Labour and delivery

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• Introduction
• Assessment of well being in labour
• Stages of labour
• The first stage
• The second Stage
• Ventouse or forceps assisted delivery
• Episiotomy and vaginal tears
• The third Stage
• Management decisions in Labour
• Elective caesarean section versus attempting a vaginal delivery
• Scientific Articles on vaginal delivery and Caesarean section

Introduction

Labour is defined as the combination of regular uterine contractions associated with dilatation of the cervix (neck of the womb).

The journey involved in labour and delivery is often described as the most hazardous or dangerous of our lives. It is important to constantly check the condition of the mother and fetus, as well as the process of labour itself. This does not always have to mean high-tech surveillance is necessary. In a pregnancy where mother and baby are considered to be low risk, the vigilance of a trained midwife or obstetrician can be just as, if not more, effective in the monitoring a labour.

Assessment of well being in labour

In labour the condition of the mother, the condition of the fetus and the process of labour are constantly assessed.

A. Assessing condition of mother

1. Alert, oriented, communicating
2. Temperature, blood pressure, pulse
3. Urinalysis ? protein, glucose, ketones
4. Full blood count / group and save
5. Management of medical problems, if any

B. Assessing condition of the fetus(es)

1. Clinical assessment of fetal size and position / presentation
2. Fetal heart rate pattern
3. Presence and amount of liquor (amniotic fluid)
4. Presence and grade of meconium or blood in liquor

C. Assessing the process of labour

1. Descent of presenting part (typically the baby’s head) through the pelvis
2. Dilatation (0cm – 10cm) of the cervix
3. Regularity / rhythm of uterine contractions

Stages of labour

Historically labour is divided into:

• A. Contracting but not pushing (the “first stage”). The head is not low enough nor the cervix fully dilated
• B. Contracting and pushing (the “second stage”). Head deep down in the pelvis, cervix fully dilated
• C. Baby delivered, waiting for placenta to deliver (the “third stage”)

The first Stage

The priority is to ensure mother and baby are well, and that the labour is progressing in a satisfactory manner. If the labour is not progressing well, the available evidence would suggest that augmenting the process of labour with Oxytocin (Syntocinon, Pitocin) is beneficial. Precise timing of such a decision or intervention must be taken on an individual basis between the attending midwife / obstetrician and the patient concerned.

The second Stage

Pushing a baby into the world is one of the most terrifying and exhilarating moments in a woman’s (and a man’s) life. There is a balance to be struck between inappropriate early intervention (assisting with a forceps or vacuum extractor/ventouse), or delaying until the mother is exhausted or the condition of the baby deteriorates to a dangerous level.

Ventouse or forceps assisted delivery

A ventouse or vacuum cup is often applied to the baby’s head in the second stage, to assist with the delivery of the baby. The ventouse is now the first choice, as it causes less trauma to the mother’s pelvic floor. Occasionally a forceps is preferable to a ventouse, e.g. where the mother is unable to push with contractions.

The main reasons for using the Ventouse or forceps are:

• Concern for the wellbeing of the baby
• Maternal exhaustion or lack of progress with pushing
• The available evidence suggests that prolonged pushing or pushing before the cervix is fully dilated increases the risk of excessive damage to the pelvic floor. This can lead to problems with incontinence and prolapse of the pelvic floor, as well as problems with sexual dysfunction. These risks must be weighed up against the mother’s natural wish to push her own baby out without the assistance of a ventouse or forceps.

Episiotomy and vaginal tears

It is not necessary to cut a woman’s vagina and perineum when the baby is being delivered. However, where it is clear that the woman’s perineum is going to tear badly, it may be wise to control the tear with an episiotomy. In experienced hands this will lead to less trauma and quicker healing. When using a ventouse or forceps it may also be necessary to perform an episiotomy.

The third Stage

Once the baby is delivered there is typically an air of great excitement and relief. However, the immediate concern remains that the placenta is delivered and the mother is watched carefully for signs of excessive bleeding (haemorrhage).

Reasons to consider early assistance with delivery

1. Long or complicated first stage of delivery
2. Known medical problems in the mother
3. Concern regarding the fetus e.g. growth restricted
4. Evidence of problems with mother (exhaustion) or baby (abnormal fetal heart rate, thick meconium, bleeding) once pushing has commenced

Causes of excessive bleeding after delivery:

A. Uterine causes

1. Lax or “atonic uterus”
2. Low lying insertion of placenta (bleeding harder to spot)
3. Uterine tumours e.g. fibroids
4. Uterine rupture
5. Cervical tear

B. Other causes

1. Vaginal / perineal tear
2. Weak blood clotting e.g. D.I.C. (disseminated intravascular coagulation)

Management decisions in Labour

When assessing the progress of the labour, all the factors in table I should be taken into account. There are three choices for the doctor / midwife and patient to discuss at any given situation.

1. Do nothing and allow the labour to progress naturally. (Appropriate if progress is satisfactory with no sign of problems)
2. Encourage the labour the through intervention, mobilise, good analgesia, Syntocinon infusion. (cont. next page)
3. End the labour (Caesarean section or ventouse / forceps assisted delivery). (Appropriate where there are serious concerns for the health of mother and baby or where there are clear signs that the labour is not progressing satisfactorily {obstructed or failed labour})

Elective caesarean section versus attempting a vaginal delivery

As you can see from the table below, the two options facing the woman before delivery is either to have an elective (non-labour or pre-labour) Caesarean section, or to try for a vaginal delivery, where she may end up with a vaginal delivery, an assisted delivery e.g. forceps / ventouse or an emergency (in labour) Caesarean section.

The majority of risk associated with having a Caesarean section is when the woman is already in labour, that is an emergency Caesarean section.

Elective Caesarean section

There is greater short term morbidity (more pain, less mobility) but probably less long term morbidity (reduced need for pelvic floor or perineal surgery), when compared with vaginal delivery. The risks of elective Caesarean Section become greater after one Caesarean, but a significant increase in risk occurs after three operations.

What about the risks for the baby?

So long as the Caesarean section is performed after 37 completed weeks of gestation, there is no increase in long term risks to the baby.

A baby undergoing a vaginal delivery has a small risk of developing complications e.g. low oxygen levels which in a small number of babies can lead to brain swelling (hypoxic ischaemic encephalopathy or HIE). A small number of these babies will go onto develop cerebral palsy. It is important to stress that 85-90% of babies that have cerebral palsy will have no problems in labour, as the cause of the cerebral palsy is from much earlier in the pregnancy.

National Health Service Recommendations for deciding on the mode of delivery follow NICS guidelines, which can be found at http://www.nice.org.uk/Guidance/CG13

As already discussed comparing Caesarean section with vaginal delivery does not allow a woman to compare her choices, i.e. and elective Caesarean Section versus trying for a vaginal delivery, where the outcome can be natural, assisted with forceps or ventouse, as well as an emergency C section.

The following information is a summary of recent scientific research looking at different aspects of vaginal delivery and Caesarean section. Some papers look at the risk of sexual dissatisfaction, urinary and anal incontinence when comparing vaginal with Caesarean birth, while others look at the outcome for the baby, demonstrating that babies born vaginally are more likely to require medical attention, and a finding whose implications are as yet unknown: the increased risk of intracranial haemorrhage (bleeding into the brain) in babies born vaginally.

These papers simply demonstrate that there are risks whatever route your baby takes when coming into the world: good assessment and experienced advice are the key elements in ensuring the best outcome for your and your baby.

The expectant mother should be involved in the decision process regarding the route of delivery and be aware of the benefits and risks of Caesarean section versus vaginal delivery. It is important to stress that a woman should not be routinely offered a Caesarean Section – The decision for intervention at any stage in a pregnancy or labour has to be taken by the attending midwife or obstetrician in agreement with the woman, and for good reason.

Scientific Articles on vaginal delivery and Caesarean section

Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience

Monika Schindl et al Volume 82 Issue 9, Pages 834 – 840 Acta Obstet Gynecol Scand, 2005

Background

To investigate birth experience and medical outcome in women with elective cesarean section (CS) compared with women with intended vaginal delivery.

Methods

A total of 1050 pregnant women were included in this prospective trial. Psychological factors, pain levels and birth experience were investigated using a self-designed questionnaire and three established psychological tests in gestational week 38, and 3 days and 4 months postpartum. In addition, medical data were evaluated from the records.

Results

Out of 903 women with planned vaginal birth, in 484 women (53.6%) minimal perineal surgery had to be performed after birth, 41 women (4.5%) had vacuum deliveries, and in 93 cases (10.3%) emergency CS had to be performed. In the 147 elective CS (103 based on medical and 44 on psychological factors), a significantly lower rate of maternal and fetal complications was observed when compared with vaginal birth (5.4% vs. 19.3%; p < 0.0001). Birth experience (Salmon test) was significantly better in elective CS compared with vaginal delivery, but worse in women with emergency CS and worst in those with vacuum delivery. We found that 83.5% of women with vaginal delivery would choose the same mode of birth again, 74.3% of women with CS on demand, and 66% of women with medically necessary CS. Only 30.1% of women with emergency CS wanted to receive CS at the next birth.

Conclusions

Elective CS is a safe and psychologically well tolerated procedure. The results are comparable with uncomplicated vaginal delivery and far superior to secondary intervention such as vacuum delivery or emergency CS.

Mode of delivery and subsequent long-term sexual function of primiparous women

International Journal of Impotence Research (2007) 19, 358–365;

Minimal information exists on unintended health consequences following childbirth, particularly in relation to mode of delivery. This study aimed to evaluate the impact of mode of delivery on long-term sexual satisfaction of women by using a validated questionnaire. Forty-five primiparous women who had cesarean deliveries and 90 primiparous women who had vaginal deliveries with mediolateral episiotomies enrolled in the study. Quality of sexual relations and sexual satisfaction were self-reported by using the Golombock–Rust Inventory of Sexual Satisfaction. Prevalence of sexual dissatisfaction was compared between the two groups and logistic regression analysis was carried out to identify the predictors of sexual dissatisfaction. The prevalence of overall sexual dissatisfaction was 4.4% in the cesarean group while it was 14.4% in vaginal delivery group (P=0.081). The vaginal delivery group demonstrated a trend toward higher prevalence of dissatisfaction in all subscales except sensuality, however the differences between two groups did not reach statistical significance.

Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms Ekström et al: International Urogynecology Journal 19, 4, April 2008 , pp. 459-465(7)

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9-42] and for urinary urgency (RR 7.3 95% CI 1.7-32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5-19) and at 3 months follow-up (OR 3.9, 95% CI 1.7-8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.

Ceasarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia. Culligan et al. Int UroJl Vol16, Number 1 / February, 2005

Abstract

Our aim was to determine the cost-effectiveness of a policy of elective C-section for macrosomic infants to prevent maternal anal incontinence, urinary incontinence, and newborn brachial plexus injuries. We used a decision analytic model to compare the standard of care with a policy whereby all primigravid patients in the United States would undergo an ultrasound at 39 weeks gestation, followed by an elective C-section for any fetus estimated at Your browser may not support display of this image.4500 g. The following clinical consequences were considered crucial to the analysis: brachial plexus injury to the newborn; maternal anal and urinary incontinence; emergency hysterectomy; hemorrhage requiring blood transfusion; and maternal mortality. Our outcome measures included (1) number of brachial plexus injuries or cases of incontinence averted, (2) incremental monetary cost per 100,000 deliveries, (3) expected quality of life of the mother and her child, and (4) Your browser may not support display of this image.quality-adjusted life yearsYour browser may not support display of this image. (QALY) associated with the two policies. For every 100,000 deliveries, the policy of elective C-section resulted in 16.6 fewer permanent brachial plexus injuries, 185.7 fewer cases of anal incontinence, and cost savings of $3,211,000. Therefore, this policy would prevent one case of anal incontinence for every 539 elective C-sections performed. The expected quality of life associated with the elective C-section policy was also greater (quality of life score 0.923 vs 0.917 on a scale from 0.0 to 1.0 and 53.6 QALY vs 53.2). A policy whereby primigravid patients in the United States have a 39 week ultrasound-estimated fetal weight followed by C-section for any fetuses 4500 g appears cost effective.

Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery

Mark B. Lando et al, NEJM Volume 351:2581-2589December 16, 2004

Background

The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain.

Methods

We conducted a prospective four-year observational study of all women with a singleton gestation and a prior cesarean delivery at 19 academic medical centers. Maternal and perinatal outcomes were compared between women who underwent a trial of labor and women who had an elective repeated cesarean delivery without labor.

Results

Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). Hypoxic–ischemic encephalopathy occurred in no infants whose mothers underwent elective repeated cesarean delivery and in 12 infants born at term whose mothers underwent a trial of labor (P<0.001). Seven of these cases of hypoxic–ischemic encephalopathy followed uterine rupture (absolute risk, 0.46 per 1000 women at term undergoing a trial of labor), including two neonatal deaths. The rate of endometritis was higher in women undergoing a trial of labor than in women undergoing repeated elective cesarean delivery (2.9 percent vs. 1.8 percent), as was the rate of blood transfusion (1.7 percent vs. 1.0 percent). The frequency of hysterectomy and of maternal death did not differ significantly between groups (0.2 percent vs. 0.3 percent, and 0.02 percent vs. 0.04 percent, respectively).

Conclusions

A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section.

Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors Looney et al Radiology 2007;242:535-541

Purpose

To retrospectively evaluate the prevalence of neonatal intracranial hemorrhage (ICH) and its relationship to obstetric and neonatal risk factors.

Materials and Methods

Pregnant women were recruited for a prospective study of neonatal brain development; the study was approved by the institutional review board and complied with HIPAA regulations. After informed consent was obtained from a parent, neonates were imaged with 3.0-T magnetic resonance (MR) imaging without sedation. The images were reviewed by a neuroradiologist with 12 years of experience for the presence of ICH. Medical records were prospectively and retrospectively reviewed for selected risk factors, which included method of delivery, duration of labor, and evidence of maternal or neonatal birth trauma. Risk factors were assessed for relationship to ICH by using Fisher exact test statistics.

Results

Ninety-seven neonates (mean age at MR imaging, 20.8 days ± 6.9 [standard deviation]) underwent MR imaging between the ages of 1 and 5 weeks. Eighty-eight (44 male and 44 female) neonates (65 with vaginal delivery and 23 with cesarean delivery) completed the MR imaging evaluation. Seventeen neonates with ICHs (16 subdural, two subarachnoid, and six parenchymal hemorrhages) were identified. Seven infants had two or more types of hemorrhages. All neonates with ICH were delivered vaginally, with a prevalence of 26% in vaginal births. ICH was significantly associated with vaginal birth (P < .005) but not with prolonged duration of labor or with traumatic or assisted vaginal birth.

Conclusion

Asymptomatic ICH following vaginal birth in full-term neonates appears to be common, with a prevalence of 26% in this study.

Neonatal Outcome after Trial of Labor Compared with Elective Repeat Cesarean Section

Fisler et al Birth, Volume 30, Number 2, June 2003 , pp. 83-88(6)

Background

Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean.

Methods

All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83).

Results

Infants delivered after a trial of labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p < 0.001); and mild bruising (8.0% vs 1.5%, p = 0.008). Within the trial of labor group, infants of mothers who received epidural analgesia were more likely to have received diagnostic tests and therapeutic interventions including sepsis evaluation (29.6% vs 6.0%, p = 0.001) and antibiotic treatment (13.9% vs 4.8%, p = 0.03) than within the no-epidural analgesia group.

Conclusions

Infants born to mothers after a trial of labor are twice as likely to undergo diagnostic tests and therapeutic interventions than infants born after an elective repeat cesarean section, but the increase occurred only in the subgroup of infants whose mothers received epidural analgesia for pain relief during labor. The higher rate of intervention could relate to the well-documented increase in intrapartum fever that occurs with epidural use.