deliveries.

The Second Stage of labour commences when the cervix is fully dilated and the babies head is fully engaged in the pelvis. This stage can last from 20 minutes up to 2 hours and will culminate in the physical delivery of your baby. Provided there are no complications and your baby is in good health you will immediately be given your baby to cuddle including skin-to-skin contact to help with bonding. In some cases your paediatrician may need to help your baby to establish breathing or to clear some mucus from the nose and mouth. The umbilical cord will be clamped and, if you wish, your partner may cut the umbilical cord.

The Third Stage of labour is delivery of the placenta.

RANZCOG have produced a Patient Information Resource on labour and birth with additional information.

Summary: The aim of CTG monitoring in labour is to record the baby’s heartbeat pattern to assess wellbeing.

It is possible to create a continuous record of the unborn baby’s heartbeat using Doppler ultrasound. The woman wears two plastic discs containing sensors on her abdomen, held by a belt around her waist. One sensor picks up the baby’s heartbeat and the other detects contractions. The continuous, combined recording of the baby’s heartbeat and contractions is called the ‘cardiotocograph’ (CTG).

The RANZCOG have produced a Patient Information Resource on Monitoring the Baby's Heart Rate in Labour.

Summary: There are a number of pain relief options available including medical options (like nitrous oxide, pethidine and epidural analgesia) and non-medical (like heat packs, cold packs, controlled breathing and meditation). We will discuss your needs and circumstances to find the right ones.

Childbirth can, at times, be painful. Fortunately there are a range of pain relief options available. It is important to note that in some cases the pain associated with childbirth can be overwhelming or much greater than anticipated. If, during labour, you find that the pain becomes too much then please do not hesitate to speak up and let us know.

Medical pain relief includes:

• Epidural: An anaesthetist will inject a pain killing medication into the epidural space of the spinal cord which can block sensation and pain sensation by blocking signals through the nerve fibers in or near the spinal cord. An epidural usually provides rapid and very effective pain relief and is generally quite safe. However there can be some increased risks - which we will discuss with you - including potential for fetal distress so usually increased monitoring of your baby is also required.

• Fentanyl: A drug similar to morphine and pethidine. It is a commonly used pain relief medicine during labour. It is now more widely used than Pethidine as it has a faster onset and wears off quicker. It helps the body block pain signals and can reduce the perception of pain. It is commonly given via a small tube which sits under the skin. It can for some women cause sedation, nausea, vomiting or itch. It does cross the placenta but is cleared quickly from the baby. After birth the midwife will monitor the baby and very rarely if the baby is too sleepy an antidote can be given.

• Nitrous Oxide: Also known as "happy gas" or "laughing gas" it is also commonly used with dental procedures. It is usually administered via breathing through a mouthpiece held in the mouth during contractions. Unfortunately, in around one third of people nitrous oxide only provides limited or no pain relief. Side effects can include nausea.

Non-medical pain relief includes:

• Heat Packs / Cool Packs: Or alternatively warm / cold washers or a warm shower.

• Controlled Breathing: focusing on slow, gentle, controlled breaths.

• Meditation / Relaxation: such as the techniques of Hypnobirthing, Calm Birthing, or JuJu Sundin Birth Skills.

RANZCOG have produced a Patient Information Resource on pain relief.

Summary: Your baby being in a breech position at term occurs in around 3%-5% of pregnancies, if this occurs we will discuss the implications with you.

The expected positioning of your baby for delivery is with their head down so that it can engage with your pelvis during delivery. If your babies head is up (bottom or feet down) immediately prior to delivery then your baby is considered to be in the breech position. The risk of complications occuring during delivery if your baby is in the breech position is significantly higher. We will always discuss your individual circumstances with you first, but we are likely to recommend a Caesarean Section in these situations. The RANZCOG have produced a Patient Information Resource on Breech Presentation at the End of your Pregnancy.

Sometimes it is possible for a baby in the breech position to be rotated by a procedure called an External Cephalic Version (ECV) to enable a normal vaginal delivery to be planned, however the success rate may only be around 50%. We would discuss the risks and benefits in the context of your individual circumstances with you first. The RCOG have produced a brochure on ECV "External Cephalic Version"

Summary: There are a number of reasons why we may recommend inducing labour but we will always discuss these with you first.

Induction of labour is where the commencement of the first stage of labour is triggered artificially through the use of medications. It is commonly associated with pregnancies where labour has not commenced naturally within 1 - 2 weeks after term due to the risks of an adverse outcome increasing significantly from 42 weeks gestation onwards. However it may be recommended in many other circumstances, for example to assist with the management of various complications like pre-eclampsia or if the pregnancy was achieved through IVF.

The RANZCOG have produced a Patient Information Resource on Induction of Labour.

Summary: Sometimes it may be necessary to assist a vaginal delivery through the use of ventouse or forceps. Such a decision would depend on your specific circumstances and the progress of your labour.

There are many reasons why an assisted delivery through the use of ventouse or forceps may be required, including if there are concerns for your baby's health during delivery or if the delivery is not progressing as expected. A ventouse is a vacuum extraction cup that is attached to the top of your baby's head that is used to help pull your baby during delivery. Often multiple pulls may be required. Forceps are best described as a pair of spoons or tongs that are curved to fit around your baby's head. Again, often multiple pulls may be required.

The RANZCOG have produced a Patient Information Resource on Assisted Birthing.

Summary: In some circumstances we may recommend a caesarean section. Where possible we will always discuss the reasons and implications with you first.

A Caesarean Section or C-Section is the delivery of your baby using surgical means during an operation. Typically we will deliver your baby through an incision across the lower segment although in some cases a more classical longitudinal incision will be used. Caesarean Sections are often categorised by urgency. A planned Caesarean Section may be recommended for a variety of reasons including unfavourable positioning for a vaginal delivery, twins / triplets, or for the management of a variety of complications. An emergency Caesarean Section may be required due to an obstructed vaginal delivery, foetal distress or due to other emergency complications.

The RANZCOG have produced a Patient Information Resource on Caesarean Section.

Summary: If you have had a previous caesarean section you may in some circumstances still be able to have a vaginal delivery. However there are risks and we will discuss these with you so you can make an informed decision.

A vaginal birth after caesarean section (VBAC) has some specific risks that need to be considered. For example the reason that you needed a previous caesarean section for may still exist. There is also a small chance that the previous scar may rupture which despite having a low chance of occurring is a very serious complication.

A recommendation for a VBAC can only be done on a case-by-case basis after understanding your particular circumstances. However in general we do not recommend a VBAC where:

• You have had more than one previous caesarean section.
• You have an increased risk of obstructed labour.

The RANZCOG have produced a Patient Information Resource on Vaginal Birth after Caesarean Section.

Summary: Cord blood collection is an option if you want it.

Cord blood is blood left behind in the umbilical cord and placenta after delivery and has a significant percentage of stem cells. In particular it can be donated to patients who need a bone marrow transplant. Increasingly, there are claims that cord blood can prevent and / or cure a whole range of diseases however the reality is that this is still an emerging science. Research is ongoing around the world and it has the potential for some very interesting developments. For further information see:

• Cell Care

RANZCOG have produced a Patient Information Resource on Umbilical Cord Blood Banking with additional information.

There are a number of unlikely concerns that may arise during delivery. The RCOG have produced a number of brochures and we have included them here for reference even though they have a low likelihood of occurring. Please be aware however that this list is by no means exhaustive.

• Umbilical Cord Prolapse in Late Pregnancy
• Shoulder Dystocia

Summary: Sometimes, following delivery, additional intervention is necessary for example for the repair of tears or management of heavy bleeding.

In a small number of cases additional intervention may be required following the delivery of your baby.

• Third or Fourth degree vaginal tears: Can occur during later stages of labour and are tears of the perineum (the area between the vagina and the anus) which, if severe enough, may require stitches to repair. A third degree tear extends to the anal sphincter and a fourth degree tear extends to the anus. In some cases we undertake a surgical cut called an episiotomy to try and control the amount of tearing and to enable more effective repair post delivery. The RCOG have prepared a brochure on Third and Fourth degree vaginal tears
• Postpartum Haemorrhage: is excessive bleeding following delivery. It is usual for there to be some bleeding following delivery but usually the body is well able to handle the blood loss. However in around 6% of cases the bleeding can be excessively heavy and may require intervention. The RCOG have prepared a brochure on Postpartum Haemorrhage.In some cases a Blood transfusion may be required.
• Retained Placenta: sometimes all or part of the placenta fails to detach completely which can cause painful cramping, fever, foul discharge or heavy bleeding (postpartum haaemorrhage). Often you will be given oxytocin to cause the uterus to contract which helps the placenta be expelled to minimise the likelihood of retention. In some cases manual removal or a Dilation & Curettage may be required.
• Venous Thrombosis: pregnancy increases the risk of venous thrombosis with the highest risk being shortly after delivery. There is a risk that if part of the blood clot breaks off, travels around the body, and gets lodged in the lung it can cause a pulmonary embolism. Symptoms of a pulmonary embolism can include collapsing, tightness in the chest and sudden difficulty breathing. The RCOG have prepared a brochure on Reducing the risk of venous thrombosis

Summary: We strongly recommend your baby be given a vitamin k injection just after birth.

Babies do not get enough vitamin K from their mothers during pregnancy, or when they are breast feeding. Without vitamin K, they are at risk of getting a rare disorder called Vitamin K Deficiency Bleeding which in rare cases can cause bleeding into the brain, brain damage, or even death. A single injection immediately after birth can provide protection for several months. After about 6 months babies will have built up their own supply. Additional information on vitamin k at birth can be found at HealthDirect.

Summary: The first few weeks after having a baby are a time of great change.

The first few weeks after having a baby are a time of great change. Regardless of the type of birth you have had, your body will go through many changes as it adjusts to not being pregnant and recovers. These changes are different for every woman.

The RANZCOG have produced a Patient Information Resource on The First Few Weeks Following Birth.