Common Interventions during Childbirth
We are fortunate to live in a country where the majority of women who need medical interventions during the birth process have access to them. But because no intervention comes without side effects, judicious discretion should be practiced when using interventions during birth.
No doubt about it- most obstetric interventions are over-used. Educate yourself as to the risks that are associated with interventions so you can make your choices from a conscious and empowered position.
"For far too many women pregnancy and birth is something that happens to them rather than something they set out consciously and joyfully to do themselves."
Routine Continuous Electronic Foetal Monitoring
In South African private hospitals it is almost universal to strap belts and sensors around your abdomen, leave you in bed, and watch the monitor to see your contractions.
Many women say that they feel like everyone forgets them. Nurses and even labor partners are too busy watching the screen and printouts.
Continuous electronic fetal monitoring has a high false positive rate – meaning that it often says that a baby is in danger when the baby is doing just fine.
Often if a baby’s heart rate drops a simple change in position will bring it right back up. Unfortunately the fetal monitor leaves you stranded on your back in bed.
There have been studies showing that continuous monitoring does not significantly improve birth outcomes for women and babies.
Because of the high false positive rates continuous fetal monitoring puts you at greater risk for caesarean section.
There is also a possibility of your labor being slowed or ineffective because you’re unable to move. You may feel more pain because you are unable to work with your body.
The inability to change position may cause your baby to get less oxygen than he or she should. If you are hooked up to an internal monitor, infection could be introduced to your birth canal and uterus. Your water will have to be broken. And your baby will have a monitor hooked into his or her scalp.
Nine randomized controlled trials showed that Electronic Foetal Monitoring does not make births safer. Babies are just as safe when someone listens to the foetal heart just after contractions has finished and in the interim between contractions with a Pinard’s stethoscope or a handheld Doppler machine.
– Obstetrics and Gynecological Journal Nelson MD 1996.
• May enable early detection of potential risks to the baby’s health and well-being during the labour.
• It provides the hospital/care provider with a hard copy print out of your labour, very helpful in litigation.
• Can be reassuring to watch the babies heart rate
• Allows a care provider to visit the labouring women less often.
• Allows the mother to visually monitor the labour which she may be unable to feel if she has had an epidural
• Biggest disadvantage is that the EFM increases the caesarean rate.
• Doesn’t tell the future, it only tells what is going on now and is often misread.
• Considerably hampers the women’s ability to move
• It can be frightening to watch the baby’s heart rate
• Can lead to the labouring women being left alone for longer than she would be if a Doppler was being used
• Care providers can become obsessed with the EFM and stop focusing on the labouring women.
• If an internal monitor is used this will be screwed into the babies head.
• Internal monitor can leave a small abscess, even a permanent bald patch on the baby’s head.
• It is possible for the EFM not to work properly or for the information to be interpreted incorrectly resulting in unnecessary caesareans.
• Discuss the use of EFM with your care provider, if you do not what one used on you, say so.
• The alternative is for a midwife to listen to your baby using a doppler or Pinard’s stethoscope.
• This enables you to move around freely to manage your labour. You can also labour more freely in the shower and bath.
• Using a doppler also prevents the use of the internal monitor being screwed into the baby’s head lessening foetal distress.
• One of the greatest benefits from using the doppler over to EFM is that is creates a situation where your care provider needs to have one on one contact with you more often, look you in the eye and see how both you and your baby are doing.
Induction of Labour
Induction of labour is the deliberate start of labour by means of artificial methods, before spontaneous, natural onset of labour. This method is used commonly in private practice in South Africa and is second only to Caesarean Sections. Inducing labour should have a sound reason for doing so.
Attending births is like growing roses. You have to marvel at the ones that just open up and bloom at the first kiss of the sun but you wouldn't dream of pulling open the petals of the tightly closed buds and forcing them to blossom to your time line. -Gloria Lemay
Indications for Inductions
If an induction is done for the baby, it should be asked whether it is safer for the baby outside the uterus than inside. If it is done for maternal reasons, it should be done because continuing the pregnancy will endanger the life of the mother.
• Uncontrolled high blood pressure
• Intra uterine foetal death
• Premature rupture of membranes (depends on duration)
• Cancer, where chemotherapy or radiotherapy is indicated
• Intrauterine growth retardation, where the foetus is not growing due to placental insufficiency
• Post-maturity – if the foetus is moving well, most care providers will induce by 10 days after the due date, although induction can wait until 42 weeks
Contra-indications (when it should not be done)
• Previous caesarean sections (depending on reason for previous Caesar)
• Cephalopelvic disproportion, where baby is too big for the pelvis and no engagement (baby has not moved into pelvis) has occurred after 40 weeks gestation
• Foetal distress
• Malpresentations, as in breech baby or transverse lie
• Placenta praevia, where placenta is lying in front of the cervix (birth canal)
• Congenital abnormalities of the uterus or cervix
• Active herpes infection
• Multiple pregnancies
• Mother is tired of waiting
Factors affecting the success or failure of an induction
The closer to 40 weeks gestation or thereafter, the higher the chances of success.
The sensitivity of the uterus to stimulus and the amount of Braxton-Hicks contractions occurring. Whether it is a first baby or not is also important, as first pregnancies are less likely to respond well to induction than second or third pregnancies.
The technique of induction and the state of the cervix. For a successful induction the cervix should be at least 1-2cm open, 1cm or less long, baby’s head must be in the pelvis, the cervix must be softening and come forward to the central or anterior position. This is called the Bishop score and should be assessed before any induction is performed.
Methods of Inducing
Surgical induction can be done if the induction is not urgent. This is done by stretching the cervix and stripping off the membranes from the lower segment, called a stretch and sweep. Breaking of the membranes also classifies as a surgical induction. After the stretch and sweep the mother can wait a few days for the onset of labour, but after artificially rupturing the membranes labour needs to commence within 6-12 hours or risk infection.
Medical induction is generally done if the cervix is not ripe or favourable for an induction. The ideal is to ripen it before with prostaglandin gel or tablet, placed in the back of the vagina behind the cervix. A percentage of women will go into spontaneous labour after this. If not, the cervix should be re-evaluated after four to eight hours and the procedure repeated until the cervix starts to become favourable, and this should not exceed 24 hours. Unsupervised administration can lead to over stimulation of the uterus and is not easily reversed.
If the cervix is favourable, prostaglandins or oxytocinon (artificial oxytocin hormone, in SA Syntocinon, in USA Pitocin) can be used. This is administered through a drip. It is started at a slow rate and increased every half an hour until good strong contractions occur, three strong contractions in every 10 minutes, or until the maximum dosage is reached. Contractions stimulated intravenously by oxytocinon are usually physiological. The amount administered can be closely controlled and if over stimulation of the uterus occurs, the infusion is discontinued and the effect of the oxytocinon stops within two to three minutes. Enemas and hot baths can possibly sensitise the uterus to go into labour, although the effectiveness of this method is doubtful.
Why it’s only for emergencies
In any method of induction the chances for an operative delivery (caesarean section, forceps or vacuum delivery) is higher due to dystocia (see below) and foetal distress. The incidence of opting for pain relief like Pethidine, Aterax or an epidural is also increased, because of the artificial introduction of hormones which does not allow the mothers natural hormones to kick in when they are supposed to. This results in more painful and rapid contractions for the mother.
What is dystocia?
Dystocia refers to a difficult or prolonged labour, and can either be cervical or uterine based. With cervical dystocia normal uterine contractions occur and the cervix normally effaces or thins out, but does not dilate adequately. Cervical dystocia generally occurs as a result of previous scarring and lesions, or cervical cancer. Uterine dystocia happens when a constriction ring or spasm forms in the uterus and prevents the foetus from descending. It occurs in one in 10 000 labours.
Did you know?
An elective or social induction is done solely for convenience of the mother or doctor, and offers no benefit to baby. Social inductions – a highly controversial subject – is under critical scrutiny, since the risks are very real to both mother and foetus, and there is an increased incidence of unnecessary caesarean section after failed induction of labour.
Inductions are also done to allow doctors to practice ‘daylight obstetrics” says Dr. Marsden Wagner, a neonatologist who served for 15 years as a director of women’s and children’s health in industrialized countries for the World Health Organization. “It means that as a doctor, I can come in at 9 a.m., give you the pill, and by 6 p.m. I’ve delivered a baby and home having dinner.”
Tips to avoid labour induction
• Recognise that, according to almost all experts, a normal pregnancy lasts between 38 and 42 weeks. In your mind, add two weeks to your due date in case your pregnancy lasts 42 weeks.
• Understand that many researchers believe that it’s the baby that starts labour. Studies suggest that once the baby is fully mature and ready for life outside the womb, he releases a substance that tells the mother’s body to start the process of labour. In most cases, the best way to know that your baby is ready to be born is to wait for labour to begin on its own.
• Choose a care provider who induces labour only for medical reasons.
• Don’t be induced without a medical reason. Be aware that a large baby is not a medical reason for induction.According to experts, including the American College of Obstetricians and Gynecologists, induction for suspected large babies does not improve outcomes for babies and almost doubles the risk of a cesarean for mothers.
• Stay active and exercise at least 30 minutes most days at a moderate pace. Research indicates that healthy women who exercise regularly throughout pregnancy are less likely to need to be induced or have their labour speeded up.
• Stay well-nourished and drink plenty of fluids. If there’s a concern with the baby being overdue, tests (such as a biophysical profile and amniotic fluid index) may be scheduled to evaluate the baby. Several studies have found links between maternal dehydration and poor results on these. If you are scheduled for these tests, be sure to drink plenty of liquids and eat well in the days before the tests.
• If your water breaks before labour begins, ask your care provider to allow you time to go into labour on your own. Most women begin labour soon after their water breaks, and 90% will be in labour within 2 days of their water breaking. There’s no need to rush labor unless you or your baby are in danger or there are signs of infection. Follow your care provider’s advice for reducing the possibility of infection and ask him or her to do vaginal exams only when medically necessary.
• If labour induction is planned for non-emergency medical reasons or because you are getting close to 42 weeks, discuss alternative ways of inducing labour with your health care provider. To start labor, research suggests the use of acupuncture, nipple stimulation, and “sweeping the membranes,” a procedure in which the care provider uses her fingers gently to separate the bag of waters from the cervix during an internal exam. Many have suggested the use of sexual intercourse to help labor begin, but these methods haven’t been studied in high quality research.
Augmentation of Labour
Augmentation of labour means that labour has spontaneously started and preparations are used to strengthen or ‘boost’ the contractions. This has not proven to be of benefit as it does not shorten the labour period and only makes the labour process more painful and uncomfortable for the mother.
To possibly prevent this from happening, the labouring mother should stay at home until her labour is well established.
During labor, they are performed to assess how dilated your cervix is (dilation goes from 0-10 centimeters).
Cervical checks can be very uncomfortable, especially during labor. A gentle and sensitive care provider can make a difference.
Research has also shown that different people will get a different measurement for dilation. This means that if different nurses, doctors, or midwives are tracking your dilation, the measurements may not be completely accurate.
Each internal exam also raises the chance of infection. If your water has broken this is an especially valid reason to decline internal exams.
You will know when you are close to being fully dilated, and a skilled care provider will also be able to tell. There is no reason to have countless exams or to endure the pain or the anxiety that may come from being told “you’re not making progress.”
It is best to work with your body and allow your skilled caregiver to notice the signs that you’re close to the end of the first stage. You will also be able to tell because you’ll begin to feel pushing urges.
Restricted Movement and Intravenous Therapy
It is impossible to move around when you are flat on your back. It’s even more difficult if you have internal and external fetal monitors attached to your body, an IV running into your arm and after a narcotic drug was given to “take the edge off.” It goes without saying, that if you had an epidural, you would not be going anywhere at all as your legs would have no feeling and even “walking epidurals” are misleading because even if you are able to walk, the equipment makes it too difficult and odds are the staff would never allow it.
Some hospitals encourage walking and moving around. Others do not like you to be out of your room, which may be quite small and loaded with equipment, making any real walking about nearly impossible. Studies have shown that moving about and being upright and changing positions can shorten labor.
Intravenous Therapy Drip
Most hospitals routinely use IV line birth interventions. Usually they do this because they forbid food (and sometimes drink) during labor. This has negative consequences above and beyond the IV. This is also performed when the hospital protocols call for an intravenous line to be available if any medication needs to be administrated.
Having the IV inserted is painful for many women. The cold fluids can cause pain and irritation. The IV pole limits movement. Excess fluids can cause you to have to go the bathroom constantly.
You’ll have more energy during labor if you’re not restricted from food or drink. It makes no sense to require you to do extensive and exhausting work with no food or drink! IV lines do not solve this problem and create new problems.
However, if, for medical reasons, you need to be induced and this has been explained to you, a intravenous drip will be necessary.
Artificial Rupture of Membranes
Artificially breaking the amniotic sac or rupture of the membranes is done routinely at many hospitals to speed labour up, get labour going, to test the fluid or to get it out of the way so that an internal monitor can be hooked into the baby’s head. This is done with a long thin plastic hook called an amniohook.
It was believed that breaking the water would speed up labour by 30 to 60 minutes but the only randomized control trial done disproved this. This procedure can cause cord prolapse, a serious complication for the baby and increases the chances of an infection. With less amniotic fluid in the uterus during labor, the baby has a greater risk of cord compression problems leading to foetal distress and malpositions of the head.
In most hospitals, in some birth centers, and for some homebirths, ruptured membranes also require that a clock begin ticking – in other words, you must have your baby delivered within a certain amount of time after your water has been broken (this is often 8 to 12 hours at the hospital).
This regulation is in place to decrease the risk of infection; however, it could lead to unnecessary ceasarean or other interventions.
Breaking the waters also removes the watery cushion from around your baby’s head. It may be more painful for you as your baby’s head passes through your pelvis, or you could have back labor a little more strongly.
If your water breaks naturally, or if it is broken by your care provider, try to keep internal exams to a minimum. More exams mean more chances of infection.
Forceps and Vacuum Assisted Births
Forceps are obstetrical tools which are shaped like large spoons have been in use since the 1500′s. Years ago, forceps were used for many problems which are now handled by cesarean section. Today, most forceps deliveries are low forceps, which means they are applied when the babies head is low in the pelvis and birth is imminent. According to Henci Goer, “There is no research to support the elective use of forceps.”
The risks to the mother are perineal trauma, extensive episiotomy, possible extension tearing from episiotomy, hematoma and nerve damage. Lasting effects of forceps or vacuum extraction to the mother may be anal incontinence in spite of a repaired third degree tear. The baby may have damage to the head, eyes, the nerves that lead to the face and neck and arms.
Vacuum extraction is a newer technology that sometimes takes the place of forceps. As with low forceps, the baby’s head must be very low in the pelvis before the suction cup can be attached. It has the benefit of not requiring an episiotomy and maternal perineal trauma is less than with forceps, but the baby still has the possibility of trauma to the head and face. Chiropractors also recognize that pulling a baby out by the head changes the spinal alignment, although this is not recognized in any medical texts.
The best way to avoid the use of forceps or vacuum extraction is NOT to have an epidural.
Being able to move about freely and change positions greatly assists you to give birth without the need for the violence of forceps or vacuum extractions.
Indications for Instrument Assisted Birth
• When allowing the women to continue pushing is detrimental to the mother due to a condition such; severe pre-eclampsia, high blood pressure or heart condition
• When foetal distress is present, forceps may prevent a baby from becoming hypoxic (oxygen-starved) which if severe, can lead to brain damage or death
Vacuum extraction (Ventouse) – Advantages over Forceps
• Can be used before the cervix is fully dilated if rapid delivery is necessary
• Episiotomy is not usually required
• Little internal bruising
• Mother can still feel the birth due to not having to have analgesic so she can still feel her contractions and assist with pushing
Episiotomy is rarely justified, except in cases of foetal distress necessitating immediate delivery. — Elizabeth Davis, author of Heart & Hands: A Midwives Guide to Pregnancy & Birth
An episiotomy is a cut made in the perineum (the skin and muscle between the vagina and anus). Although some people believe that an episiotomy is necessary to have a baby to prevent damage to the baby’s head, prevent trauma to the mother’s perineum and the cut will heal faster and prevent 3rd and 4 degree tears, no research supports these myths.
Shiela Kitzinger writes that as many as 9 out of 10 American women will have an episiotomy with her first baby although in Holland, only 2 or 3 out of 10 will. The facts are that episiotomy is a cultural phenomena. Research shows that episiotomy is done because the doctor was trained to do it, not because it was a necessary procedure.
It can be avoided by using more physiologic positions to give birth (not lithotomy or semi-sitting), pushing only when mom feels need to, giving birth gently, slowly to the head, preparing for the birth by doing perineal massage and Kegel exercise and avoiding forceps delivery.
A slight tear is always better than a cut and will heal must quicker. Research has shown that tears heal better than cuts.
Directed Pushing & Active 3rd Stage of Birth Management
Though it is not technically an “intervention” in that something is done to you, we list directed pushing here because it is an unnecessary intrusion in the birth process. Being forced to push in a certain way and certain positions can results in loss of control, extra pain, and can contribute to tearing.
Almost all television portrayals of women giving birth show a woman flat on her back with her legs in stirrups. She’s surrounded by several nurses and perhaps her partner, all counting loudly “1, 2, 3 … 10″ as a way of instructing her how to push.
This intervention into the 2nd stage of labor is generally unnecessary – when you are fully dilated after a natural labor, your body will begin to push on its own. The urge will be undeniable. Pushing contractions are generally spaced out more than dilation contractions. You get a nice rest in between each one.
Many care providers try to rush this stage along by shouting at a woman to push forcefully and continuously. They give episiotomies to encourage the baby to come faster and in come cases resort to assisted delivery with forceps or vacuum extraction.
They may also use these invasive procedures when a woman cannot effectively push – usually because she is flat on her back and strapped into stirrups. There are far more effective positions to give birth in – kneeling, on all fours, leaning forward on a bed or in water.
Active 3rd Stage Management
The third stage is the final stage of birth. Your baby has already been born and is in your arms. Now you must deliver your baby’s placenta.
Most of the time the placenta will come within an hour or so after birth, and all on its own. The birthing of the placenta is much easier than the baby – it has no bones and pretty much just slides out.
Some caregivers try to “actively” manage this stage of birth by giving the mother an artificial hormone injection in her leg and then pulling on the cord and pushing on the woman’s abdomen. Their reasoning behind this is to prevent bleeding and to allow the uterus to contract so that the placenta will release. You can aid this on your own by allowing your baby to suckle at the breast, which will allow your body to release the hormone necessary to contract the uterus. Allowing the placenta to detach from the uterus on its own will also prevent any bits of the placenta left behind in the uterus, which can cause excess bleeding.
A perceptive midwife or doctor can watch the cord and notice signs that the placenta has detached. Often if the mother moves into a supported squat the placenta will easily be born.
Pulling on the cord and rushing the mother along can lead to complications and it can also rob the mother and child of their first few moments together.