Preparing for labour You have been given this booklet to help you make some choices about your labour. This booklet may be all that you need to help you but should you wish to have additional information please speak to your midwife and/or book onto a course of antenatal classes which are organised by the hospital CONTENTS Supervisor of midwives
2
Pain relief in labour
21
Antenatal education
2
Anaesthesia in labour
29
Birth plans
3
Fetal monitoring in labour
30
Perineal repair
31
What you need to bring into hospital with you
4
Vitamin K
31
Where to have your baby
5
Stem cell collection
32
The different stages of labour
7
The early postnatal days
33
Prevention of sepsis advice
35
Types of birth
16
Induction of labour
20
www.homerton.nhs.uk
2 Preparing for labour
Supervisor of midwives A Supervisor of Midwives is an experienced midwife who has had extra training and education to assist and support midwives in providing the best quality maternity care. Supervisors of Midwives aim to make sure that you receive the best guidance and information about the right type of care for you. They are there to help and support you if you are having any problems with your care, or if you feel that your wishes and requests are not being considered. Discussing issues with the Supervisor of Midwives will not affect your care or influence how you are further supported in your pregnancy, birth and aftercare. If you would like to contact a Supervisor of Midwives they can be contacted via the Homerton Hospital switchboard 020 8510 5555 or by email: supervisorofmidwives@ homerton.nhs.uk Things you can do to help yourself during your pregnancy •• Communicate with your midwife during pregnancy to make sure that you find out as much information as you can from her. •• Attend antenatal classes.
•• Some women find it helpful to read about labour. ‘The pregnancy book’ can be viewed online via our website: www.homerton.nhs.uk/ourservices/maternity-services •• You may wish to use the internet, for instance, the NHS Choices website: www.nhs.uk or the information for parents website: www.nhs.uk/ InformationServiceForParents/ pages/home.aspx
Antenatal education Antenatal classes are sessions that can help you to prepare for the arrival of your baby. They are a good chance to meet some of the professionals involved in your care, talk about things that are worrying you and ask any questions. Antenatal classes give you information about labour and birth and the choices available to you and can help you to plan your own birth. As well as being informative, classes are often informal and fun and a chance to make friends with other expectant mothers. In some areas there are antenatal classes for women whose first language is not English and for younger mums.
Preparing for labour 3 The topics covered include: •• health in pregnancy •• what happens during labour and birth •• coping with labour and pain relief •• exercises to keep you fit during pregnancy and help you in labour •• relaxation •• caring for your baby, including feeding •• your health after birth •• your emotions during pregnancy and after birth •• refresher classes for second-time mums •• a tour of the unit.
Birth plans Once you and your partner know what you would ideally like to have for your labour and birth, we would advise you to complete a birth plan so that the midwives and doctors caring for you also know. You should discuss your birth plan with your midwife between 32-36 weeks of your pregnancy. You will find a section in your hand held records where your birth plan can be written. What should be included in a birth plan?
Most women include information about the options they would like when they have their baby for example: •• Place of birth: Home, Birth Centre, Delivery Suite •• Partner/husband/supporter presence during labour and delivery •• Eating and drinking in labour •• Mobility during labour •• Various positions to adopt during labour •• Monitoring your baby’s heartbeat •• Relaxation techniques including the use of water, music, massage •• Pain relief •• Episiotomy (small cut below the vagina) •• Partner cutting the cord •• Skin to skin contact following the birth of the baby •• Breastfeeding •• Giving vitamin k to your baby. See page 31 If you require a caesarean section you may also want to consider: •• partner being present •• epidural anaesthesia •• skin to skin •• breastfeeding.
4 Preparing for labour
What you need to bring for your stay in the Maternity Unit For yourself: Clothes to wear during the day
For your baby
Nightdresses
Baby grows (sleep suit)
Dressing gown / slippers Maternity bras
Change for the bedside TV and telephone
Underwear
Vests
Soap or shower gel
Nappies
Flannel / towels
Cotton wool
Toothpaste & toothbrush
Baby bath or soap
Sanitary pads – thick maternity pads Pillows
Hats / mittens
Baby lotion or baby oil Towels Shawl
If you are going to bottle feed your baby you will need to bring:
•• four to six feeding bottles with teats •• your choice of formula e.g. SMA, Cow & Gate.
Preparing for labour 5
Where to have your baby One of the most important decisions that you will make is where to have your baby. Homerton Hospital offers three options: Homebirth: Having a homebirth is considered safe for women whose pregnancy is low risk (one with no medical or obstetric complications) or women who have not previously had a caesarean section or had more than five babies. More information can be obtained from the leaflet having a homebirth. Please ask your midwife for a copy. Advantages of a homebirth:
•• You are in familiar surroundings. •• Women say they feel more comfortable, relaxed and in control.
•• You can have the people you want with you.
•• You are able to move about freely.
•• Low risk women who have their baby at home have fewer interventions.
Disadvantages of a homebirth:
•• If complications arise before or during the labour you will need to be transferred to hospital. •• Only simple pain relief e.g. water or gas and air is available. •• Midwives who attend to you when you are in labour bring basic resuscitation equipment. Homerton Birth Centre: This is a midwife led unit situated alongside the delivery suite at the hospital. It has been designed to be a home from home unit for women who wish to have a natural birth but do not want to be at home. We recommend women whose pregnancy and labour are low risk to have their baby here if not having their baby at home. Advantages of the Birth Centre:
•• An alternative to home birth. •• Birthing pools are available to use during the labour and birth. •• Less likely to have any interventions during labour. •• You can easily be transferred to the main delivery suite if problems develop in labour. •• You can go home after a few hours if you and your baby are well.
6 Preparing for labour Disadvantages of the Birth Centre:
•• Not suitable for women with complicated labours or women who have had a previous caesarean section. •• Epidural pain relief is not available. •• There may be a need to transfer you to the delivery suite if there are any problems (although this is easier than being transferred from home). If you would like more information about having your baby in the birth centre please ask you midwife for the Homerton Birth Centre leaflet. Delivery Suite: this is where the majority of births take place. This is either because women choose to have their baby here or because the pregnancy/labour is high risk and requires additional monitoring. Advantages of a Delivery Suite:
•• You will not need to move if complications arise. •• It is the essential place to be if your pregnancy has not been straightforward, if your labour has been induced or your labour is predicted to be complicated or has additional risks e.g. multiple pregnancies.
•• Epidural pain relief is available as an option. Disadvantages of a Delivery Suite: •• You are more likely to have interventions in labour. •• The Delivery suite may be more intimidating as there is more medical equipment. Whichever place you decide your midwife will be able to explore the advantages and disadvantages further with you. It is recommended that you view the places of birth before making a decision. If you would like to tour the unit please book to go on one of our tours. The following information will help you understand what happens during labour, the types of births and how you can cope with labour.
Preparing for labour 7
The different stages of labour Most women usually go into labour between 37 – 42 weeks. There are three stages of labour:
(womb) contract and make the cervix become flat and soft, at the same time as opening it to three to four cm. This flattening is called ‘cervical effacement’ or thinning.
The first stage, when the neck of the womb (cervix) opens to 10 centimetres before labour starts, the neck of the womb is long and firm. The first stage of labour is divided into two phases the latent phase and the active phase.
The latent phase can last several days or weeks before active labour starts. Some women can feel backache or cramps during this phase. Some women have bouts of contractions lasting a few hours which then stop and start up again the next day. This is normal.
The latent phase: This is the very first part of your labour – the early part of first stage of labour. During this stage the muscles of the uterus
‘Braxton Hicks’ contractions occur all through pregnancy. They are tightenings of the muscle of the uterus and last for about 30
These pictures give some indication of the cervical changes that occur during the first stage of labour.
The cervix is closed
The cervix is effacing
The cervix is dilating
The cervix is fully dilated
8 Preparing for labour seconds. They are usually painless. During the latent phase Braxton Hicks contractions may become more noticeable and more frequent, lasting between 35 and 45 seconds. However some women may not notice anything happening at all. The active stage: During this stage the labour becomes more established and the contractions become more frequent and regular. At the end of the first stage, the cervix has opened to 10cm and is described as being ‘fully dilated’. The second stage, when the baby moves down through the vagina and is born. The third stage, when the afterbirth (placenta) is delivered. For more details about each stage of labour and what to expect please see the table on pages 12-15. What signs can I expect to tell me that labour is beginning? The ‘show’: As the cervix begins to flatten and open, the mucus which has been protecting the entrance to your womb comes away. Many women experience what is known as a ‘show’ from the vagina. The
mucus will be tinged pink or brown from blood – this is normal. Having a ‘show’ means that your body is starting to get ready for labour, but the actual birth is very likely to be some time away. Some women have a ‘show’ several days before labour starts. If there is bright red blood you should phone Delivery Suite immediately. Your waters breaking: Before active labour starts, your waters may break. During pregnancy, your baby is surrounded by amniotic fluid – the ‘waters’. For some women (about one in 10), the first sign that labour is going to start is when the waters begin to leak. It is quite common for women to leak a small amount of urine at the end of pregnancy and it can be difficult to tell if your waters have broken or if it is urine. If you are not sure if your waters have broken, put a sanitary pad on and check it 30 minutes later. If it is damp you can assume that your waters may have gone. If you have a definite gush of fluid when you stand up, it is a clear sign that your waters have broken and you should telephone the Delivery
Preparing for labour 9 Suite. If not, then you can assume your waters haven’t broken. Contractions: In the latent phase of labour, contractions may start and stop. This is normal. Contractions may continue for several hours but not become longer and stronger. They may last for about 30 – 40 seconds. The contractions may stop for a few hours. This is normal in the latent phase Many women have a vaginal examination during the latent phase which finds, for example, the cervix is one to two centimetres dilated. This is a good time to rest and make sure you have something to eat. When your body has built up some energy supplies, your contractions will start again. If you are in hospital when you have this examination, the midwife may suggest you go home and wait for contractions to get longer, stronger and closer together. Most women are more relaxed at home in the latent part of 1st stage and you can use this booklet to help you manage this part of labour. Remember that a ‘start-stop’ pattern of contractions is common in the latent phase.
In the active phase, contractions should continue until the baby is born. When you are having regular contractions that are getting longer, stronger and closer together, approximately every five minutes and lasting for at least a minute, you may be going into the active stage. It is at this stage that you should contact the hospital. What do I do if I think I may be in labour? If you think that you might have started labour, please ring one of the following numbers, depending on where you are planning to have your baby: Homerton helpline (10am-6pm) 020 8510 5955 Homerton Birth Centre 020 8510 5548 Delivery Suite 020 8510 7351 / 020 8510 7352 Home birth – via Delivery Suite
10 Preparing for labour When the midwife has assessed you, she will give you a clearer picture of what is happening.
•• keeping your breathing quiet
If you are ‘assessed’ (checked over) in hospital, and are in the latent phase of labour and every thing is normal, the midwife will encourage you to return home until you reach the ‘active phase’ of the first stage. She will recommend that you stay at home for as long as possible. This is because there is evidence that the further on in labour you are when you come in to hospital, the more likely you are to have a normal birth. Remember, if you are fit and well you can choose at this stage to stay at home to have your baby, if you find you are comfortable in your own environment.
•• trying massage – ask your
There are things you can do to help yourself, such as:
•• pottering around the house •• taking a walk •• watching a DVD/video •• taking a warm bath or shower (showers are more beneficial in the early stages)
•• having a nap •• doing some relaxation
and fluid – ‘breath in gently, sigh out slowly’ partner or labour supporter to do this for you
•• trying a soft gel sports injury pack which you have cooled in the freezer
•• keeping as mobile as you can, while remembering to save your energy for the active part of labour
•• trying out different positions and using a birthing ball to experiment with what helps
•• drinking plenty of fluids – water, sports drinks, apple juice are all good
•• eating little and often – carbohydrates (bread, pasta, rice, cereal) for slow – release energy plus sugary foods for quick-release energy. You may find it helps to make love – kissing, cuddling and having an orgasm all cause your body to produce oxytocin. This is the hormone which is also produced in labour and which makes the uterus contract.
Preparing for labour 11 Some women who have hired a TENS machine put it on during the latent phase. It is not possible to say when active labour will begin. It could start in a couple of hours or in several days, so try to stay as relaxed as you can and distract yourself from focusing only on the contractions. Experiment with positions that you find comfortable. Stay upright and mobile as there are advantages to staying off the bed and keeping upright in labour. This can mean standing, sitting, squatting, kneeling and walking around. You may find a birthing ball, a floor mat and a beanbag useful at this stage. Choose a supportive birthing partner who can be with you through your labour. Some women choose to have the support of more than one person (maximum of two). Your birth supporters can encourage and reassure you and help to tell your midwife what you would like. Partners can help with things such as: massage, keeping you active, getting you drinks, praising and encouraging you, giving you cuddles, keeping you company and
even trying to make you laugh! Remember – the ‘latent phase’ of labour can last a very long time, especially for women in their first labour.
12 Preparing for labour
The stages of normal Labour Prior to the onset of labour Expected length
Very early labour (latent Phase) Can last several days
Contractions
Painless practice or “Braxton hicks” contractions are common
Contractions feel uncomfortable but are not yet regular
Meals
Normal, eat as usual
Small light, meals containing carbohydrates prepare the body well.
Monitoring
You should expect to feel at least 10 movements everyday
Keep an eye on the baby’s movements at least 10 a day
Activity
A walk or stretch can help you to relax.
Support
You should be thinking about who you would like to be your birth partners, ensure you have contact numbers for when you go into labour.
You may not want to be on your own, a birth partner can hold you, rub your back and be reassuring.
Vaginal loss
Pregnancy often increases the amount of clear vaginal discharge
You may pass a “show”, the plug of mucus is released from your cervix, it can be streaked with blood. Your waters may break.
Cervical
Your cervix is closed and about 2cms in thickness.
The cervix thins out.
dilatation Pain relief
How you may feel
Bathing, mobilising, a Tens machine, massage, relaxing music and Paracetamol (no more than 8 in 24hours) can really help. Expectant, excited, uncertain and anxious
Excited but pace yourself, get as much rest as possible
Preparing for labour 13
Active labour - 1st stage 1st baby - 6 - 20 hours 2nd baby onwards - 2 - 10 hours Contractions are coming regularly about every 5 mins (or more frequently) and lasting about 60 Seconds. Lots of fluids help; you may not feel like eating much. The midwife will listen to the baby’s heartbeat every 15 mins, your blood pressure and temperature will be taken every 4 hours and your pulse every 30 mins. Remaining upright and active can mean less need for pain relief and a shorter 1st stage of labour - see page 10 for ideas You are advised to contact a midwife at this stage. A midwife will care for you throughout labour
The midwife will monitor the vaginal loss, Your waters may break.
The cervix gradually dilates to about 10 cms. This is called fully dilated. Being active and having a bath/shower have no side effects. Pain killing drugs are available; your midwife will discuss them.
At the end of 1st stage, you might become a bit “tetchy” and feel you cannot cope. This is a good sign - you are nearly there. Adapted from All Wales Normal Birth Pathway
14 Preparing for labour
Active labourSecond stage
Active labourThird stage
Expected length
1st baby: 1-2 hours
20 mins - 1 hour or
2nd baby onwards: 10 mins 1hour
5-15 mins with an injection
Contractions
Contractions are very strong and close together with strong urges to push down.
You may feel a strong urge to push your placenta out.
Meals
Sips of fluid can help your mouth from drying out.
Monitoring
The midwife will listen to the baby’s heartbeat every five mins.
Activity
Movement and changing position can help. See page 23 for some ideas.
Support
Your midwife and birth partner’s will encourage you with your pushing.
Vaginal loss
Your waters may break, the midwife will monitor the vaginal loss.
Cervical dilatation
The cervix is fully dilated.
Being upright can help you expel the placenta
A small gush of blood is usually passed before the placenta comes out.
Pain relief
How you may feel
Very focused requiring all your efforts.
An enormous relief, you will be holding your baby for this part.
Preparing for labour 15
After the birth
“After pains” may make your tummy tender.
Tea and toast has never tasted so good!
Your temperature, pulse and blood pressure will be taken. The baby will be weighed and its temperature taken. You have earned a good rest! We would encourage you to hold your baby close to you in skin to skin
You will stay in hospital for a few hours and then transfer home to the care of the community midwife. If you have a homebirth the midwife will stay for 1-2 hours
The vaginal loss will be like a heavy period for a few days.
The cervix closes after the placenta and membranes have been delivered.
If you need stitches, local anaesthetic will be used to take away the discomfort.
Very tired but totally fulfilled - congratulations
16 Preparing for labour
Types of Birth Normal vaginal birth: this is the unassisted birth of your baby through the vagina. This means that you can push your baby out yourself in the normal way. The majority of women give birth this way. Uncomplicated normal births are undertaken in the birth centre. Vaginal birth after caesarean (VBAC): What are the advantages of a successful VBAC?
•• A vaginal birth. •• A quicker recovery, less pain after delivery and a shorter stay in hospital. •• Avoiding surgery and the complications of surgery. •• A greater chance of a normal birth in your next pregnancy. What are my chances of a successful VBAC? •• Three out of four women (75%) with a straightforward pregnancy who go into labour will give birth vaginally following one caesarean delivery. •• Nine out of 10 women (90%) who have had a vaginal birth either before or after their caesarean delivery will give birth vaginally.
•• Most women with two previous caesarean deliveries will deliver by caesarean section. Should they choose a VABC, the chance of a vaginal birth is slightly lowered – 70 -75% VBAC success rate. There is no evidence of an increase in scar rupture in labour but if you have had two previous caesareans, you should have a fully informed discussion with an obstetrician prior to making a decision on mode of delivery. Your chance of having a successful VBAC will be increased if the following apply.
•• You have already experienced a vaginal birth. •• You have a body mass index (BMI) of 30 or below at the beginning of your pregnancy. •• Your previous Caesarean was ‘elective’ (planned before labour started) and not performed in labour because of slow progress. •• The cut for your previous Caesarean was made around your pubic hair line and runs from side to side along this line •• Your labour is not induced. However, even if you are overweight; have not experienced a vaginal
Preparing for labour 17 birth; had your caesarean because of slow progress in labour, and are having your labour induced, your chance of a successful VBAC is still 40%. What are my choices of place of birth? A planned VBAC should take place in the Delivery Suite, where there are the right staff and facilities for both caesarean delivery and advanced neonatal resuscitation if needed. You will be advised to have your baby’s heartbeat continuously monitored when your labour contractions are coming regularly. This is because often the first sign of scar rupture is that your baby’s heart rate becomes abnormal. Picking up this early warning sign of problems means you can then move quickly to having a caesarean. This emergency delivery will help reduce the risks of scar rupture to both yourself and your baby. Your midwife can help you to remain as upright and mobile as possible while you are being monitored. For example you can sit in an arm chair or use a birthing ball. You are then able to stand up and change position during labour. Remaining
active and mobile can help labour to progress more quickly and smoothly. For more information about the risks and benefits of having a VBAC delivery please see our leaflet, Birth after caesarean. Assisted birth: a small number of women require an assisted birth. Sometimes babies need to be helped out of the birth canal because they are in distress or you are exhausted or you have had an epidural. When this happens a vacuum (also called a Ventouse) or forceps may be used. With a vacuum delivery a small rubber cap is fitted to the baby’s head by suction and with gentle firm pulling by the doctor the baby can be born. With a forceps delivery an episiotomy is usually made. The forceps are placed on either side of the baby’s head and with gentle firm pulling the baby’s head is born. These are undertaken on the delivery suite Caesarean section: A caesarean section is the birth of your baby through an incision or cut in you abdomen to deliver your baby from
18 Preparing for labour the uterus (womb) and out through your abdomen. One in five women have their babies this way. Reasons for needing a caesarean: a caesarean may be needed before your labour begins and is known as an elective caesarean. This will happen if the doctors are worried about you or your baby. Some of the reasons that you may be offered an elective caesarean section are:
•• if your baby is positioned bottom first (breech) at the end of your pregnancy
•• if you have placenta praevia which is a condition where the placenta is low lying in the uterus and covers all or part of the cervix
•• if you have a viral infection such as HIV or active genital herpes. Sometimes the caesarean will be needed after the labour has started because a complication has arisen. In this situation the caesarean is usually done as an emergency. You may need an emergency caesarean section because:
•• there is a concern that your baby’s health is compromised •• your labour is not progressing
•• you have vaginal bleeding during your pregnancy or labour •• you go into labour before your planned caesarean. Caesarean sections are performed in an operation theatre. Where possible it is undertaken with an epidural or spinal anaesthetic or sometimes both. Although you will not feel any pain you may feel some tugging as the baby is born. A general anaesthetic is occasionally use especially if the caesarean needs to be undertaken quickly. Benefits of caesarean: if your baby needs to be delivered by caesarean you may benefit from being:
•• less likely to have bladder incontinence •• less likely to have pain between the vagina and anus •• less likely to have sagging of the womb through the vaginal wall. Risks from caesarean: After the caesarean you will be quite uncomfortable for a few days and may need some pain relief. If there are no complications you can usually go home after two or three days. You will need to have some help at home while you
Preparing for labour 19 recover from this operation. It will be four to six weeks before you can resume normal day to day activities including driving. However, it is important that you try to be active soon after you have had your baby to prevent deep vein thrombosis (DVT) developing. This is a serious blood clot that can form in the main artery of your leg. It is also important to know that caesarean section is a major operation that carries other risks which include:
•• an increased risk of bladder injury •• a higher risk of being admitted to the intensive care unit if a serious complication develops •• a higher risk of placenta praevia in a future pregnancy •• an increased risk of tearing the uterus in a future pregnancy •• increased risk of death of the mother •• increased risk of death of the baby before labour starts. Breech presentation: your baby will lie downwards in the uterus and will be born headfirst. Sometimes babies decide to come bottom first or feet first. This is called breech
presentation. Lots of babies that are in breech position turn around in the last couple of months of the pregnancy. If your baby does not turn around on its own by 36 weeks you will be offered an opportunity for one of the doctors to turn your baby. This is called external cephalic version (ECV). You will need to go into hospital for the procedure which involves the doctor gently moving the baby round to the head first position by placing their hands on your abdomen and pushing on the outside. Studies have shown that ECV is safe, usually successful and should be available to you. However you should not be offered an ECV if:
•• your waters have broken •• you are in labour •• you have a scar on your uterus or if your uterus is irregularly shaped •• the health of your baby is at risk •• you have any vaginal bleeding •• You have an existing medical condition such as a heart condition. If the baby cannot be turned by ECV you will be offered a caesarean section. This reduces the risk of
20 Preparing for labour harm to your baby. However, if you would like to attempt a breech vaginal delivery please discuss this with your doctor. Breech vaginal deliveries are undertaken on the delivery suite.
Induction of labour If your labour has not started by 40 - 41 weeks, you will be seen by your midwife and will be offered a sweep of the membranes that surround your baby (consultant obstetrician for high risk women) and will have the opportunity to discuss the different options. These should include:
•• waiting for labour to start spontaneously •• planned induction of labour •• repeat elective caesarean delivery. Some women plan a VBAC if they start labour spontaneously, but choose a repeat elective caesarean delivery rather than induction of labour. What methods do we use? During your induction the methods we use will depend on your progress, assessed by regular monitoring of you and your baby and by internal examinations.
Membrane sweep This is usually offered at or after your due date. This involves the doctor or midwife performing a vaginal examination then placing a finger inside the cervix and sweeping the membranes. The procedure can be uncomfortable and you may notice some bloody discharge afterwards. This may increase the chance of labour starting in the next 48 hours. Prostaglandin gel and tablets Prostaglandins are hormones that help the body go into labour. At Homerton we use two versions: Prostin This gel will be placed at the top of the vagina when a midwife or doctor performs a vaginal examination to check the length and thickness of your cervix. Misoprostol This is a small tablet that dissolves under the tongue. We have been using it for some years and studies have shown it to be equally effective as the gel, however it is not currently licensed for use in labour induction. Both medicines promote contractions. Initially you may have some cramping pains that, as with a
Preparing for labour 21 normal labour, will become longer and stronger over time. We will encourage you to remain mobile for as long as possible and your midwife will discuss pain relief options with you. You may require one or two doses of either medicine. Depending on how you respond we may advise breaking your waters (artificial rupture of membranes). Monitoring will involve listening to your baby and checking the frequency of any contractions you are having for approximately half an hour before and after any medication we give you. Artificial rupture of membranes This involves a vaginal examination. If the cervix is open enough we will break the membranes that surround the baby. This helps the labour progress and is essential if we want to start a hormone drip to regulate your contractions. Syntocinon drip Syntocinon is a manufactured hormone that is used to strengthen and regulate contractions. It is given via a ‘drip’, on the Delivery Suite.
Where will I be induced? If your pregnancy has been uneventful your doctor will discuss outpatient induction with you. If suitable we give the first dose of medicine in our Fetal Welfare Unit and monitor you and your baby for one hour. If all is well you will go home and return the next morning to continue the induction, or sooner if you are in labour. If your pregnancy has developed a complication or you have a medical condition which requires us to monitor your induction closely, you will have your induction of labour undertaken on either Turpin Suite or the Delivery suite. When your induction of labour is discussed with you, instructions will be given to you advising where and when to come.
Pain relief in labour It is difficult to know in advance what sort of pain relief will be best for you. The midwife who is with you in labour should be able to advise you. Here is some information for you to consider before your labour starts.
22 Preparing for labour Self-help methods: •• Calm breathing may increase the oxygen supply to you muscles and so make the pain of your contractions less intense. Focusing on breathing, you are less likely to be distracted by the pain. •• Using relaxation techniques. •• Having a massage during labour is comforting and reassuring. •• Adopting different positions in labour – please see pictures opposite for some ideas. Hydrotherapy: The use of water for labour and birth has been used for many years. Warm water is soothing and calming and can be very helpful for use in labour and during birth itself. If your pregnancy has been straight forward and you do not go into pre-term labour (before 37 weeks pregnant) you may want consider the use of water during your labour. Please ask your midwife if you are unsure if you should use the pool. A birthing pool is deeper and wider, allowing you to move more freely. The deep water also helps your body to work better with your labour, releasing hormones to help
your contractions become more effective and other hormones to help you cope with them. Research suggests that the effect of this may be that your labour time reduces and that you are less likely to use other forms of pain relief. There are two birthing pools in the Birth Centre at the Maternity Unit and an inflatable pool that can be set up in either the Birth centre or Delivery Suite. We cannot guarantee that they will be free for you to use when you arrive but please mention it when you call for advice prior to coming in. Nearly all midwives have skills in facilitating labour and birth in the pool. Alternative Therapies: You may be keen to avoid the types of pain relief listed on this page, and choose acupuncture, aromatherapy, homeopathy, hypnosis, massage or reflexology. If you’d like to use any of these methods, it’s important to discuss it with your midwife or doctor and let the hospital know beforehand. If you want to try an alternative technique, make sure that the practitioner you choose is properly trained and experienced. Although some women find
Preparing for labour 23
Side lying - useful for resting
Semi-sitting, in bed, on a couch, or leaning against your partner also useful for the second stage of labour.
Sitting with one foot up. Asymmetrical positions help enlarge the pelvis on one side, and change the shape of the pelvis, which helps the baby find the best position
These positions are useful if you have a lot of backache during your labour
Kneeling positions can relieve backache and can help a baby in the posterior position rotate
24 Preparing for labour alternative therapies helpful, particularly in the early phases of labour, they often don’t provide effective pain relief throughout labour, so it is a good idea to consider any other forms of pain relief you might find acceptable. Examples of Complementary therapies •• Self-hypnosis: There are a range of techniques which you can learn during your pregnancy, either by attending “hypnobirthing” classes or from books, CDs and even the internet (try typing “hypnobirthing techniques” into Youtube). As well as breathing exercises and selfhypnosis tools, these include relaxation and visualisation exercises (for example imagining your contractions as “tightenings” or “waves” bringing your baby into the world rather than “pains”). Even if you expect your birth to be complicated or you would like to use other forms of pain relief, using some of these techniques can make you feel much more positive about the labour process and help you to
feel calm and relaxed. •• Aromatherapy involves using concentrated essential oils to reduce fear, improve your wellbeing and encourage you to keep going. •• Reflexology is based on the idea that points on your hands and feet relate to points on the rest of your body. A reflexologist usually massages points on your feet that relate to the parts of your body that are painful in labour. •• Acupuncture is an ancient Chinese therapy which involves putting tiny needles into points on your body to help reduce your pain. To use this technique in labour, you would need to arrange for a qualified practitioner to be with you. Transcutaneous electrical nerve stimulation (TENS): A gentle electrical current is passed through four flat pads stuck to your back. This creates a tingling sensation. You can control the strength of the tingling yourself. It is best to use it as early as possible in your labour as it helps to release the body’s own endorphins to reduce the pain, especially backache. If you hire a
Preparing for labour 25 machine you will be able to use it at home. It has no harmful effects on the baby. Most women will require additional pain relief as their labour progresses. Entonox: Entonox is 50% nitrous oxide and 50% oxygen and is often referred to as “gas and air”. It is a popular pain relief during labour as you control the amount of gas you use by breathing through a mouth piece. It is simple and quick to act and wears off very quickly. It does not harm the baby and, as it contains oxygen, it may be beneficial to you and your baby. It will not take all the pain away but it is helpful as it can be used at any time during the labour. If you are having a homebirth the midwives can bring it with them for you to use. To get the best effect, timing is important: You should start breathing the Entonox as soon as you feel a contraction coming on, so it reaches its full effect when the contraction is at its strongest. You should not breathe the Entonox between contractions, as this may make you feel dizzy, tingly or sick. Pethidine: This is usually given as an injection by the midwives. It has
less effect on the pain than using Entonox but some women find that it helps them to relax. Pethidine can make you feel drowsy and sick (another injection can be given to help this). It is recommended that you do not use the birthing pool for at least an hour after you have had pethidine. It can also make the baby drowsy so it should not be given if you are likely to deliver soon. The effects of pethidine can last for some hours on the baby and therefore it may effect the establishment of breastfeeding. Epidurals: An epidural is a very thin plastic tube that sits in between the bones of your spine and your spinal cord to deliver local anaesthetic to numb the nerves that carry the pain from the birth canal to the brain. It is the most effective form of pain relief for labour and often relieves the pain completely. It can be helpful for women who are having a long and/or particularly painful labour, or who are becoming distressed. An epidural shouldn’t make you drowsy or sick or make your baby drowsy after birth. Only an anaesthetic doctor can give an epidural, so this form of pain
26 Preparing for labour relief is only available on delivery suite (not at home or in the birth centre). To have an epidural: •• A drip will run fluid through a cannula (fine plastic tube) into a vein in your arm. •• While you sit up in a curled position, an anaesthetist will clean your back with antiseptic and numb a small area in your lower back with some local anaesthetic. •• You will feel a small amount of pushing and pulling as a needle is used to insert a very small tube near the nerves in your spine. It is important that you stay very still during this process, but as soon as the needle is removed and the epidural is secured in place you can move freely. It takes about 20 minutes to set up the epidural, and another 15 minutes for it to work. •• This thin tube is the “epidural”. It can be used for the rest of your labour to give pain-killing injections (a mixture of local anaesthetic and fentanyl- a morphine-like drug). At Homerton, we use “mobile epidurals”, so the medicine
should be just strong enough to take away the pain of your contraction, while letting you feel some tightening with each contraction and keeping the strength in your legs, making it easier to move around and push the baby out. Occasionally, your legs still may be too heavy to walk so we ask all mothers to stay in bed for 30 minutes after each medication top up and your midwife will check how strong your legs are before you get out of bed. •• If you need to have a caesarean section or forceps or suctioncup delivery, the epidural can be topped up with much stronger medicines so that you can be awake and comfortable for the procedure. •• While you have epidural pain relief, your baby’s heart rate will be monitored more closely, by a machine and your blood pressure will be checked frequently. •• Combined Spinal and Epidural: Occasionally, your anaesthetist may recommend that, while your epidural is inserted, you also have a one-off pain-killing injection into the bag of fluid around your spinal cord
Preparing for labour 27 (a “spinal”). This can make the pain relief take effect more quickly. Problems and side effects •• About one in eight times, the epidural does not work well enough to completely ease your labour pain. It may work better on one side than the other so you may need to lie on a different side when further doses of medication are given down the tube. If changing position does not work, the epidural may need to be adjusted or completely replaced. •• Some women find that their legs feel weak while the epidural is working (although this is less common with mobile epidurals). This can prolong the second stage of labour and make it more difficult to push the baby out. Having an epidural increases the chance of instruments such as forceps or a suction cup being used to help you deliver your baby (instrumental delivery). An epidural will not increase your risk of having a Caesarean section. •• The medications used in an epidural may make you itchy.
•• You may develop a fever, which may be associated with distress to your baby. •• Your blood pressure can drop, so this will be checked frequently. •• You may find it difficult to urinate as a result of the epidural: if so, a small tube called a catheter may be put into your bladder to help you. •• Your back might be a bit sore for a day or two after the procedure but epidurals are not associated with long-term backache. Rare complications •• About one in 100 women get a severe headache after an epidural because the bag of fluid around the spinal cord is punctured: a “dural puncture headache”. If this happens, your anaesthetic doctor will advise you on treatment options. •• Nerve damage can occur during childbirth whether you have an epidural or not. This means that about one in 2,000 women have a problem such as a weak muscle, tingling or numbness down one leg
28 Preparing for labour after having a baby: this is five times more likely to be the result of childbirth itself rather than the epidural. The chance of you getting a long-lasting nerve injury from the epidural is around one in 13,000. The chances of a severe injury, including paralysis is around one in 250,000.
•• Other very rare complications which have been reported include meningitis, accidental unconsciousness, epidural haematoma or abscess (a blood clot or infection pressing on the spinal cord). Who cannot have an epidural?
•• Most people can have an epidural, but certain medical problems (such as spina bifida, a previous operation on your back or problems with blood clotting) may mean that it is not suitable for you. If you would like to discuss if an epidural will be suitable for you please ask your midwife at one of your antenatal visits.
Who do we particularly recommend should have an epidural? •• We particularly recommend that overweight mothers have an epidural inserted early in labour. This allows more time for insertion when you are in less discomfort. Also, should you have to go to theatre for any emergency operation an epidural will be in place to give strong medications to keep you comfortable throughout the operation, avoiding the risks of a general anaesthetic. If you are overweight, an epidural may be more difficult and take longer to put in place. However, once it is in you will have all the benefits. •• If you are having twins, your obstetrician may recommend an epidural, so that you can quickly and easily be kept comfortable if you need assistance to deliver the second twin. •• If you have high blood pressure or pre-eclampsia, it may be recommended that you have an epidural, as it can help to reduce your blood pressure.
Preparing for labour 29
Anaesthesia in labour Some women will need an anaesthetic during childbirth (for a caesarean section or forceps delivery) or for complications soon after childbirth. Usually a regional anaesthetic (an epidural or spinal) is used, meaning that you will be awake, but you can’t feel any pain in your lower body. In this case, your partner can stay with you the whole time. If you need to have a general anaesthetic for your caesarean, your partner will not be allowed in the operating theatre. Epidural anaesthesia If you already have an epidural in place, the anaesthetic doctor will usually top it up with strong pain-killing medicines so that your legs become very heavy and numb and you can’t feel your tummy. You may find that you get very shaky during the operation, but your anaesthetist will be with you the whole time to explain everything that is happening. Spinal anaesthesia If you don’t have an epidural, you will usually be given a spinal anaesthetic. This is a very similar technique to an epidural (as explained above) but, instead
of threading a tiny tube into your back, a single injection is given into the bag of fluid around your spinal cord. This works more quickly than an epidural and lasts for about two hours before wearing off. Combined spinal and epidural anaesthesia Occasionally, your anaesthetist may feel that you would benefit from both the speed of a spinal anaesthetic and the longer lasting effects of an epidural anaesthetic. The two procedures can be done at the same time. General anaesthetic: Below are listed some of the reasons why you may need a general anaesthetic:
•• You have certain conditions when the blood cannot clot properly, it is best not to have an epidural or spinal.
•• You need a caesarean suddenly, there may not be enough time for a spinal or epidural to work.
•• Abnormalities in your back may make a regional anaesthetic difficult or impossible.
•• Occasionally, a spinal or epidural anaesthetic can’t be put into the right place, or doesn’t work properly.
30 Preparing for labour You will be given an antacid to drink (to reduce the acid in your stomach) and a midwife may insert a catheter into your bladder before the general anaesthetic is started. The anaesthetist will give you oxygen to breathe through a face mask for a few minutes. Once the obstetrician and all the team are ready, the anaesthetist will put the anaesthetic in your drip to send you to sleep. Just before you go off to sleep, the anaesthetist’s assistant will press lightly on your neck. This is to prevent stomach fluids getting into your lungs. The anaesthetic works very quickly. When you are asleep, the anaesthetist will place a tube into your windpipe to prevent fluid from your stomach from entering your lungs, and to allow a machine to breathe for you. The anaesthetist will continue the anaesthetic to keep you asleep and allow the obstetrician to deliver your baby safely. When you wake up, your throat may feel uncomfortable from the tube, and you will feel sore from the operation. You may also feel sleepy and perhaps a bit sick for a while.
You will be taken to the recovery area where you will join your baby and partner. Further information: If you know that you are coming in for a planned caesarean section, or you would like more information about anaesthesia in childbirth, there is useful information for mothers on the Obstetric Anaethetists’ Association website: www.oaa-anaes.ac.uk (click on “information for mothers”, “overview” to see the leaflets, information cards and short films)
Fetal monitoring in labour Your baby’s heart will be monitored throughout labour. Your midwife will watch for any marked change in your baby’s heart rate, which could be a sign that the baby is distressed and that something needs to be done to speed up the delivery. There are different ways of monitoring the baby’s heartbeat:
•• Your midwife may listen to your baby’s heart intermittently, but at least for one minute every 15 minutes when you are in
Preparing for labour 31 established labour, using a hand-held ultrasound monitor – 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 (cardiotocography). The monitor will be strapped to your abdomen on a belt.
•• Alternatively, a clip can be put on your baby’s head to monitor their heart rate – the clip is put on during a vaginal examination and your waters will be broken if they have not already done so. Ask your midwife or doctor to explain why they feel that the clip is necessary for your baby.
Perineal repair 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 anaesthetic 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.
Vitamin K Newborn babies have low levels of vitamin K. Vitamin K occurs naturally in food, especially in liver and some vegetables. We all need vitamin K to help make our blood clot. Without enough vitamin K a baby is at risk of internal bleeding which can cause brain damage or can be even fatal. This is called vitamin K deficiency bleeding (VKDB). It is a rare condition that can occur in one in 10,000 babies. VKDB is more common in babies:
•• that have been born prematurely •• that have had a complicated delivery such as forceps or ventouse
32 Preparing for labour
•• a delivery where bruising occurs •• some babies born to mothers that required medication during their pregnancy, the most common being treatment for epilepsy. The risk of bleeding is effectively removed when sufficient extra vitamin K is given to babies. Since 1998 the Department of Health has recommended that all newborn babies are given vitamin K at birth. There are two ways that this can be given: by one injection given at birth or two or three doses of oral medicine – one after birth, one when the baby is a week old and the third, if the baby is breastfeeding, when the baby is one month old. Your midwife will discuss whether you want to give Vitamin K to your baby. If you decide against giving Vitamin K to your baby you should be aware of the following possible symptoms:
•• bleeding that does not stop from either the nose, cord and injection site or from circumcision •• unexplained bruising •• bloods in stools or vomit.
The following may be signs of liver disease which can cause VKDB
•• jaundice, even if mild , which continues after two weeks •• pale, whitish-grey stools •• very dark urine. If you have any questions you should discuss them with your doctor or your midwife.
Stem cell collection If you are interested in stem cell collection from your baby’s umbilical cord, there is an excellent information package from the Royal College of Obstetricians & Gynaecologists (www.rcog.org.uk stem cell collection, information for parents), that explains this in detail. Legally, we are not allowed to take cord blood for private banking. We are happy for a third party, who is licensed appropriately, to take the stem cells, and many of the private companies have experience with this. You would need to contact the third party phlebotomist, who would need to come to your delivery and collect the blood from the baby’s umbilical cord and placenta after delivery. You would then
Preparing for labour 33 need to arrange for the package to be collected by courier. If you would like to go ahead with this procedure please download the information and forms to be completed from our website: www.homerton.nhs. uk/our-services/maternity-services
The early postnatal days If you and your baby are well you will go home a few hours after the delivery unless you have had a Caesarean or forceps/ventouse delivery. Following your transfer home the community midwife will continue the care until your baby is at least 10 days. The visiting schedule will be discussed with you on her first visit. Whilst you are on the postnatal ward the visiting times are: 9am-12 pm One adult per patient (no swapping) 4pm-7pm Two visitors (including the partner) per patient
Children of the patient on the ward may visit during this period.
Maximum visitors per bed: one adult and two children of the patient on the ward. Children under 16 cannot visit unless they are the brother or sister of the new baby. Restrictions to the numbers of visitors apply to minimise the risk of infection and ensure the health and safety of mothers and their newborn babies. The first few days with your baby can be a very emotional time for you and your partner. There is a lot to learn and do. There is the excitement of getting to know your baby, but you will also be tired and your body will be recovering from labour and the birth. Keep your baby close to you as much as you can. Your partner should also spend time holding and being close to your baby. They may feel a little left out, especially if they have to leave you and the baby in hospital and return to an empty home. They may need support and encouragement to get involved. The more you can both hold and cuddle your baby, the more confident you will all feel.
34 Preparing for labour How you feel: You may feel tired for the first few days, so make sure you get plenty of rest. Even just walking and moving about can seem like hard work. You can find some tips on coping with stitches, piles and bleeding. For a lot of mothers, the excitement and the pleasure of the new baby far outweigh any problems. But you can begin to feel low or rather depressed, especially if you are very tired or feel you cannot look after your baby in the way you would like. Giving birth is an emotional and tiring experience and your hormones change dramatically in the first few days The baby blues: During the first week after childbirth, many women get what is often called the ‘baby blues’. This is probably due to the sudden hormonal and chemical changes that take place in your body after childbirth. Symptoms can include:
•• feeling emotional and irrational •• bursting into tears for no apparent reason •• feeling irritable or touchy, or •• feeling depressed or anxious.
All these symptoms are normal and usually only last for a few days. Postnatal depression: Depression after a baby is born can be extremely distressing. Postnatal depression is thought to affect around one in 10 women (and up to four in 10 teenage mothers). Many women suffer in silence and friends, relatives and health professionals don’t know how they are feeling. Postnatal depression usually occurs two to eight weeks after the birth. Sometimes it can happen up to a year after the baby is born. Symptoms such as tiredness, irritability or poor appetite are normal if you’ve just had a baby. Usually these are mild and don’t stop you leading a normal life. Whenyouhavepostnataldepression, you may feel increasingly depressed and despondent. Looking after yourself or your baby may become too much. Other signs of postnatal depression are:
•• anxiety •• panic attacks •• sleeplessness •• extreme tiredness •• aches and pains
Preparing for labour 35
•• feeling generally unwell •• memory loss or being unable to concentrate •• feelings of not being able to cope •• not being able to stop crying •• loss of appetite •• feelings of hopelessness •• not being able to enjoy anything •• loss of interest in the baby, and •• excessive anxiety about the baby. Getting help for postnatal depression: If you think you have postnatal depression, don’t struggle alone. It’s not a sign that you are a bad mother or are unable to cope. Postnatal depression is an illness and you need to get help, just as you would if you had the flu or a broken leg. Talk to someone you trust, such as your partner or a friend, or ask your health visitor to call in and visit you. Many health visitors have been trained to recognise postnatal depression and have techniques that can help. If they can’t help, they may know someone in your area who can.
It’s also important to see your GP. If you don’t feel up to making an appointment, ask someone to do it for you.
Prevention of sepsis advice The number of maternal deaths from Group A b - haemolytic streptococcus (Streptococcus pyogenes) infection has been increasing over the past 10 years. Group A streptococcus is typically community based and 5–30% of the population are asymptomatic carriers on skin or in throat. It is easily spread by person to person contact or by droplet spread from a person with the infection. Streptococcal sore throat is one of the most common bacterial infections of childhood, and all of the mothers who died from Group A streptococcal sepsis either worked with, or had, young children. Several mothers or family members had a history of recent sore throat or respiratory infection. Contamination of the perineum is more likely when a woman or her family or close contacts have
36 Preparing for labour a sore throat or upper respiratory infection. The organism may be transferred from the throat or nose via her hands to her perineum. Therefore it is important to maintain good personal hygiene by washing hands before and after using the lavatory or changing sanitary towel. If you have any concerns or wish to discuss this further please speak to your midwife, obstetrician or GP.
References: National Institute for Health and Clinical Excellence (NICE) 2007. Intrapartum care – care of healthy women and their babies during labour. NICE. London.
Useful telephone numbers Hackney Maternity helpline
020 8510 5955
Antenatal Clinic: Appointments and enquiries:
020 8510 7175
Delivery Suite:
020 8510 7351/7352/7354
Homerton Birth Centre:
020 8510 5548
Obstetric Assessment Unit (OAU) 020 8510 5306 Fetal Welfare Unit:
020 8510 7597
Scan Department:
020 8510 7929
Authors: Midwifery Department Date: December 2012 Review: December 2014
www.homerton.nhs.uk
