It's time to give birth! First signs
A “term” birth occurs between the 37th and 42nd week of pregnancy, while the first signs of impending labor can be noticed a few days/weeks before the actual action: the abdomen dropping (the fundus of the uterus drops when the baby’s head is inserted into the birth canal), the mucus plug falling out of the cervical canal (a “plug” of secretions that blocks the cervix and separates the fetal membranes from the outside world; it looks like an elongated piece of jelly; sometimes it falls off before labor, sometimes a few days before, and sometimes even long before labor, especially in multiparous women), uterine contractions, the so-called prodromal contractions (they appear after the 20th week of pregnancy; they may resemble labor contractions, but are milder and irregular; they “train” the uterus for labor; they cause the cervix to dilate and shorten). Importantly, the above symptoms can appear at different times and do not always herald imminent labor. Of course, it is worth paying attention to the signals coming from the body, but it is important to remember that each organism reacts differently.
Uterine contractions and the course of labor
The very beginning of labor is the aforementioned irregular pre-menstrual contractions, felt as lower abdominal pain (similar to pre-menstrual pain), lower back pain, or tension in the entire uterus. They can be very bothersome and are often the reason for reporting to the hospital. So, to save yourself a few hours in the emergency room, it is worth taking antispasmodic medication beforehand (yes, you can use No-Spa as needed) and a warm bath/shower, which should allow you to verify the type of contractions: to disperse the pre-menstrual contractions or to intensify the labor contractions.
The actual labor is divided into 4 phases. The first phase of the actual labor begins with regular, painful contractions. The contractions appear at first about every 10 minutes. When they occur every 4 to 5 minutes, you can go to the hospital (which is why it is worth monitoring the duration of the contraction and the intervals between individual contractions). The contractions cause the cervix to smooth out, if it has not happened before, and lead to full dilation, until the diameter of the entrance reaches 10 centimeters.
Formalities
After arriving at the hospital, the first steps should be directed to the admissions office. There, each person giving birth shows the necessary documents (ID card, pregnancy card, test results and the original blood type test), and then changes into a birthing gown. Sometimes a CTG is done in the admissions office, sometimes only in the delivery room. Importantly, a fetal ultrasound is performed only if there are indications for it. Then, the pregnant person is transported on a hospital trolley to the delivery tract, where they are cared for by midwives (or obstetricians, although based on my own experience I will briefly write about midwives) and are taken to the delivery room. There, tests are performed (during labor, a rather unpleasant obstetric examination is often performed) and an intravenous catheter is inserted (usually on the forearm), from which blood is taken for testing and through which medications and fluids are administered. If necessary, the patient can have a CTG. Between contractions, the midwife collects information and determines the plan (course) of labor. In the delivery room, in addition to the delivery chair, there are usually ladders, bean bags, and a bathtub or shower. During the entire stay in the hospital, body temperature is often measured, first of the parent and then of the child.
Importantly, during labor, a midwife is most often responsible for the care of a patient in a physiological pregnancy, while those in high-risk pregnancies are cared for by a doctor. In practice, labor is always led by a midwife, and if there is a need or necessity, a doctor appears in the room. In some hospitals, a doctor is required to supervise the second stage of labor and dress perineal injuries.
Anesthesia
It is worth being active during the first stage of labor, because movement accelerates the dilation of the cervix. If a person wants to receive an epidural, in some hospitals you must visit an anaesthesiology clinic no earlier than 2 weeks before delivery to qualify for anesthesia. According to the regulation of the Minister of Health, epidural anesthesia can be used when the cervix is dilated more than 1 centimeter, and in justified cases even earlier. A necessary condition is regular uterine contractions, which are very painful for the patient after exhausting other, non-pharmacological methods of pain relief. In exceptional situations, for example when it is known that labor may last longer and the patient is very tired, anesthesia is sometimes administered even when the cervix is dilated 8 to 9 centimeters, i.e. before the second stage of labor. Qualification for anesthesia is an individual assessment of each case. It is absolutely not eligible in the absence of regular uterine contractions, very dynamic course of labor (due to lack of time to perform anesthesia), fetal heart rate disorders and in the case of obstetric indications for cesarean section and anesthesia contraindications (including thrombocytopenia, spinal curvature, skin lesions in the lumbar spine, tattoo).
In order to administer anesthesia, the anesthesiologist asks you to lie on your side (as if curled up) or sit with your head bent and inserts a long, thin needle into the lumbar region of the spine, leaving a catheter through which the anesthetic will be administered. The catheter port is glued to the neck so that a larger amount of the anesthetic can be easily administered. Usually, during anesthesia, the patient can move her legs and walk freely, she only does not feel pain during contractions, but sometimes she loses control of her legs or has so little control of the movement of her legs that the midwives do not allow her to leave the delivery chair. Pain during labor can be relieved by a lumbar massage by a companion, water immersion (shower or bath), laughing gas (administered with a special mouthpiece) or painkillers: paracetamol administered orally or intravenously (the latter is rarely practiced).
Just a moment…
The water may break before the onset of labor and the first stage, but also at the beginning, during dilating contractions, or already in the second stage of labor. It is worth remembering the time of the water breaking - after about 2 hours you should report to the hospital. If it is GBS+ (positive result of infection with group B streptococcus), you should go to the hospital as soon as possible to receive antibiotics to protect the child from infection.
7th Centimeter Crisis
This is the famously hardest moment of labor, when the patient exceeds the limits of her own fatigue. Gathering information from other people, I heard not very optimistic words: "you are overwhelmed by the enormous fatigue and pain during labor, you think you will not survive another contraction, that it will never end"; "this is the moment when even a shy, gray mouse often throws meat at the father of the child or just like that, because there is nothing else left"; "you feel a tight hoop on your belly and you stay in this straddle with the absolute conviction that you are the first woman whose child is simply stuck and from now on will stay there forever - you can't escape, you can't give birth and no one can help you"...
BUT:
"…despite the racing thoughts and the mixture of emotions, this state lasts only a short moment, because as soon as your brain registers the drop in form and the stagnation in previous activity, you get a shot of adrenaline that allows you to keep pushing, so that in a moment you can touch the baby's head!"
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The obstetrician-gynecologist (and in some hospitals the midwife) may decide to pierce the amniotic sac with a special needle to speed up the labor. A full bladder may slow down the progress of labor and if the laboring person is unable to pee on their own, they may be catheterized. Similarly, they may ask for an enema to prevent involuntary bowel movements.
The second stage of labor begins when the cervix is fully dilated (10 centimeters) and pushing contractions begin (pushing the baby out). Surprisingly, pushing contractions hurt less than dilating contractions. However, they do require cooperation with a midwife and a lot of effort.
You can push in a sitting position on a labor chair or in the following positions: vertical, kneeling, leaning on ladders or a companion. Everyone has the full right to choose the position in which they will give birth to a child. However, it must be borne in mind that labor verifies previous ideas or dreams. It often happens that the patient has set her mind on water birth, and then the water turns out to be unimaginably irritating. Or she really wanted to give birth in a vertical position and be in constant motion, and during labor she begs to lie down. The second important issue: positions during labor have a big impact on the baby's head insertion, the course of labor, and sometimes also on the well-being of the fetus, so the midwife can suggest a position that may not be comfortable for the person giving birth, but better for the child.
The second stage of labour, the pushing period, should last no longer than 2 hours. At this stage, the midwife may wish to perform an episiotomy (which can be refused). The episiotomy is performed at the peak of contraction, so it is not painful.
Incision
The topic of episiotomy has been controversial for years. Most often, it is caused by ignorance of recommendations, the mechanism of labor, or simply unpleasant personal experiences.
Routine episiotomy has been shown not to reduce the risk of perineal injury and is not recommended. The key word here is "routine."
The incidence of second degree perineal laceration (perineal muscle injury) ranges from 0.8 to 8.5%, third and fourth degree (sphincter damage or full-thickness rectal laceration) from 0.4 to 2.5%. Not many, which is why no one has had any doubts for a long time that perineal protection is the preferred procedure, BUT not at all costs and not always! Because extensive perineal injuries, anal sphincter laceration carry serious consequences affecting the basic physiological functions of the body, quality of life and mental health of the patient.
Perineal protection is one of the tasks of the midwife managing the delivery, and it is her skills and experience that determine both the course of the delivery and minimizing the risk of perineal injuries. The midwife managing the delivery knows which position will be the best, and therefore the safest for the mother and child. She also knows how to guide the patient through the second stage of labor and sometimes (figuratively and literally) bends over backwards to help a new person come into the world without traumatizing the mother.
However, there are situations in which an experienced midwife/doctor knows when to perform an episiotomy, choosing the so-called lesser evil. Such situations include a clinically high risk of uncontrolled extensive damage to the perineum, delivery of a large fetus, a deviated position of the fetal head, acute fetal distress, operative deliveries.
Does episiotomy in such cases completely eliminate the risk of perineal rupture? No. In most cases, however, it protects against rupture of internal tissues and damage to the muscles of the urogenital diaphragm, directs perineal injuries away from the anus, and allows for easy suturing with restoration of anatomical conditions. Remember that uncontrolled, extensive perineal ruptures are associated with a longer time of wound care, and thus with increased perinatal bleeding - the consequences are secondary anemia, weakness, increased risk of infection and improper healing of the perineum, as well as many other systemic complications. Therefore, the "easiness" of suturing the incised perineum significantly reduces this risk. The statement "a rupture heals better than an incision" can only apply to minor abrasions and first-degree perineal ruptures. In other cases, this assumption is far from true.
To summarize – what are the recommendations for episiotomy?
- routine episiotomy is not recommended,
- if there are indications, it is recommended to perform a medial-lateral episiotomy; another method is a median (vertical) incision - not recommended due to a higher risk of anal sphincter rupture,
- episiotomy in specific indications: clinically high risk of uncontrolled extensive damage to the perineum, delivery of a large fetus, deflexed position of the fetal head, acute fetal distress, operative deliveries, perineal incompatibility or anatomical conditions causing prolonged second stage of labour and lack of progress in labour.
Birth
Contractions that are designed to push the baby out are called forced contractions. Towards the end of the second stage, it may be necessary to use tools to help push the baby out. This is usually a vacuum (it looks like a vacuum cleaner with a suction cup), or forceps. Sometimes the midwife uses manual maneuvers to facilitate the birth of the baby - it is worth establishing consent for this in advance. The second stage of labor ends with the DESCENT BEING BROTHED INTO THE WORLD. It is said that once the baby's head comes out, the rest is a formality (because the head is the largest).
Finally! The end of labor
The newborn is usually placed on the woman's stomach, the umbilical cord is cut (the later the cord is cut, the more blood will flow to the baby, it will store more iron and will have a lower risk of anemia) and the placenta is delivered. This is the right time to collect cord blood. The third stage of labour, which involves the delivery of the placenta, can last up to 30 minutes. Sometimes the midwife will ask you to perform a few additional pushes similar to pushing contractions but requiring less effort, and sometimes the placenta is delivered on its own. It may turn out that there are some pieces of the placenta left in the uterus, in which case the doctor, if an epidural was used, will try to remove them with a special spoon through the vagina . If no anesthesia was given earlier and it is suspected that there may be many pieces and the procedure will be painful, the anesthesiologist will administer a short-acting anesthetic intravenously.
Your doctor may recommend intravenous oxytocin, a hormone that stimulates the uterus to contract, in several situations: after your water breaks (to induce labor), during the first or second stage of labor (because labor has not progressed), the third stage (because the placenta has not been expelled), or the fourth stage (because of postpartum bleeding).
The fourth, or postpartum, stage lasts about 2 hours. You are then under strict medical supervision to detect any complications or complications (for example, bleeding). If the cervix or perineum has ruptured, the midwife starts sewing. It is possible to sew under local anaesthesia (administered via subcutaneous injection), if the wound is large and an epidural has not been administered before. During this time, the baby should be kangaroo-carried for at least 2 hours. It is a good idea to start breastfeeding then - sucking the breast speeds up the contraction of the uterus and helps to reduce excessive bleeding. Don't worry if it doesn't "click" the first time. It's a bit more difficult than training with dolls in childbirth classes.
Often the baby will be taken for measurements, intramuscular injection of vitamin K (to prevent hemorrhagic disease of the newborn), the Credé procedure (instillation of silver nitrate eye drops to prevent gonococcal conjunctivitis), and medical tests.
Childbirth isn't so scary... once you're done
After the fourth stage of labor, the patient is usually taken to a room where she will stay with the newborn until discharge. If she feels like it, she can ask the midwife to look after the baby and take a shower. In some hospitals, it is possible to leave the baby with the midwives to rest after the birth (although the baby usually needs to sleep off the labor too). In the postpartum room, rounds are usually held once a day in the morning: one for the postpartum person, who is examined by a gynaecologist, and the other for the newborn, who is examined by a neonatologist.
Midwife
In some hospitals, it is possible to sign a contract for individual care with a midwife. This is not necessary, but it certainly increases comfort and reduces the stress associated with labor.
The birth itself is similar everywhere, but each hospital has different customs and many things often depend on the shift change, such as whether the person giving birth is allowed to eat a meal in the delivery room. Some midwives allow it, and sometimes it is even forbidden. It is always worth having some snacks in your bag, so that when the green light comes on you can quickly reach them. It is similar with jewellery – in some hospitals the staff asks you to take everything off when you are admitted to the hospital, in others no one pays attention to it. The fact is that not all hospitals have prenatal and postnatal rooms. Not every facility takes a patient to delivery in a wheelchair. In some, under no circumstances are you allowed to have your nails painted (even with regular nail polish), while in others this is treated as a personal choice. Interestingly, the hospital where I gave birth took great care to ensure that the nail plate was natural and not covered with anything, so the midwives told an anecdote about a woman who urgently called her manicurist to remove her hybrid!
Dangers lurking in the postpartum period
There are many myths that function in the environment of young parents. They concern the course of pregnancy, the birth of a child, what labor looks like, and also the postpartum period itself, starting from physiological issues, such as problems with urinary incontinence always and only after natural childbirth, ending with golden advice for the postpartum period, including the salutary role of an inflatable ring to sit on after an episiotomy and the need to use a compression belt. Don't be fooled!
What are the facts?
Urinary incontinence is a physiological and temporary condition IN THE POSTPARTUM, similar to frequent urination, heavy sweating (getting rid of excess water from the body) or swollen feet and ankles in the first days after delivery, as well as a feeling of "pulling" in the vagina or even prolapse of the uterus. Yes, yes, it is normal and will pass. However, after the postpartum period, be sure to go to a doctor for a check-up if any of the above symptoms persist - this is no longer physiological, regardless of the method of delivery.
The postpartum period is a time for a person after giving birth. This is when the postpartum wounds heal, the uterus cleanses itself and shrinks to its proper size, the organs start to return to their place and lactation continues. It cannot be rushed (for example by wearing compression belts - it is dangerous to your health!). A tornado has passed through your body, psyche and emotions, now you have to put yourself back together. It will be difficult for you on your own - do not hesitate to ask for help from specialists.
Take advantage of your right to at least 2 patronage visits. Let the midwife look into you (literally!). Write down all the questions that are troubling you and ask them boldly, describe the color and smell of the discharge in detail. Be vigilant about the condition of your body and breasts. Let someone competent dispel all your doubts, not a team of advisors from a parenting forum.
Giving birth to a child is not a guarantee of fulfillment and boundless happiness (which is often what pregnant people are told, which intensifies the feeling of failure if it is different after giving birth). You may feel depressed, you may feel scared, you may even feel disappointed. However, if you feel deep sadness, exhaustion, overwhelmed by responsibility to such an extent that it makes it difficult for you to function daily - you should definitely contact a psychotherapist. Do not leave your psyche unattended. It sounds like a commonplace, but seriously: a happy parent means a happy child and the entire environment.
However, if you have any postpartum wounds, instead of using an inflatable seat ring, it is better to make an appointment with a urogynecological physiotherapist who will perform an examination and suggest, for example, urogynecological rehabilitation to ensure the proper functioning of the pelvic floor muscles (no, you cannot give these muscles a "rest" because they are quite necessary!).
Coronavirus - childbirth during a pandemic
Same, only different :) There are a few additional procedures (like reporting for a coronavirus smear test before the planned delivery date), family births and hospital visits are also limited. And although this may increase anxiety in pregnant people and the feeling that they have to face a huge challenge alone, it also increases the willingness to help each other. I am writing this based on my own observations from my stay in the pre- and post-partum rooms, and I have a comparison of the times before and during the pandemic. Whispered conversations have turned into the hubbub and laughter of patients who (as usual?) are fully prepared to, in short, "GET THE JOB DONE". Relaxing conversations before delivery, focusing at the right moment, relaxing together and supporting each other in taking the first steps in a new role, and even gossiping about the latest trends in parenting! I came back from my second delivery during the pandemic with a whole list of Polish companies that I wanted to support, completing the equipment for the baby's room, restaurants that deliver delicious and healthy food, and cosmetics that would help me get through the postpartum period more pleasantly. I also enriched myself with a few great friends. The only thing I could give was a presentation of my beloved YK intimate fluid (the only cosmetic that was there with me) and a phone number and a promise that I would pick up even at night, after midnight. So that none of us would go alone! :)
For help with writing, I would like to thank my friend Adriana Mikulska. She is a mother and a doctor, so she watched over the text so that it was not just selective fragments that were preserved in memory (as in my case).
Trivia
- A primiparous woman is a woman or female mammal who gives birth for the first time.
- In the second stage of labor, it is possible to do an involuntary poop. Don't worry, it doesn't impress the medical staff at all.
- Screaming during labor is not a director's vision of natural childbirth. In fact, it relaxes the tissues of the perineum and helps release excess energy that accumulates in the body at the moment of pushing.
- A baby "born with a caul" is born when the amniotic sac does not burst (amniotic fluid does not appear) - then the doctor or midwife punctures it only at the end of the labor process.
- Postpartum feces are bleeding from the genital tract during the postpartum period. They contain mucus, blood, and remnants of fetal membranes from the uterus, i.e. the effect of its cleansing.
Created at: 06/08/2022
Updated at: 16/08/2022
