Caesarean birth

Vaginal births are the natural way to give birth to an infant and, while most women aspire to have a complication-free vaginal birth, there are some instances during labour when health and safety concerns for both mother and infant make natural birth too risky and medical intervention is required, resulting in an emergency caesarean. Other medical complications or personal choice can result in a planned caesarean and in these instances birth is scheduled and labour is not experienced by the mother.

Vaginal birth

Vaginal birth experiences vary dramatically from person to person. And while the ideal scenario is to experience a spontaneous vaginal delivery (SVD) – going into labour and delivering the baby naturally without the use of drugs, medical instruments or intervention – it is common that some form of intervention will need to take place.

With the exception of planned caesareans, what all births have in common is the experience of labour – the process of childbirth from the start of uterine contractions to delivery. Labour should generally begin between 37 and 42 week of pregnancy. If it starts sooner than 37 weeks it is considered pre-term or premature labour and immediate medical observation will be required.

 

Preparation for labour and birth

A woman’s body undergoes many unique physical changes, to carry, grow and nurture her child, then move through labour to give birth. Here are five significant changes that take place during the third trimester in preparation for labour and birth:

1. The uterus expands to accommodate the growing baby.

2. The cervix prepares to dilate and expand so the baby can make its way through the birth canal.

3. The placenta acts like a sieve, moving oxygen and nutrients from the mother’s body to the baby’s through the umbilical chord, taking carbon dioxide and waste materials from the baby into your body for elimination.

4. During late pregnancy, hormones soften and relax the ligaments of the pelvis, making the bones elastic rather than rigid, so they can stretch and open more easily for the birth of the baby.

5. The perineum, the strong, flexible muscle between the opening of the vagina and anus, stretches during a vaginal birth to allow your baby to be born.

The baby should engage – meaning it will position itself with its head down in preparation for its journey down the birth canal – any time from around week 34 of gestation. If the baby does not engage prior to labour there is the possibility of a breech birth (the baby will come down the birth canal feet first).

Birth plan

A birth plan is a written plan or verbal agreement outlining your preferences (and those of your partner) for the environment and procedures pertaining to the labour and birth of your child. A birth plan is just that, a plan and plans change. Rather than a set of rigid requests your birth plan should aim to be more of a guide as to how you would ideally like the labour and birth to be. Flexibility is the key with birth plans, bearing in mind the great unknown of what the labour will bring on the day.

A birth plan can be written early on, even as soon as the first trimester if you’re choosing a private obstetrician. If you’re booked into a labour ward or birth centre you’ve more time, but don’t leave it right up until your due date..

Support during labour

As part of planning for your birth, you should consider who will be with you during the labour. Perhaps you intend to just have your partner, or perhaps a close friend, relative or a doula. Whoever you choose, ideally they are the sort of person who can be unconditionally supportive on both emotional and physical levels throughout labour. Research has shown that if a woman has continuous, hands-on nurturing and encouragement from a sympathetic caregiver, or childbirth companion throughout her labour, she is LESS likely to:

• need pain relief
• have a prolonged first stage of labour
• need an oxytocin drip to stimulate her labour
• need an episiotomy
• need an operative delivery (i.e. forceps, ventouse or caesarean)
• have a baby that becomes distressed during labour, or for her baby to need assistance at birth

Pain management during labour

You may choose to give birth without the use of pain medication. But if you’re open to using it as and when you need it, there are many types of pain relief you can choose form to help you cope with the pain of contractions during labour. From epidural, pethidine, hot water, homeopathy and gas and air, thinking about pain relief before you go into labour means you’ll be as prepared as you can be – and that you’ll find yourself in the most appropriate environment for you to give birth in. Pain relief options include:

• Epidural: An anaesthetic injected into the lower part of your spine to numb the nerves that feel the pain of contractions. An epidural can be used from early labour until you’re fully dilated.
• Warm water: A bath that can be filled with hot water is installed in most birth centres and some labour wards. Filled with water at 35-38°C that’s deep enough to reach your armpits, sitting or lying in the bath helps ease the more intense contractions.
• Pethidine: A painkiller from the same family as morphine, pethidine works by relaxing your body and involves an injection in your thigh or bottom, administered by a midwife. It takes about 20 minutes to have effect and lasts around two to three hours, causing drowsiness and dulling pain.
• Gas and air: ‘Happy gas’ – a mixture of oxygen and nitrous oxide – is inhaled through a rubber mask placed over your mouth and is often used towards the end of the first stage of labour, when you breathe deeply through the mouthpiece. The gas builds up in your blood, relaxing your muscles as the contraction builds.
• Homeopathy: For a natural method of pain relief, homeopaths make up remedies using tiny amounts of compounds from plant and mineral sources containing no chemicals and that can work alongside conventional medicine. Homeopathic remedies can be used to establish labour if it slows down and help with exhaustion as childbirth progresses.

 

Signs of pre-labour

 

First stage of labour

During the first stage of labour, the cervix opens slowly, with regular contractions of the uterus. Fully dilated, the cervix will open to 10cm. Each contraction works to open the cervix wider so the baby can pass through the birth canal.

The first stage is made up of three different phases. These are:

• The latent phase – Generally, this stage is the longest and the least painful part of labour. The cervix thins out and dilates zero to three centimetres. This may occur over weeks, days or hours and be accompanied by mild contractions. The contractions may be regularly or irregularly spaced, or you might not notice them at all.
• The active phase – This phase is marked by strong, painful contractions that tend to occur three or four minutes apart, and last from 30 to 60 seconds. The cervix dilates from three centimetres to seven or eight centimetres.
• The transition phase – During transition, the cervix dilates from eight centimetres to 10 centimetres (that is, fully dilated). These contractions can become more intense, painful and frequent. It may feel as though the contractions are no longer separate, but running into each other. It is not unusual to feel out of control and even a strong urge to go to the toilet as the baby’s head moves down the birth canal and pushes against the rectum.

How long labour takes can vary dramatically from woman to woman. As a guide (only), the average time of labour for a first baby is 12-14 hours.

When to go to the hospital / birthing centre

Most women spend the early part of their labour at home. Advice for when is the best time to come into hospital varies. The most important guide is the length and strength of the contractions, which need to be around 60 seconds long before they efficiently dilate the cervix.

If alone, it’s also a good idea to contact someone to keep you company. If the contractions become uncomfortable, a warm bath or shower may help take the edge off the pain. Staying active and moving around can also offer some pain relieve.

By the time your contractions are seven to 10 minutes apart, you’ll need to start planning your next step. Ring the hospital and ask to speak to a midwife to let them know about your labour. The midwife will ask you some questions about what is happening and may advise you to come in or stay home a little longer. It’s the right time to go to hospital when:

• your contractions are about five minutes apart, or
• you no longer feel comfortable being at home, or
• your waters break (it doesn’t matter whether or not you are having contractions).

On average, the cervix of first-time mothers dilates at a rate of around 1cm per hour. Second-time mothers are normally expected to progress a little faster than this. In reality, many women will deviate from this guide and dilate faster or slower (but still progress over time).

During this first stage of labour, it is important to remain calm and focused. Here are some suggestions on what you can do to alleviate the pain and enjoy the amazing experience of birthing:

• Drink plenty of fluid (water, juice or ice blocks)
• Suck on sweets to keep up your energy
• Vary your position to keep as comfortable as possible (standing, kneeling, lying down, straddling a chair, or on all fours)
• Have a bath or hot shower
• Ask your support person for a back rub or massage
• Try to relax between contractions
• If you need or want it, discuss having some pain relief
• Resist any urge to push until your cervix is fully dilated (your midwife will let you know when this has occurred)
• The pressure of your baby’s head helps to widen your cervix, so use gravity and walk around, stand or sit upright
• Don’t feel embarrassed or inhibited by your appearance or behaviour – your midwife has seen it all before. If you want to grunt, yell or swear – go ahead
• Remember that passing a bowel motion during labour is normal and nothing to be concerned about.

Sometimes labour can go slower than expected. Interpretations of slow labour can vary from caregiver to caregiver. In some cases, interventions will definitely be needed for the health and wellbeing of the mother and baby. But in others it may be unnecessary. To truly assess the progress of a woman’s labour, the caregiver will consider more than just the dilation, thinness and consistency of her cervix. They will also review:

• the woman’s behaviour when labouring.
• the pattern, length and intensity of her contractions (for some women their contractions will only ever be five minutes apart, or more, yet they will progress).
• the descent of the baby’s head into the pelvis, the position the baby is lying in and if the baby is ‘rotating’ into an anterior position.

If there is concern regarding the above, medical intervention or an emergency caesarean may be required. But all going well, labour will continue until the cervix has dilated to 10cm and the transition stage begins.

 

Transition

Transition is the phase of labour between the first and second phase. During transition, contractions become very strong, and often their duration and frequency are less predictable.

While transitional labour is the most intensive part of labouring, it is also the shortest. The cervix will dilate from seven to its final 10cm at this time and contractions will be very strong – usually 60 to 90 seconds long and with intense peaks. Because they’re spaced only about two or three minutes apart, it may seem as though you barely get to relax before the next contraction begins.

Transition may be brief for some women, possibly only one to two contractions, or prolonged for others, up to one to two hours. Not everyone experiences a defined transition and if the woman has been administered pain relief, while her body will change, most of the signs or behaviours will not be exhibited. Some of the physical signs of the transition phase can include:

• Frequently feeling hot and cold
• Involuntary shaking
• Feeling nauseated, vomiting
• Feeling tired or exhausted as your body releases endorphins
• Starting to make noises
• Heavy bright blood-stained vaginal loss
• Feeling confused because you have an overwhelming feeling that you want to open your bowels

Once this stage is complete, the woman will move on to the second stage of labour – pushing and birth.

 

Second stage of labour

The second stage of labour starts when the cervix is fully dilated. A strong urge to push may be overwhelming – this is because of the pressure that the baby’s head is putting on the pelvic area.

There are generally four different phases of the second stage of labour:

1. The resting phase: This is when the woman’s cervix is fully dilated but her urge to push, or to ‘bear down’, is not yet felt. The resting phase can be quite short, lasting as little as five to seven minutes, or relatively long, lasting up to 15 to 20 minutes or more. Pushing is hard physical work. The resting phase allows the woman time to rest and recover from the transitional phase of the first stage and to gather her energy to help push her baby out.

2. The active pushing phase: This phase starts when the woman feel the urge to push (usually during a contraction) until most of the baby’s head can be seen at the opening of her vagina. The sensations during this phase can range from a slight urge at the peak of the stronger contractions, to an irresistible urge to push (or bear down). The initial pushing is usually experienced in short bursts during some of the contractions, increasing to a tremendous need to push several times during each and every contraction as the baby comes down.

3. The crowning phase: As the pushing continues, the baby’s head extends upwards, moving around and under the woman’s pubic arch, stretching the perineum to its limit. The baby’s head continues to advance in this way for a few contractions until it ‘crowns’. This is when the widest part of the baby’s head (or their crown) has emerged.

4. The birthing phase: After the baby’s head crowns, their eyebrows, eyes, nose, mouth and chin emerge until their whole head is out. Your caregiver may need to ease the perineum over your baby’s chin, if their chin is not completely born.

At this stage, it is important to listen to your body and push when the urge is strong. Usually you will find that, through each contraction, you push several times. By kneeling, squatting or even standing you can use gravity to help, which can make the process easier. If you have had an epidural and can’t feel your contractions, your midwife will tell you when to push.

The second stage can last from minutes to two hours (usually second or subsequent babies are quicker than the first). Contractions during this stage may be several minutes apart.

 

Baby after birth

Straight after birth, if you have had a vaginal birth you will be able to hold your baby for the first time. This skin-to-skin contact is an important bonding experience. From the very moment of birth you’ll be overwhelmed by your desire to know him, love him and most of all, protect him. Bonding can happen in one intense moment that knocks new parents off their feet, or it may take a couple of days for new parents to warm up to the little stranger who’s turned up in their lives; in the end, though, every parent falls for the charms of their newborn.

The baby will then be evaluated for its ability to adapt and transition normally to life outside the uterus. To aid in this process, the baby is transported to a warming unit with a radiant heat source. The baby should begin crying within the first 30 seconds to one minute of life. To accomplish this, gentle stimulation is usually required and achieved by rubbing the baby’s back or gently stimulating its feet

The baby will need to undergo several routine procedures at this time. These include an APGAR test, a Vitamin K shot and weight and height measurements.

APGAR

The APGAR test is used shortly after birth in order to assess a newborn baby’s health. It assesses five basic indicators of health: activity level, pulse, grimace (response to stimulation), appearance and respiration. The baby is given a score of 0, 1 or 2 on each indicator and the scores are added up to give an overall APGAR score out of a possible 10.

In general, a low APGAR score identifies those babies who may require extra attention and care. The five-minute APGAR score is generally used to evaluate how effective any resuscitative efforts were.

The APGAR table is comprised of five areas in which the baby will receive a score. These areas include the baby’s heart rate, muscle tone, respiratory effort, reflexive response to stimulation and the baby’s colour:

The APGAR Scoring System

Sign	0	1	2
Heart Rate	Absent	< 100 per minute	> 100 per minute
Respiratory Effort	Apneic	Weak, Irregular, Gasping	Regular
Reflex	No Response	Some Response	Facial Grimace, Sneeze, Cough
Muscle Tone	Flaccid	Some Flexion	Good Flexion of Arms and Legs
Colour	Blue, Pale	Body Pink, Hands and Feet Blue	Pink

Vitamin K

Vitamin K is found naturally in leafy green vegetables and is a fat-soluble vitamin that assists in the clotting of blood and keeping bones healthy. When babies are first born they are deficient in vitamin K, with most having between 40-70 percent less vitamin K than adults. While these lower levels are usually enough to keep them healthy while their bodies begin to create their own stores, some babies can become dangerously deficient in vitamin K after birth, which can make him more prone to bleeding. This condition is known as Vitamin K Deficiency Bleeding (VKDB)

All Australian parents are encouraged to supplement their newborn baby’s vitamin K store as a way of preventing VKDB. Supplements can be given either as one injection given just after birth or as three oral doses during the first month of life.

Measurements

Weighing and measuring your baby is something that is usually done soon after birth. In many cases a baby will be weighed and measured within the first 30 minutes, although there is no real reason why procedures such as weighing and measuring can’t be left until later, providing the baby is well. Around the same time the caregiver will perform a general overall check of the baby, examining physical appearance – five fingers, five toes, etc.

Breastfeeding

Babies are generally quite alert for an hour or so after birth and will then often drift off into a deep, long sleep for several hours. It is usually the priority of the caregiver to ensure that the baby has a feed (if the baby and mother are well) at sometime within the first hour after being born. It can take a baby from five to 50 minutes to become interested in feeding. It often takes them a while to adjust to being outside the uterus and many will happily look around for 20 to 40 minutes or so before showing interest. Despite the myth that the baby will ‘go straight to the breast’ as soon as they are born, not many will attempt to feed this soon.

When the baby is interested, they will often start opening and closing their mouth – trying to latch onto something, or anything! This is called the rooting reflex and is an inbuilt survival response that helps them to search out nourishment.

That first breastfeed provides the baby with colostrum, a yellow, creamy substance that expresses from your breasts that is high in fibre and nutrient rich. Colostrum is often referred to as ‘liquid gold’ perhaps for its properties; not only does it provide perfect nutrients for a newborn, it also imparts large amounts of living cells that provide your child with immunity against many harmful agents.

 

Third stage of labour

The third stage of labour begins from the moment the baby is born until the delivery (or expulsion) of the placenta, cord and membranes (or the ‘afterbirth’) from the woman’s uterus.

In the majority of cases, the third stage is actively managed by the caregiver. This involves the woman being given an injection of a synthetic oxytocin hormone drug, the umbilical cord being clamped and cut usually within minutes after the birth and the cord being gently pulled (while the caregiver uses their other hand on the woman’s belly to support her uterus) to help deliver the placenta.

Some women will choose to deliver their placenta using their body’s natural processes. This is known as a natural or ‘physiological’ third stage. This happens more often in birth centres and home births.

 

Every birth is unique

The above is a very general guide of labour and birth and certainly does not reflect the experience of all women. No two births are the same and sometimes things may happen that require a different approach to birth. Here are some possible variations:

• Assisted delivery: If a woman’s labour progress is slow, the baby is distressed or there are complications such as heavy bleeding, the baby may need medical assistance to be born quickly. The type of intervention used will usually depend on the position of the baby. Depending on the scenario, forceps or ventouse may be used to assist in the safe delivery of the baby.
• Breech birth: In about 3-4 percent of pregnancies, the baby approaches full-term by presenting in breech position – meaning it is bottom down, rather than head down.
• Cephalopelvic disproportion: This is when the baby’s head is too large to pass through the mother’s pelvic opening. The reasons behind it vary – either because the baby is disproportionately large, the baby is not in the best position for birth resulting in a larger head diameter than normal, the mother’s pelvis is small, or as a result of other abnormalities of the birth canal. Cephalopelvic disproportion is a common cause of obstructed labour and often results in delivery by caesarean section.
• Emergency caesarean: A caesarean section (‘c-section’) is the delivery of a baby via a surgical incision to your abdomen. The most common method is via a transverse (or ‘bikini’) incision, along the top of the pubic hairline. These days, vertical (‘classical’) incisions are less common but may be required in certain circumstances.
• Episiotomy: The perineum (the area between the vagina and the anus) is stretched during a vaginal delivery and may be surgically cut during birth in a procedure known as an episiotomy.
• Induction: This involves the use of a synthetic drug that will initiate or speed up labour for medical and personal reasons. Perhaps it’s for the health and wellbeing of the mother and the baby as the caregiver feels there may be risks involved in waiting for the labour to start spontaneously, such as being well overdue. Or perhaps it is a decision relating to convenience of either the parents or the birthing facility.
• Foetal distress: During labour, your doctor, midwife or birth attendant will check for signs of distress. Any warning signs, such as slowed heartbeat or absence of foetal movement is monitored. If your baby’s life is in danger, the baby should be delivered immediately.
• Jaundice: A common condition in newborns, jaundice refers to the yellow colour of the skin and whites of the eyes caused by excess bilirubin in the blood. Bilirubin is produced by the normal breakdown of red blood cells. It is common for a baby to show the beginnings of jaundice around the second or third day and it often starts disappearing when the baby is around seven to 10 days old. Although a specialised light treatment may help, rest assured it will go away naturally.

 

Find more:

• Choosing your LMC
• Your body after birth
• Coping with contractions
• Breastfeeding positions