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Birthing Types

woman in labour
 

Introduction of birthing types

The advancement of modern medicine has seen the introduction of new ways in which women can give birth. The traditional vaginal birth method is still widely used. However, more and more women are now opting to undergo elective caesarean delivery. The use of a water bath during labour and/or birth is also beginning to gain popularity. With so many choices, it is important for women to fully understand the procedures, benefits, and risks involved in each of these birthing types before selecting one.

It is, however, important to note that seemingly “elective” options, such as undergoing a caesarean delivery for no medical reason, carry with them significant risks. These risks have to be carefully considered and weighted against the benefits of such a procedure before making any decisions. Hospital policies can vary on the issue – some may not provide the facilities needed for a water birth, or may not carry out caesarean sections unless there is a medical reason to do to. In addition, some medical practitioners may refuse to carry out any procedure that may inflict a significant amount of unnecessary risk on the mother and baby, even if such a procedure is requested by the patient out of personal choice.

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Vaginal birth

Who is present

Doctor: It is possible to choose whether or not to have a doctor present at a vaginal birth. Doctors who specialise in pregnancy and delivery are known as obstetrician gynaecologists or OB/Gyn for short. However, it is also possible for general practitioners to deliver at a vaginal birth. Choosing what kind of doctor to overlook a vaginal birth generally depends on the personal wishes of the woman. Factors that may influence the type of doctor a woman chooses include:

  • Whether the pregnancy/birth is a high or low risk one
  • If a pregnancy is a particularly risky one, it may be better to have a more specialised doctor perform the delivery
  • The nature of any pre-existing relationships between the patient and the doctor
  • Some women may feel more comfortable having their baby delivered by the family practitioner because he/she may be someone they know well and trust

Doctors may tend to take on a more medical approach to pregnancy and delivery, which can be more of an advantage and disadvantage at the same time.

Advantages: They are capable of dealing with both high and low risk pregnancies, and are able to administer pain relief during labour if it is requested by the patient. They are also more likely to be better equipped to handle emergencies, such as a premature delivery, if they do arise, and have the authority to perform emergency procedures that may not be able to be performed by a midwife.

Disadvantages: Doctors are often overbooked with patients. This, combined with the general medical approach usually taken, may sometimes result in a lack of personal attention during labour and birth. Some patients may find that they are unable to establish a personal trusting relationship with their doctor. However, it is important to note that the level of personal attention received will vary between individual doctors.

Midwife: A midwife is usually a certified nurse specialising in the area of labour and delivery. They may perform the delivery on their own, or they may work together with a doctor. They provide continual assessment of labour, usually staying with the patient throughout labour and childbirth.

Advantages: Midwives generally provide a lot of personal attention during labour and childbirth, staying with the woman throughout the entire process. As a result, they usually build up a personal relationship with the patient, establishing a sense of trust which may put women at ease. They are also more likely to support more natural non-medical types of childbirth, if desired by the patient.

Disadvantages: Midwives are not qualified to perform certain procedures that doctors can, nor can they administer pain medication if required. In addition, they are less equipped to deal with emergencies and high risk pregnancies and births. If an emergency does arise, it will be necessary to consult a doctor at a hospital, which can be inconvenient and dangerous for both the woman and her baby.

Doctor’s assistant(s): Assistants do not usually play any major role in delivery. They are there to assist the doctor and midwife (if present) in performing the delivery. They may perform tasks such as sterilising medical instruments, cleaning the baby when it is born, and providing assistance during emergencies.

What happens

A vaginal birth generally takes place in a hospital in most developed countries. However, some women prefer to give birth at home, usually with the assistance of a midwife and/or doctor.

Women who have a vaginal birth in a hospital usually check into hospital when they start to experience contractions. When they arrive, their general condition is evaluated, including the vital signs of pulse, blood pressure, breathing and temperature. The condition of their foetus is also checked. In particular the foetal heart rate is closely monitored to check for signs of foetal distress.

Most hospitals encourage the patient to choose a birth companion to provide personal labour throughout labour and birth. This person is often, but not necessarily, the father of the child to be born. The birth companion is usually encouraged to provide emotional and mental support for the woman, as well as some physical support such as rubbing her back and assisting her to move about.

The woman is encouraged to empty her bladder regularly, and to eat and drink as desired throughout labour. Breathing techniques are also taught, where the woman is taught to breathe out more slowly than usual, and to relax during each breath out.

Confirmation of labour: Although the woman usually checks herself into hospital at the onset of contractions, labour is generally suspected if irregular abdominal pain is present after 22 weeks of gestation, blood-stained mucus associated with pain, and/or a watery vaginal discharge or a sudden gush of water.

The onset of labour itself is confirmed by checking the cervix. Cervical effacement (the progressive shortening and thinning of the cervix) and cervical dilation (the increase in cervical opening diameter) are indications of the onset of labour.

Progress of labour: Once labour has been confirmed, the doctor/midwife will assess its progress by monitoring changes in cervical effacement and dilation. The decent of the foetus through the birth canal is also tracked by examining the abdomen. In addition, vaginal examinations are usually carried out at least once every 4 hours during the first stage of labour to monitor the colour of amniotic fluid, extent of cervical dilation and stage of foetal descent.

Delivery: Once the cervix is fully dilated, the woman is said to be in the expulsive phase of the second stage of labour. It is at this time that she is encouraged to assume her preferred birthing position and to push. Contractions may decrease just prior to the urge to push is felt. During the actual pushing stage, the contractions are usually strong and forceful, and may be accompanied with an urge to push, so that the woman can push in time with the contractions of the uterus. Most women feel in increased pressure in their lower back, perineum (vaginal tissue) and rectum during this stage. The rectal pressure can feel the same as having a bowel movement to many women.

The delivery of the head is generally controlled in part by the doctor/midwife, who place their fingers of one had against the baby’s head to keep it flexed. As the head is being delivered, the woman may feel a stretching or burning sensation. If needed, this process may be assisted by the use of forceps or a vacuum suction cup.

Once the baby’s head is delivered, the doctor/midwife will feel around the neck for the umbilical cord. If the cord is present around neck, it will either be slipped over the baby’s head or doubly clamped, cut, and unwound from around the neck before the rest of the body is delivered.

The rest of the body is generally easier to deliver, requiring only gentle contractions from the woman. When the whole body is delivered, the woman enters the third stage of labour, during which the placenta is delivered. The delivery of the placenta only required gentle pushing, and is much easier to deliver than the baby.

After delivery of the placenta, the whole process of labour is complete. The doctor/midwife will examine the placenta and its membranes to ensure that it is intact. The patient’s abdomen will also be felt to check that the uterus is contracting in order to stop the bleeding that occurs when the placenta is torn away. The woman will also be examined for tears to the cervix or vagina.

Labour and a subsequent vaginal birth takes an average of 13 hours in women giving birth for the first time, and 8 hours in women who have given birth before. However, the exact duration varies a great deal from one woman to another.

 

 

How to prepare

It is necessary to prepare for a vaginal birth well before going into labour, so that when labour does occur, there is no rush to pack things for the hospital. It is advisable to have a hospital bag packed by the time a woman is 36 weeks pregnant. It should be noted that various hospitals provide different things (eg. number of pillows and cushions), and that they may have restrictions on what you can bring. Hospitals are also often short on space, only providing a small bedside cabinet to store items. It is therefore a good idea to check with the hospital before packing.

What to pack: Items to be brought can be divided three ways – a set of items for the patient, a set of items for the baby, and a set of items for the patient’s birth companion.

The patient: It is advisable to bring at least 2 extra sets of clothes, in addition to what is worn to the hospital. One set should be brought to wear during labour, keeping in mind that they are likely to get messy. The other set should be a set of maternity clothes to wear after the birth on the way home. Comfortable slippers should also be packed, in case the patient wishes to walk around the hospital during early labour. A dressing gown may also be useful for this purpose.

Other things to pack include toiletries, snacks and drinks, items to help the patient relax (eg. books and music), and watch to help time contractions. The patient may also wish to bring other items to make her more comfortable, such as pillows from home, or a hand-held fan to keep cool.

Items should also be packed for after the birth, including maternity pads and nursing bras.

Finally, it is quite common and useful for patients to write up a birth plan before going into labour. The birth plan is then brought to the hospital and given to the doctors and midwives when the woman goes into labour. This plan describes to the midwives and doctors the kind of birth and labour the patient desires. It is important to remember that births can be unpredictable, and that things may not go exactly to plan. However, it is useful to write down what the woman wants to happen and what she wants to avoid beforehand.

A birth plan can include (but is not restricted to) what birthing and labour positions are preferred, what kind of pain relief is to be used (if any), whether the baby is to be breastfed or bottle-fed, and what the woman wishes to do if the baby has to go to the intensive care unit. Any religious needs should also be mentioned.

The baby: Clothes should be packed for the baby to wear in hospital and on the way home. Other items to pack include socks, a blanket, and nappies. An infant car seat should also be prepared beforehand so that the baby can be taken home safely.

The birth companion: Extra clothes and toiletries should be packed for the birth companion, as well as food and drinks to keep him/her refreshed. The birth companion may also want to bring items such as books and magazines, in addition to those the patient might bring.

Benefits

Contrary to popular belief, vaginal birth remains the safest birth option for delivery, compared to elective caesarean section, for a normal low-risk pregnancy. Babies born by this method have been found to have a lower incidence of respiratory problems, as it is thought that the contractions that occur during labour help prepare the baby’s lungs for breathing. There is also less risk of blood loss and infections to the mother, compared to caesarean section deliveries.

Also, despite the process of labour and birth itself being painful, women who give birth vaginally usually recover very quickly. Mothers are often able to walk and care for the baby within a few hours after birth. Women are generally discharged from hospital the same day of the birth, or the day after.

Risks

Vaginal birth is generally only more risky than a caesarean option if the baby is in breech position, or if there is an emergency that requires the baby to be delivered quickly. Babies delivered vaginally in breech position are at risk of oxygen deprivation as a result of cord prolapse or prolonged cord compression due to head entrapment.

If the attending doctor/midwife has not had much experience in breech vaginal deliveries, it may be safer to perform a caesarean section.

 

 

 

Caesarean section

Who is present

Doctor: Since a caesarean delivery is a surgical procedure, the doctor performing the operation will be an obstetric surgeon. He/she performs the actual surgery, including making the incision, delivering the baby, and closing up the abdomen.

Doctor’s assistant(s): The doctor’s assistant is there to assist the surgeon in the caesarean delivery, as they would in any other operation.

Anaesthetist: The anaesthetist administers the anaesthetic to the patient. A local spinal or epidural trigger point injection of local anaesthetic will normally be used, so that the woman remains conscious during the operation, but is completely numb from the waist down. In some circumstances, a general anaesthetic may be advised, where the woman is completely unconscious during the procedure. The anaesthetist also plays a large role in monitoring the patient’s vital signs such as heart rate and blood pressure.

An anaesthetist’s assistant may also be present to help the anaesthetist.

Scrub nurse: A scrub nurse is usually present, along with 1 or 2 other nurses to assist the surgeon by passing surgical instruments to him/her.5

Paediatrician: A paediatrician is always present at a caesarean section delivery to examine the baby after it is born. If necessary, he/she will administer resuscitation of the newborn, since caesarean sections often take place due to complicating factors.

What happens

A caesarean delivery is an operation whereby the surgeon removes the baby directly from the uterus , bypassing the birth canal. If a caesarean section is planned, the woman will have a pre-set date on which to have the surgery. However, in some circumstances, caesarean sections are performed as a last-minute alterative to a vaginal delivery, due to complicating factors such as a breech birth.

After checking into hospital, the patient is prepped for surgery. Local anaesthesia is usually used so that the woman is awake and fully alert during the procedure. Most hospitals allow the woman’s partner to be present at the delivery if a local anaesthetic is used. However, if a general anaesthetic is used, no one else is allowed in the delivery room. An IV infusion is also used to transfer nutrients and if needed, pain relief to the woman. Throughout the surgery, the woman’s vital signs are monitored, including her heart rate and blood pressure. A screen is normally set up so that the patient cannot see the actual surgery. Because of the anaesthesia, no pain is felt but there us often a sense of pressure during the surgery.

After the anaesthetic IV drip have been administered, an vertical incision of about 20cm is made across the abdomen through the skin. The abdominal wall muscles are then separated using scissors and fingers. Next, an opening is made in the membrane covering the abdominal organs near the belly button, and the uterus is exposed. An incision is made in the uterus and extended with scissors.

To deliver the baby, the surgeon places one hand inside the uterine cavity and grasps the baby’s head. The head is delivered through the incision in the uterus, and the baby’s mouth and nose suctioned. The rest of the body is then delivered. After clamping and cutting the umbilical cord, the baby is examined by the paediatrician, cleaned, and given to the mother (if local anaesthetic was used). The placenta and its membranes are delivered by the surgeon, who then closes the uterus and abdomen.

A normal uncomplicated caesarean surgery takes about 30 minutes from beginning to end.

How to prepare

The list of items to pack for a caesarean delivery is similar to the list for a vaginal delivery. However, because a patient can expect to remain in hospital for 3-4 days when having a caesarean delivery, quantities of clothes etc should be appropriately increased. The woman will also be told by their doctor not to eat or drink for about 8-12 hours prior to the surgery. When preparing for a caesarean delivery, it is important to fully understand the risks involved.

Women are strongly encouraged to ask plenty of questions, and to ensure that they understand the reasons for undergoing the surgery, as well what is involved at each stage. If the caesarean is planned beforehand, it may even be desirable to attend c-section prenatal classes, which prepare women for undergoing caesarean deliveries by familiarising them with the procedure.

Benefits

Caesarean deliveries allow for the birth of babies that would otherwise be very unlikely to survive a normal vaginal delivery due to a number of complicating factors including obstetrical problems or maternal illness. A major reason for undergoing caesarean delivery is breech presentation, where the foetus has its feet facing the birth canal, contrary to the usual cephalic presentation where the head is facing the canal first.

With breech presentation, c-section has a large protective effect, and foetal mortality is greatly reduced.

Risks

Although emergency caesarean sections are generally a better option that undergoing a risky vaginal delivery, there is a growing body of evidence that elective caesarean surgery for a normal pregnancy may be significantly riskier than a normal vaginal delivery. Planned caesarean sections have been found to be significantly associated with risks for severe complications after birth, including haemorrhage which can require hysterectomy, cardiac arrest, venous thromboembolism, infection, and complications relating to anaesthesia. Higher rates of babies that stay in neonatal intensive care for longer than seven days have also been reported. In addition, women undergoing caesarean surgery generally have to remain in hospital for a longer period after birth, compared to those undergoing a vaginal birth.

Recovery is also slower, and the patient often experiences a pain and discomfort during the recovery period, whereas women who have a vaginal birth are known to be able to resume normal activities a few days after giving birth.

Caesarean delivery is also associated with long term risks to the mother, including placenta praevia (a low lying placenta) and abruption in subsequent pregnancies. It was also believed for a long time that once a woman had had a caesarean section, all subsequent children had to be born by the same method. However, there is now evidence that it is possible to have a vaginal birth after having a previous c-section, although this must be approached with caution.

Water birth

Who is present

Midwife: The midwife is normally the person who plays the biggest role at a water birth. Midwives are not doctors, but registered nurses specialising in the area of labour and childbirth. They support the patient during labour, assisting in moving the patient to try out different positions in or out of the water. They are usually the key personnel in a water birth, as opposed to doctors, because water births tend to place more emphasis on the natural birth process and less aggressive medically-driven birth management. Midwives are responsible for the comfort and safety of the patient and her baby. They remain with the patient throughout labour, and deliver the baby and placenta.

Doctor: Some hospitals offer water birth as an option. In some circumstances, a doctor may be present to deliver the baby. A midwife is normally also at hand to support the woman during labour and birth. A doctor may be present especially if there is the risk of complicating factors, or if the woman requests pain relief, since midwives are not equipped to administer pain relief or attend to emergency situations.

What happens

Since being introduced in 1991, water births have become increasingly popular as an alternative birth method that is thought to be less restrictive, and more mindful of the individual and the natural birth process.

A water birth is essentially the same as a vaginal birth, except that the process of labour, and sometimes even birth itself, occurs with the mother submerged in a bathing tub. The bath, also sometimes known as a birth pool, may either be situated at home or in a hospital, if a particular hospital happens to cater for such births.

As with a vaginal birth, the patient generally checks herself into hospital when contractions begin, or if she is having a home birth, she may be assisted by he midwife in getting into the bath. Midwives play a key role in water births, and are always with the woman. During early labour, the patient may be encouraged to experiment with various positions in and out of the bath. The decision on where to be, and in what position to be in, is always ultimately left up to the mother, and she is usually welcome to change positions and locations as and when she desires.

Some hospitals have birthing rooms which can provide a calm and peaceful surrounding, emphasising the soothing effect of the water. Some of these rooms may also supply options such as bars and railings on the wall to allow easy access to water immersion.

The temperature of all water baths can also be regulated so that it is kept at a comfortable level. The patient is usually able to do this directly herself if she wishes, or it may be regulated by the midwife. If the birth takes place at home, it may be more difficult to get the water temperature to exactly the correct level. The temperature of the water is important because although warm water help sooth the patient and is said to reduce the need for painkillers, a bath that is too hot can damage the foetus.

Being in a water birth can lead to a sense of buoyancy and freedom of movement. Many women also report a soothing sensation and a sense of being supported, resulting in a decreased sensation of pain. If the birth takes place in hospital, a doctor may administer painkillers if requested.

As previously mentioned, the actual process of labour and birth is very similar to a normal vaginal birth. This includes the monitoring of the woman and foetus to assess their vital signs. When the baby is about to be born, the woman may choose to either remain in the bath to deliver the baby, or to get out of the bath and deliver the baby as normal. Babies who are born in the bath are always immediately removed from the bath as soon as they are delivered. The placenta is then delivered either in the bath or outside, depending on the woman’s wishes.

How to prepare

Women giving birth in a hospital should have a bag packed well beforehand. Items to bring are similar to those needed in a normal vaginal delivery.

The birth pool is a key feature of a water birth. It is therefore necessary to organise this well before the birth, whether the birth is taking place at home or in a hospital. Things to consider are the bath specifications, such as its depth, shape and size. It is important to consider how these might relate to the hydrostatic pressure of the water, as well as the amount of buoyancy and freedom of movement it provides to the woman during labour and birth. Women should think about how they want their birth experience to be like while selecting a bath. For example, some women may prefer to have plenty of space so that there is freedom to move around while at the same time being supported by the water during labour.

Benefits

Water birth is a procedure promoted mainly as a way to decrease maternal discomfort. It has been associated with a decrease in instrumented or operative delivery, as well as a reduction in the need for pain medication. Water births are also thought to result in less perineal injuries and maternal blood loss. The lack of maternal blood loss may be a result of the hydrostatic pressure of the water. The decreases need for pain medication is due to a number of factors. Being in the bath during labour provides the woman with a soothing warm pleasurable sensation, as well as the feeling of being supported by the water. This is thought to stimulate the closing of the gate for pain at the level of the dorsal horn, so that women experience a temporal stabilising effect in between contractions. It is likely that women who have water births do not actually experience less pain, but they are instead able to cope with the pain better because of the relaxing effect the bath provides.

Another benefit of water births is the amount of support received from the midwife. Women are generally constantly being emotionally supported and encouraged by their midwife during a water birth. Water births also tend to be less focussed on the medical aspects of birth. Birth is viewed as a natural process, and the mother is emphasised as an individual. This can make the woman feel at ease and more secure, which may also contribute to her state if relaxation and hence a decrease need for pain medication.

Risks

The risks of water births to the newborn have been widely debated. Some studies find no increased risk to the baby, while others suggest that the risks to the neonate outweigh the benefits to the mother.

Water births have been associated with respiratory distress, infections, ruptures umbilical cords, seizures, hyper- or hypothermia , aspiration of bathwater and near drownings. Tachycardia (increased heart rate) and fever have also been linked to bath temperatures that are too high. Mothers who undergo labour in the water are also more likely to have infants who require oxygen or positive-pressure-ventilation in the delivery room after they are born, since the increasing temperature of the bath may cause foetal cerebral vasodilation, increasing foetal oxygen requirements.

Some studies however, state that there is no risk of the infant drowning because of the diving reflex. This reflex is responsible for the inhibition of water inspiration in utero, inhibiting respiration movements when the face comes into contact with a fluid. An infant’s first breath will therefore only be taken when the face comes into contact with the air outside the bath.

 

More information

BirthFor information on birthing statistics,stages of labour, various birthing types and other information related to giving birth, see Birth.

 

References

1. Committee on Fetus and Newborn of the American Academy of Pediatrics. Underwater births. Pediatrics. 2005; 115(5): 1413-1414.

2. Geissbühler V, Eberhard J. Waterbirths: A comparative study. Fetal diagnosis and therapy. 2000; 15(5): 291-300.

3. Liu S, Liston RM, Joseph KS, Haeman M, Sauve R, Kramer MS. Maternal mortality and severe morbidity associated with low-risk planned caesarean delivery versus planned vaginal delivery at term. Canadian medical association journal. 2007; 17(4): 455-460.

4. Lowdon G, Derrick DC. Caesarean section or vaginal birth – What difference does it make? Association for improvements in the maternity services. 2002; 14(1). Available from: URL: http://www.aims.org.uk/Journal/Vol14No1/csdifference.htm

5. Maude RM, Foureur MJ. It’s beyond water: Stories of women’s experience of using water for labour and birth. Women and birth. 2007; 20: 17-24.

6. Mills MS, Stirrat GM. Water immersion and water birth. Current obstetrics and gynaecology. 1996; 6: 35-39.

7. Obstetrician Gynecologist or Certified Nurse Midwife: The Choice is Yours [online]. 2008 [cited 2007 Jan 15]. Available from: URL: http://www.stages-in-pregnancy.com/obstetrician-gynecologist.html

8. Romano AM. Research summaries for normal birth. The journal of perinatal education. 2006; 15(4): 46-49.

9. Shorten A. Maternal and neonatal effects of caesarean section. British medical journal. 2007; 335: 1003-1004.

10. Sutter Health. The Process of Labour: Pushing – the second stage [online]. 2008 [cited 2008 Jan 15]. Available from: URL: http://babies.sutterhealth.org/laboranddelivery/labor/ld_push.html

11. The New York Times. Preparing parents for a birth. 1981 Dec 18; Sec A:3.

12. The Royal Women’s Hospital. Normal labour and birth – low risk [online]. 2006 [cited 2008 Jan 15]. Available from: URL: http://www.thewomens.org.au/NormalLabourandBirthLowRisk

13. Villar J, Carroli G, Zavaleta N et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. British medical journal. 2007; 335: 1025-1035.

14. World Health Organisation. Managing complications in pregnancy and childbirth – A guide for midwives and doctors [online]. 2003 [cited 2008 Jan 15]. Available from: URL: http://www.who.int/reproductive-health/impac/Clinical_Principles/Normal_labour_C57_C76.html#C59%20Diagnosis

Dates

Posted On: 8 February, 2008
Modified On: 12 May, 2010

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