THE BIRTH PROCESS
5.1 Describe the birth process
For 9 months, heredity and environment factors have interacted to shape a new life. At 38 weeks the foetus is now ready to leave the comfort of the mother’s womb to join others in its next world. By this time the foetus has a strong chance of survival. The question that many ask is how this transition finally takes place. Like many other reproductive issues, many children find it a tricky puzzle. Questions like: How is a child born? Does the baby need to bite his way out? or Does the doctor cut through mummies tummy to access the baby? are not uncommon. In this unit I will describe the process of birth and its implications.
What Happens To The Baby Just Before Birth?
During the last month of pregnancy, the head of the baby turns down toward the mother’s pelvis and the uterus descends into the pelvic cavity. The ideal position for the baby’s head is down and facing the mother’s back. This position allows the baby to move most easily through the cervix and birth canal.
What Are The Signs Of Labour?
Labour is the process by which a woman gives birth to her baby. The onset of true labour is marked by the appearance of any one or combination of three signs: (1) Labour pains-these are rhythmic contractions of the uterus. These contractions are perceived to come from the lower back. They occur at regular intervals but as labour progresses the intervals shorten and the intensity of the contractions increases. (2) The Show-this is a small blood-spotted mucus plug that is discharged from the Cervical canal as a result of the dilation of the cervix and (3) Discharge of the amniotic fluid. This discharge occurs when the amniotic sac ruptures.
When any or a combination of these signs occur the mother is said to be in labour, a process which occurs in three stages. Let us look at each of these stages now.
Stages of Labour:
The process of labour unfolds in a series of three well-defined stages.
1. The First Stage: Dilation:
This stage begins spontaneously approximately 266 days after conception with a series of contractions that dilate or open the cervix to allow the baby to pass through. The muscular walls of the uterus contract pushing the baby against the cervix. The first contractions are relatively short and painless. However, they gradually become longer, stronger and more frequent. As the cervix approaches its widest aperture, the pain can reach extraordinary levels of intensity. Complete dilation to 10 centimetres takes between 2 to 20 hours for the first pregnancy and less for later pregnancies. The first stage is divided into three phases.
The early phase lasts until dilation reaches 4 centimetres, roughly the width of two fingers. The amniotic sac (bag of waters) may break, releasing a trickle or possibly a gush of liquid through the vagina. The active phase of labour lasts from two to six hours for first-time mothers. The transition phase is marked by the dilation of the cervix from 8 to 10 centimetres. This phase typically lasts about one hour. Bee (1995) likens this stage labour to putting on a sweater with a neck that is too tight. You have to pull and stretch the neck of the sweater with your head in order to get it on. Eventually the neck is stretched wide enough so that the widest part of your head can pass through. When dilation is complete, the baby’’ head moves through the cervix and begins to descend into the vagina, or birth canal. Contractions have increased to maximum intensity, lasting about two minutes each and occurring in rapid succession, often without a lapse between them. In a conventional hospital delivery, the mother is now moved into the delivery bed.
2. The Second Stage: Descent and Birth:
At the end of the transition phase, the mother will normally have the urge to push the baby out. The second stage of labour begins when the cervix is fully dilated and ends when the baby is born. The baby descends down the birth canal. The descent of the baby can take from a few minutes up to three hours. This depends on the relative size of the baby, the resistance of the vagina and the strength of the contractions. The descent is gradual and intermittent. When the top of the baby’s head appears through the vaginal opening, the opening of the vagina is stretched to its limit. Many women feel more clearheaded and have a renewed sense of optimism when pushing begins since the baby is almost born. Just before the baby is born, a mother may feel a burning, stinging, stretching sensation at the vaginal opening — a sure sign that you’re almost there! As the head crowns, mother relaxes and the head moves out through the vaginal opening. As the baby’s head emerges, it turns to one side to allow the shoulders to align, then with next push shoulders and the rest of the baby’s body slips out. The birth attendant may assist in turning foetus to facilitate this process
If the opening is not adequate to accommodate the size of the head, the physician may administer a local anaesthetic and perform an episiotomy. This is a surgical incision that widens the opening to allow the head to pass. The episiotomy reduces the risk to the baby and prevents injury that would result from a tea of the skin between the vagina and the anus. The last few contractions expel baby out of the mother’s body. The baby takes the first breath and the umbilical cord is clamped and severed.
3. The Third Stage:
The third stage of labour involves the expulsion of the placenta and umbilical cord or afterbirth, through the cervix. There are mild contractions that expel the placenta and the now-useless foetal membranes out of the mother’s body.
This stage consists of the period immediately following birth to the expulsion of the placenta. This generally takes 5 to 10 minutes. The stage also includes the after birth recovery of the mother.
Should the placenta not easily come out, tugging or pulling should not be performed. Gentle uterine massage may be utilized to assist in the release. The placenta should always be examined to be sure no parts remain within the uterus. This can become detrimental to the mother causing haemorrhage and/or death.
During the after birth recovery phase, a mother is monitored to be sure no uterine bleeding or other complications occur.
The labour and birth process may be complicated by lack of sufficient power or by inappropriate presentation of the baby
Delivery presentation refers to the orientation or the position of the baby as it presents itself for the birth process. It is often called by different names including “foetal attitude” and “foetal lie”. The preferred foetal delivery presentation is “cephalic presentation”. This a head down presentation with the topmost part of the head emerging first and the face downward in the direction of mothers back and back of head upward in the direction of the mothers’ front.
If the child is not in the face down head down position, the delivery presentation is referred to as a mal-presentation. There are various types of mal-presentations:
- Upside Down Presentation: This is a presentation where the baby presents in an “upside down” or “sunny side up” position. If the baby does not turn to the proper position or turns late, the newborn will generally develop “cone head”. This position also produces what is known as “back labour”. This can be significantly reduced in women who receive regular chiropractic care during their pregnancy. The upside down presentation occurs in approximately 13% of births.
- Breech Presentation: In a breech presentation, the feet or buttocks present first as opposed to the head. This presentation occurs in about 1 out of every 40 births. The possible complications of this presentation can be serious and include:
1. intracranial bleeding
2. neck dislocation
3. shoulder dislocation
4. hip dislocation
5. clavicle fracture
6. internal organ discruption
7. premature placental rupture
9. uterine rupture
- Face Presentation: In this presentation, the baby presents face first with the neck in extension. Causes of this kind of presentation include a lax uterus, flat pelvis, multiple foetus, or neck spasms of the foetus. This is stressful on the cervical spine. Chiropractic care by a chiropractor trained in adjusting newborns is crucial for the continued proper growth of the spine. Face presentations occur approximately every 3,000 births.
- Shoulder Presentation: The shoulder presentation is one where the shoulder emerges first. This delivery presentation occurs in every 200-300 births.
- Transverse Presentation: The tail area is presented first with legs and head at opposite sides,
Efforts are usually made to turn the baby in utero through massage, exercise or position of mother. If the baby’s position does not change a caesarean operation maybe needed to safely remove the baby.
Sufficient power and coordinated contractions are essential for a smooth uncomplicated labour. When the contractions are weak or the pattern of contractions disorganized, the mother is more likely to become exhausted. This can cause foetal distress resulting in foetal harm. A caesarean section may be necessary in such a situation.
Passage way obstructions in the uterus, pelvis, or cervix can cause serious complications in the birthing process. Causes of such complications may include:
- flat male-like pelvis (android)
- physiological changes due to degenerative joint disease, tuberculosis, rickets or osteomalacia.
Dealing with Labour Complications:
The natural process of labour is subject to a number of problems, some of which place the mother and/or the infant at risk. When serious problems arise, medical interventions are necessary to reduce the risk to mother and infant. Commonly used procedures include inducing and speeding up labour, assistance through mechanical means and caesarean delivery.
A. Inducing and Speeding Up Labour
A variety of medical circumstances may recommend that labour be initiated artificially in a process called induction. If the pregnancy is at or beyond the forty-second week, induction is recommended. If the amniotic sac has not yet ruptured, the physician can induce labour by purposely breaking the amniotic sac. This procedure is called the Artificial Rupture of Membranes (AROM). If AROM fails, a hormone can be given intravenously to induce or speed up labour. The dose can be varied to regulate the rate and intensity of contractions throughout labour. If it is medically advisable for the labour to be induced and the procedure fails, a caesarean delivery is the only reasonable alternative.
Artificially induced labour can cause very strong and painful contractions, thereby increasing the need for pain medication. The equipment necessary to administer the drug restricts the mother’s movement, adding to her discomfort.
B. Assisting Delivery through Mechanical Means
In some instances, after the baby’s head has passed into the vagina, the contractions weaken and the baby stops or dramatically slows its descent. If procedures to induce or speed up labour have failed or are inappropriate, one remaining option is to assist the descent by mechanical means. The first procedure involves the use of forceps, a tong like instrument that is inserted into the vagina around the baby’s head. The physician pulls as the mother pushes with each contraction. Forceps typically require the use of anaesthesia and an episiotomy. The forceps introduce the risk of injury to the mother and the baby.
A second mechanical procedure for assisting the descent of the baby is vacuum extraction, A plastic suction cup, connected by a tube to a vacuum device, is placed on the top of the baby’s head. Handles on the tube allow the physician to pull on the head as the mother pushes with each contraction. Compared to the use of forceps, vacuum extraction is less likely to damage the vagina, and can be applied higher in the birth canal.
C. Caesarean Delivery:
If the baby or mother is thought to be at risk for instance if there is foetal stress and other techniques are either unsuccessful or inappropriate, the baby may be delivered surgically by caesarean section. Another common reason for doing a caesarean delivery is breech birth. This complication occurs when a part of the body usually the buttocks, feet, or umbilical cord- other than the head is positioned to emerge first from the cervix. If the mother’s pelvic bone is too small to accommodate the birth of a large baby. A caesarean delivery may also be performed. In this procedure, anaesthesia is administered. An incision is made in the abdomen and uterus and the baby is removed.
Even when a caesarean is clearly indicated, there are risks. This procedure is considered a major surgery and it prolongs the recovery of the mother. There is a higher rate of postpartum infection and a prolonged period of healing in the mother. It is important to use it only when necessary for the well being of the mother and the baby.
5.6 Definition of terms