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L Labour and Birth

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Signs of Labour

Labour can start very quickly or it can seem to take ages. Sometimes it can start without you realizing it. The start of the first stage is often slow and it may take a while to establish that you are actually in labour. Once you are well dilated, your contractions are longer and stronger and your labour progresses more quickly.


THE FIRST STAGE:

The first stage is usually the longest and can last anything from one hour to twenty hours, or even longer.
Obvious signs of labour
The ‘show’: this is the release of the mucus plug, which seals the opening of the cervix. In some women it comes out of the vagina as a single blob of pinkish jelly; in others it is a series of smaller pieces, and in others it can be reddish brown and blood tinged.
It is a sign that the cervix is beginning to stretch and soften a little, in preparation for labour. It may not mean you are actually in labour. It can be several days between the show and the start of labour proper, or just an hour or so, or anything in between.
The breaking of the waters: the amniotic sac is the bag of fluid surrounding the baby inside the uterus. When the membranes break, or rupture, the fluid escapes. It can happen as a sudden gush of liquid down your legs. More usually, though, it will start to trickle.
There may be a risk of infection to the baby if the membranes rupture and labour doesn’t start within a day or so. If the baby’s head is not yet engaged, or if your baby is breech, a rush of waters may bring the cord with it. The cord could then become compressed which would be risky for your baby’s oxygen supply. Telephone your midwife or the hospital if your waters break.
Contractions: these are the only sure signs of labour if they gradually come closer together and last longer than 40 seconds. You should feel them getting stronger, longer and more rhythmical, too.
False alarms
Sometimes women start to have contractions and then they fade away. These can be deceptive, and make you think you are in labour. You go to hospital, only to find everything stops.
If this happens to you, you may be examined, and may be disappointed that you are not very far on in your labour; maybe your cervix doesn’t show that the contractions have had any effect at all. In this situation, you may be asked if you’d prefer to go home. This is sensible, unless you live a long way from the hospital. Don’t feel embarrassed, or worry. This sort of false alarm happens all the time. See our section called Braxton Hicks for more information.

SECOND STAGE :

Giving birth to your baby
Your midwife is crucial at this stage. She will guide you through the labour, encouraging you and helping you and your partner in the last minutes before the birth.
At this stage, contractions are helping to push your baby out. You may want to try different positions at this point and find the one that feels best for you.
What you can do
When you reach the second stage, you will probably feel a powerful urge to push. This is called bearing down. You may want to push about three times in each contraction. You may feel when the time is right to push, or your midwife will guide you.
If you have had an epidural for pain relief , you may not feel the urge to bear down as strongly, so your midwife will tell you when you should push. Some women like to hold their breath when they are pushing but it’s important not to hold it for too long.
As your baby’s head stretches the birth canal and the perineum (the area of skin between the vagina and the anus), you may feel a powerful burning sensation, which normally lasts only a few minutes.
You will feel your perineum stretch at this point. If there’s a risk of tearing, you may be asked to stop pushing (see Episiotomy below). Instead, you may be asked to pant or push more gently to ‘breathe the baby out’. If a small tear in your perineum occurs it may need to be repaired after your baby is born.
When her head can be seen completely at the vulva it is ‘crowning’. This is a truly amazing moment. The midwife may encourage your partner to have a first look at your new baby.
With the next couple of contractions, your baby’s head comes out. The midwife may feel for the umbilical cord to make sure it’s not around her neck. Your baby’s shoulders will turn so that she’s sideways on, facing your leg. The rest of her body then comes out quickly and easily.
Your baby is born!


Episiotomy
Sometimes the perineum doesn’t stretch easily over the baby’s head. Your midwife may suggest that she cuts the perineum to help with the birth of the baby’s head. This cut is known as an ‘episiotomy’. Before the procedure is performed, a local anesthetic may be injected into the muscle to reduce the discomfort or pain during the procedure.
Episiotomy is only done when necessary and is not a routine procedure so it will be discussed with you. You will need stitches after the birth.
Routine actions in the third stage

THIRD STAGE:

In most hospital units, the third stage is ‘actively managed’, which may speed up this stage of labour. However, you may choose a physiological, ‘unaided’ third stage.
Physiological third stage
An unaided or physiological third stage happens without an injection or cord traction and can take longer than an ‘actively managed’ third stage. The action of breastfeeding your baby, or simply having her lie on your chest with skin-to-skin contact, stimulates the release of the hormone oxytocin. This helps your uterus to contract and push out the placenta and the membranes. The cord is cut when it stops pulsating, often after the placenta is delivered.
You may want to discuss the third stage and whether it is actively managed or not when making your birth plan. If you have problems in the first or second stages of your labour (or with a previous birth) then a physiological third stage may not be a safe option. Discuss this with your midwife.
Complications
Sometimes complications can occur:
           •    Occasionally, the placenta does not detach from the uterus. When this happens, the mother needs a small operation (under anaesthetic) to remove it.
          •    Sometimes women will bleed severely during the third stage. This is called postpartum haemorrhage or PPH and needs to be treated immediately.     Routine ‘actively managed’ third stage
          •   You may have an injection to cause the uterus to contract or shrink. This is given when the baby is being born, usually when the first shoulder is coming out. The injection will go into your thigh or buttock and the midwife will ask your permission first.
          •    Once your baby is born, the umbilical cord is clamped and cut.
        •    As the injection takes effect, it stimulates the uterus into contracting, causing the placenta to detach. At this stage, you may be able to push the placenta out. More usually, the midwife will help deliver it by putting a hand on your tummy to protect the uterus and keeping the cord taut (this is called ‘cord traction’).
     •    The placenta comes away and the blood vessels that were ‘holding on’ to it close off as the muscle in your uterus contracts. This prevents bleeding – although it’s normal to bleed a little. You may feel the placenta slide down and out between your legs, followed by the membranes.
After the birth
You may hardly be aware of the third stage, as you will be focused on your baby. Seeing and handling your baby, and offering her your breast will stimulate hormones that help the placenta to separate. You may feel shaky due to adrenaline and the adjustments your body immediately starts to make, or you may simply be on a high. You may find it hard to pay attention to the baby if you have had a long labour. There’s nothing wrong with your maternal instincts; you are simply exhausted. If this happens to you, take your time. After a rest you will be much more interested in getting to know your baby. A lot of women are very hungry and ready for tea and toast, while others want to telephone everyone and tell them the wonderful news!
Admire your new baby. Count her fingers and toes. Hold her close to your body, preferably skin to skin. Rest together in skin to skin contact. Baby may start to show signs that she wants to feed and you can then offer your breast. If you’re going to breastfeed, offer your breast as soon as possible; your midwife will help you. Don’t worry if your baby doesn’t seem very interested. Even if she’s only touching and nuzzling you, this will help her to get going with breastfeeding.
If you are unsure of whether you want to breastfeed, then decide to give it a try. You can always stop later if it is not for you, and then your baby will have received some of the benefits of breastfeeding. Starting breastfeeding later on, is much more difficult.
Stitches
Small tears and grazes are often left to heal without stitches because they often heal better this way. If you need stitches or other treatments, it should be possible to continue cuddling your baby. Your midwife will help with this as much as they can.
If you have had a large tear or an episiotomy, you will probably need stitches. If you have already had an epidural, it can be topped up. If you haven’t, you should be offered a local anesthetic injection.
The midwife or maternity support worker will help you to wash and freshen up before leaving the labour ward to go home or to the postnatal area.


Post-partum haemorrhage

Post-partum haemorrhage (PPH) is a complication that can occur during the third stage of labour, after a baby is born. PPH is extremely rare in the UK. Losing some blood during childbirth is considered normal. PPH is excessive bleeding from the vagina at any time after the baby’s birth, up until six weeks afterwards.
There are two types of PPH, depending on when the bleeding takes place:
•    primary or immediate – bleeding that occurs within 24 hours of the baby’s birth
•    secondary or delayed – bleeding that occurs after the first 24 hours, up to six weeks after the birth
Depending on the type of PPH, the causes include:
•    contractions stopping after the baby is born (uterine atony)
•    part of the placenta being left in the womb (known as ‘retained placenta’ or ‘retained products of conception’)
•    infection of the membrane lining the womb (endometritis)
To help prevent PPH, you will be offered an injection of Syntocinon as your baby is being born, which stimulates contractions and helps to push the placenta out.

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