Pregnancy is time to be happy, healthy and stress-free. As women near the ninth month, they start to feel the pressure—in their body and mind— and worry about their delivery. It is important here to note that labour and delivery is the end of pregnancy and beginning of a new life. Thus, nine months of pregnancy is a preparation for the process of labour and delivery.
Antenatal care plays an important role to achieve a successful labour and delivery process. Regular antenatal classes help in the physical and mental preparation of women and help them relax during those last months.
Role of antenatal care
To ensure maternal and foetal wellbeing:
Regular visits to the doctor during pregnancy are aimed to ensure that the health of the pregnant woman and the growing foetus is well-maintained. When all stays well and proper care is taken, the pregnancy is generally low-risk. If any abnormalities develop during pregnancy or if there are any pre-existing risk factors, then it becomes a high-risk one. The abnormalities that could develop during pregnancy include increased blood pressure, diabetes, and growth restriction in the baby to name a few. The pre-existing risk factors include previous caesarean sections, and pelvic abnormality.
To prepare for labour, delivery and the post-partum period:
Normal labour and delivery depend on good physical and mental preparation during the antenatal period. The pregnant woman is taught good breathing exercises, relaxation techniques and muscle toning exercises. Yoga is now a well established form of therapy for this purpose. In order to relieve anxiety and fear, knowledge should be given about the labour and delivery process. This includes a clear understanding of what to expect in labour, ways of monitoring the labour, options for pain relief and the modes of delivery.
At about 36 weeks gestation the mode of delivery should be discussed with your doctor. If the decision is taken to proceed with normal labour and vaginal delivery, then regular visits are continued till labour starts. These weekly visits ensure that all is well and thus it is important to feel good foetal movements during this time. You will also feel contractions and pains intermittently, but these are just warm up [practice] labour pains. These help your womb muscles to get better coordinated as they are getting ready for the actual labour stage.
Onset of normal labour
The start of labour happens with one of the following:
Abdominal pains and contractions. There is backache and the contractions are typically felt coming from the back towards the lower abdomen. Initially they come every 20 – 30 minutes, but then the frequency increases. In established labour, these contractions will come every three minutes and will last up to a minute.
Leakage of clear water. You may think it to be urine, but then realise that it is coming continuously. Sometimes the bag of water around the baby breaks and the surrounding liquid starts draining.
Blood stained mucous discharge. Occasionally the mucous plus gets dislodged from the neck of the womb. This is seen as a sticky discharge with blood staining.
In any of the above events, if you are unsure, it is best to contact your doctor for guidance. You may be asked to come for a check-up. If the neck of the womb has started to open, then it indicates the start of labour. If it is very early, you may prefer to be at home and go to the hospital later.
What to do at home when labour begins?
Get ready to travel to hospital. Do not take a heavy meal as there is a risk of vomiting when pain gets strong and this will get worse if your stomach is full. Liquids are the best form of intake from now on and they are good for rehydration. You will urinate frequently; this is normal. Take as much rest as possible so that you can cope with active labour. If possible, lie down on your left side.
When awake it is good to move around. This helps the baby’s head to push against the neck of the womb and improves the contractions. During contractions you can take support and lean forward on a steady surface [wall or bed] or be supported by your husband. Sometimes a good hot water shower is very helpful. When the contractions get stronger and frequent it will be difficult to cope and you will have to go to a hospital.
What is expected at the hospital?
If you are confirmed to be in labour on examination you will be admitted. A heart rate tracing of the baby can be reassuring at this stage. You will be encouraged to mainly take liquids. If all is well, you can continue to move around. At times, it is necessary to put an intravenous needle. Sometimes caesarean section is needed on an urgent basis. If this situation arises suddenly, anaesthesia can be given to you safely. During labour, soothing music, good aroma and massage can help you cope better.
Stages of labour
Labour has three stages. The first stage is from the onset of labour to the full dilatation of the neck of the womb. The second stage is from the full dilatation to the delivery of the baby. The third stage is from the delivery of the baby to the delivery of the placenta and membranes.
In the initial phase of the first stage [latent phase], the neck of the womb is getting ready for active labour. It is getting softer and thinner. This phase continues till3 – 4cm dilatation occurs of the neck. This phase could continue for 10 – 12 hours.
When the later phase [active labour] starts, the contractions will get stronger, more regular and frequent. If the membranes are not ruptured, your doctor may choose to break the bag of water now. If the baby has opened its bowel [meconium], then the fluid is green coloured and is a worrying sign. This phase will become very uncomfortable. It is important to breathe in and out during the contractions and relax your body muscles. You must avoid pushing as valuable energy will get wasted and the baby will get tired sooner. The regular, frequent and strong contractions will lead to full dilatation of the neck of the womb. The active phase can take about 6 – 7 hours.
Pain relief. Various options can be considered to help you cope with the labour pains. In the early stages, intramuscular pain killer injections can be considered. Gas inhalation [nitrous oxide and oxygen] can also be of help.
The most effective pain relief is with epidural analgesia [painless labour]. In this form, a catheter is put into the back through a needle. The pain-killing medicine is injected through the catheter. This is very effective and takes away the pain. In case a caesarean section becomes necessary, it can be performed with the help of the epidural catheter.
Epidural analgesia cannot be used in women with bleeding disorders or spinal cord abnormalities. The disadvantage is that labour may sometimes get prolonged and your ability to push the baby at full dilatation may get compromised. In this situation, the chances of instrumental delivery may be higher. The other disadvantage is the additional cost. This form of pain relief needs close monitoring. Sometimes the anaesthetist may stay with you till the delivery.
Monitoring. It is important to assess the progress of labour and maintain foetal wellbeing. The baby’s heart beat pattern is monitored at regular intervals. At any stage, if the mother or the baby’s wellbeing is compromised; a caesarean section delivery of the baby would be performed.
Once the neck of the womb is fully open [about 10cm], the second stage starts. The delivery is now expected within two hours. During contractions it is important to relax and take a deep breath in and push right down. If there is any delay, this stage can be shortened by applying an instrument such as forceps [metal blades] or a suction cup [ventouse delivery] on the foetal head. A cut on the perineum is sometimes necessary to facilitate the delivery of the baby. This is repaired post-delivery and heals within few days.
This stage extends from the delivery of the baby to the delivery of the placenta. Generally, this is completed in 15 – 20 minutes. Rarely, the placenta may not get separated. This can become a problem as bleeding may start. In this situation, you may need to be taken to the operation theatre for a manual removal of the placenta.
If approached in an ill-prepared manner, it is unlikely to be a positive experience. Hence it is important to take utmost care and proper preparation. The first labour and delivery is most challenging and the subsequent ones become relatively easier on most occasions.