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To get this blog going I decided to write about a slight obsession of mine: The fear of, and routine midwifery management of nuchal cords at birth (umbilical cord around the neck). I have written and presented about this topic and have bored the pants off many a person who has made the mistake of mentioning the subject. So, despite telling my colleagues that I had put away my 'nuchal cord' soap box I am bringing it out to launch this blog. The content of this post is based on part of a literature review I carried out for my PhD thesis. If you are interested in finding out more you can download a poster based on my literature review here, I have also written a couple of journal articles on the topic: nuchal cords: think before you check and nuchal cords: sharing the evidence with parents

Why and how babies end up wearing their cord around their neck

The presence of a nuchal cord is a very common occurrence during birth. Up to 30% of babies are born with their umbilical cord around their neck ( Mercer et al. 2010). How and when it ends up there will be different for individual babies. Interestingly, it is more common with boy babies ( Martin et al. 2005) - perhaps because they are more likely to have longer cords ( Rogers et al. 2003). It also becomes more common with increasing gestation - I suppose there is more time to get wrapped the cord. If a nuchal cord does not occur in pregnancy it can occur during labour. As the baby moves through the pelvis he/she rotates and can spin the cord around their neck. See this post to see how rotation works.

A versatile scapegoat

The nuchal cord has become the perfect scapegoat because it lays blame with the mother/baby rather than the careprovider/system. This has resulted in fear about nuchal cords becoming embedded within our culture. Whenever I read a story about an unexpected birth outside of hospital it always seems to involve a nuchal cord. The story being about how lucky the baby was to survive the dangers of a nuchal cord away from the experts who can manage such a complication. In addition, I have heard too many birth stories where the complications were unfairly blamed on the presence of a nuchal cord.

Before I tackle some of the myths - some quick anatomy and physiology: The cord is covered in Wharton's jelly and coiled. This protects the 3 blood vessels from the kind of stretch and compression involved in being attached to a mobile baby. The umbilical cord is also long enough (average 55cm) to be comfortably wrapped around the neck with plenty of left over length. Essentially the umbilical cord is 'designed' to be worn around the neck without causing a problem.

Pregnancy

Research has found that a nuchal cord is not associated with morbidity or mortality for the baby during pregnancy ( Carey & Rayburn 2000; Aksoy 2003; Clapp III et al. 2003; Gonzalez-Quintero et al. 2004). Unfortunately some babies die before labour begins, and there is often no known reason, which can add to the devastation for the family. When these babies are born they are often found to have the cord around their neck (like a 3rd of all babies). Although I can understand the need to find a reason and to pick the obvious, I don't think this is helpful in the longer term. Parents need honest answers about the loss of their baby, even if the answer is 'we don't know'.

Labour

During labour a nuchal cord does not cause a problem. There is no indication to undergo a c-section if a nuchal cord is identified antenatally ( RCOG 2017). The baby is not 'held up' by the cord because the whole package - fundus (top of the uterus), placenta and cord are all moving down together. The uterus 'shrinks' down (contracts) moving the baby downwards, along with their attached placenta and cord. It is not until the baby's head moves into the vagina, that a few extra centimetres of additional length are required (see 'birth' below). However, when a c-section is done for 'fetal distress' or 'lack of progress' during labour, the presence of a nuchal cord is often used as the reason... "ah ha, look - your baby was stressed because the cord was around his neck" or "...the cord was stopping her from moving down". The cord is unlikely to have had anything to do with the stress or lack of progress. Most likely other interventions carried out during labour led to the end scenario (in particular the use of syntocinon).

Birth (the last bit of labour)

The nuchal cord remains around the baby's neck as his head moves out of the uterus and through the vagina. Usually the cord remains loose as there is lots of 'give' in it. A loose nuchal cord does not cause any problems ( Reed et al. 2009). Blood continues to flow through the vessels just as it did during pregnancy and labour. Occasionally a cord becomes stretched and tight during this last bit of labour - as the head is born. Either there is not enough 'give', or the cord is trapped against the pelvis by the baby's body. This may happen with a shorter than average cord that is wrapped around the neck a number of times. However, the baby is not 'strangled' because he/she is not breathing oxygen. Their oxygen is provided by the cord, not their airway. Whilst the cord is stretched and compressed the blood vessels transfer less blood (but still some). This results in short-term hypoxia (reduced oxygen supply) which resolves once the cord is loosened after birth and full blood flow resumes. These babies may arrive a little compromised but quickly recover - if the cord is left alone. Unfortunately the way in which the situation is managed (see below) can create further problems. The resulting need for resuscitation is then blamed on the nuchal cord rather than what was done to it by the care provider.

Risks associated with clamping and cutting a tight nuchal cord

Once the cord is clamped, blood flow between the baby and placenta ceases, reducing the baby's blood volume and oxygen supply. This makes resuscitation more necessary and difficult once the baby is born. Any delay in the birth of the baby (eg. shoulder dystocia) will further increase the risk of hypoxia. While waiting to be born the baby now has NO blood supply rather than a limited one that can be re-established after birth. There have been successful malpractice actions against obstetricians in the US who cut nuchal cords prior to shoulder dystocia ( Iffy et al. 2001).

One study ( Sadan et al. 2007) found that neither cutting nor leaving a nuchal cord adversely affected the outcome for babies. However, they did not look at tight nuchal cords, and the cords were cut after the anterior shoulder had birthed. The damaging effects of cutting a nuchal cord are becoming commonly understood in medicine and midwifery. A policy of keeping a nuchal cord intact has been found to improve outcomes for babies ( Parr et al. 2014).
For a baby with a tight nuchal cord the worst thing you can do is clamp and cut!
Risks associated with pulling and looping a loose nuchal cord

A far more common practice is pulling and looping a loose nuchal cord. Most care providers do this and I was taught to do this when I trained. However, handling the cord stimulates the umbilical arteries to vasoconstrict, reducing blood flow. Loosening the cord will usually involve some traction which can risk tearing the cord and subsequent bleeding (from the baby), or partial detachment of the placenta. As a student midwife I snapped a cord while looping it over the baby's head. Luckily my mentor clamped the ends quickly but not before I got blood sprayed in my eyes! I later discovered that babies can be born with the cord around their neck. They either birth through the loop, or they come out with it still wrapped.

Checking for a nuchal cord

So, if you are not going to cut or loop a nuchal cord what's the point in digging about to see if it is there? Checking for a cord interferes with the physiological process of birth. It also reinforces the notion that this is a birth complication that endangers the baby, rather than a common situation ( Reed 2007). Telling the woman to stop pushing and putting your fingers into her vagina can be disempowering and painful. There are also consent issues - how many care providers gain consent before this procedure?

Suggestions

Talk to parents before birth about the possibility and normalcy of a nuchal cord (a third of all babies have a nuchal cord at birth)

During birth DO NOTHING.

IF the cord is preventing the baby descending once the head is born (extremely rare) use the 'somersault technique' (Schorn & Blanco 1991) - see below.

Once the baby is born, unwrap the cord (the mother/family can do this).

If the baby is compromised at birth encourage the parents to talk to their baby and touch him whilst the placental circulation re-establishes the normal blood volume and oxygen for the baby. If the baby requires resuscitation do it with the cord intact.

The baby in the photo at the top of this post was born at home into water. His cord was tightly around his neck twice. The midwife is in the process of unwinding the cord whilst bringing him to the surface and into his mother's arms. He took around 30 seconds to start breathing whilst his placental circulation re-established his blood volume and oxygenated him. His father gently blew on his face and he took his first gasp - resuscitated by his placenta and his father.

Here is an amazing film of a baby with a multiple nuchal cord beautifully managed by his mother:

You can also watch a mother unwrap a nuchal cord during a water birth here.
The somersault manoeuvre
I have only had to use this twice in hundreds of births.

There is a movie of this technique available (although also it refers to checking and looping).

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Updated: January 2020 Multiple, tight nuchal cord being unwound during a waterbirth To get this blog going I decided to write about a slight obsession of mine: The fear of, and routine midwifery management of nuchal cords at birth (umbilical cord around the neck). I have written and presented about this topic and have bored...

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I am a doula and birth educator.

I also have a PhD in physiology of reproduction, and 20 years of research experience and I have a confession to make: I get REALLY irate when women get given poor quality evidence (or no evidence at all) in support of a recommendation for inducing labour.

Whether I'm wearing my doula hat, or my scientist hat, I have to admit to getting really fed up with the growing epidemic of induction of labour for dubious reasons. This article is going to explore one of the most common stated reasons for induction of labour at term : The idea that labour should be induced before a certain point in pregnancy is reached because the 'older' placenta is not as efficient.

I want to clarify one thing before we start: I am NOT anti induction, when it is justified by solid medical evidence and when a woman weighs up the evidence and decides that the risk of continuing the pregnancy is higher than the risk of inducing labour (like for example pre-eclampsia or reduced fetal movements, or when there are psychological reasons for the woman to choose to be induced).

Over the last 8 years, between teaching antenatal classes and supporting women, I have heard and witnessed hundreds of stories of induction, the majority of which ended up being traumatic for the mother.

In my area of work we often refer to this as the "car crash", which goes something like this: 3 days of prostaglandin induction (often made more stressful because the woman cannot be with her family for much of the time), followed by 24 hours of syntocinon and a caesarean at the end for either fetal distress or "failure to progress" (if only women were told : We're really sorry, we didn't manage to get you into labour with our drugs, so now the only option is a cesarean, maybe women wouldn't feel as traumatised as when they are labelled a failure. Language matters).

I have listened and held women (and their partners) as they told me of their upset, their grief, their disbelief, lack of preparation and their feelings of failure.

One of the top quoted reasons for inducing women when pregnancy goes beyond 41 weeks is the idea that the placenta somehow stops working after pregnancy reaches a certain number of weeks.
The implication is that the placenta has a sell by date, like a piece of meat in the supermarket.
Recently yet more papers have been published claiming as a fact that placentas "age", "degrade" and "fail" in older mothers and after a certain number of weeks of pregnancy.

I don't normally like to write solely about science stuff these days. I like to write about how I feel about issues, and stick a few references in for people who want to read them. I spent 20 years doing scientific research in the academic and industry setting. I've moved on from this, I find most of the scientific world too dry and frankly, too blinkered.

But I'm losing patience with this so-called science causing so much damage to women.

I was very concerned a few weeks ago to watch a heated debate on social media about this topic; seeing many of my colleagues being gaslighted into believing the so-called science by people who claim to have all the answers, using jargon that they do not understand.

I believe that my scientific background combined with my experience as antenatal educator and doula gives me a unique, broad perspective on this topic.

So it's time to put my scientific hat back on, analyse the papers in question, and offer my rather alternative interpretation of the current evidence, so that women and birth workers can make truly informed decisions, not one-sided ones based on the opinions of a few so-called experts whose views are based on their existing belief and opinion rather than a considered weighing-up of the evidence in this area.

I suggest you grab yourself a cup of tea, because this is going to be a long one!
Before I start I want to make an important point: even experts in a field often disagree with one another.
When I was working in the academic field during my PhD and 2 postdocs, working in a small niche area of biology research (clock genes, the genes which control rhythms, such as waking and sleeping), I published in fairly high ranking scientific papers, and became quickly perceived as an expert in my field. This led me to be invited as a guest speaker at conferences. I remember arguing until I was blue in the face about the interpretation of certain data with other experts in the field. It was done passionately, but it was entertaining, good humoured and fun. It happened because, as I will explain below, good scientists understand that science isn't black and white.

The conversations I see on social media about this research aren't like this. I see experts pretending to have all the answers, presenting themselves as the only ones who have all the knowledge, and frankly bamboozling and bullying non scientists with jargon.

In this particular case, they take the moral high ground, presenting themselves as saviours, as if stillbirths could be guaranteed to be prevented if only we induced all women at a certain number of weeks of pregnancy. They attack other people whose views are different, even when these people are equally or more qualified and hold PhDs in relevant fields.
This isn't right. This harms women, and this harms the people who are supporting them too.
Even in science, things are never black and white. Nothing is guaranteed. There are many shades of grey. And pretending that things are this way isn't science, it is delusion, and it is treating science as a dogma. If you want to find out more about this way of thinking, watch Cambridge scientist Dr Rupert Sheldrake's banned TED talk on the topic.

Now that's out of the way, back to the subject at hand: do placentas really age? Do they stop functioning correctly towards the end of pregnancy? And most importantly, are they solely responsible for the (let's remember, tiny) rise in stillbirth towards the end of pregnancy? These are the assumptions that currently underpin our induction policies.

I feel I need to explain first that the risk of increased stillbirth at term, which is the main reason behind induction policy, is actually very small, rising from about 0.1% (1 in a 1000) at 40-41 weeks, to about 0.3% (3 in a 1000) at 42 weeks and about 0.5% (5 in a 1000) at 43 weeks (from this paper). The Cochrane review on induction beyond term , found that induction before 42 weeks reduced the risk of perinatal death from 0.3% to 0.03%, and that the authors of the review concluded that:
" A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen. However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction)."
In practice I almost never see the part highlighted in bold being presented as an option to women (read my previous blog about it here)

I would like to quote the seminal paper by the late Dr Fox " Aging of the placenta "
" A review of the available evidence indicates that the placenta does not undergo a true aging change during pregnancy. There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not: the situation in which an individual organ ages within an organism that is not aged is one which does not occur in any biological system. The persisting belief in placental aging has been based on a confusion between morphological maturation and differentiation and aging, a failure to appreciate the functional resources of the organ, and an uncritical acceptance of the overly facile concept of "placental insufficiency" as a cause of increased perinatal mortality."
Whilst I am fully aware that this paper is dated, having being published in 1997, and that much more research has been carried out since, I still believe his conclusion stands, the last sentence in particular.

I've heard many maternity care providers coerce expectant mothers to accept induction (remember, if you feel coerced, this isn't consent) to the cries of "your placenta is failing right now". Yet, even today, we do not know what accounts for the tiny rise in neonatal mortality after 40 weeks.

There seems to be a strong desire to prove the causality between placental aging and the increase in stillbirth and this desire is guided by a positive drive, which is to reduce stillbirth.

I empathise with this drive better than you know, because my younger brother was stillborn so I fully understand the devastating effects the death of a new baby has on a family.

But for the moment it's just this: a theory.
And anyone can invent a theory about anything, but that doesn't make it true.
We need to find a balance between the real statistics and women's wishes for a positive birth experience. Because there is no doubt from the evidence in this area that, as long as mother and baby are well, it is better for all involved for labour to start on its own.
Because we mustn't forget that inductions can be very traumatic for women and they can cause fetal distress in babies.
It's quite simple, really: let the mothers decide what they want. And for this, they need real facts and numbers, not emotive coercion.
First, a bit of history
How did the whole concept of placental failure ever come about?

In her book " Inducing labour, making informed decisions " , Dr Sara Wickham explains that this theory came about first via the work of Ballantyne who described a wasting condition of the newborn in 1902, followed by Runge in 1958 who coined the term placental insufficiency. This became known as the Ballantyne-Runge syndrome, and led to the assumption of a relationship between the length of pregnancy and placental failure.

Dr Wickham goes on to explain that this theory has never been proven and that there is no evidence behind it. She explains that, while we know that some women's placentas do sometimes fail to provide sufficient nutrients for their baby, this doesn't mean that all women's placentas routinely fail at a certain point in time. Further evidence of how much those who are challenging this theory really do care about the wellbeing of babies can be seen where Dr Wickham notes in her talks that the concern is not just about preventing unnecessary inductions for women who do not need them. By trying to make standardised, population-level recommendations (or a 'one size fits all' approach), we not only lead many women to have inductions that they do not need, but we may also fail to identify and help the small number of babies who truly do need help but at a point earlier than the current population-level cut-off point for induction.

Even in the papers claiming that there is a relationship between the length of pregnancy and the state of the placenta, when you dig into them, the conclusion reached is always that there is a "possible link" rather than a proven one.

And as I explained before, experts in the field do not agree with one another. In her book " Why induction matters", Dr Rachel Reed quotes a couple of prominent papers, in particular a paper by which claims a direct link between placental aging and stillbirth, and a paper by Mazzurato et al " Guidelines for the management of postterm pregnancy" which states that:

" Although the fetal, maternal and neonatal risks increase beyond 41 weeks, there is no conclusive evidence that prolongation of pregnancy, per se, is the major risk factor. Other specific risk factors for adverse outcomes have been identified, the most important of which are restricted fetal growth and fetal malformations. In order to prevent PT (Post term) and associated complications routine induction before 42 weeks has been proposed. There is no conclusive evidence that this policy improves fetal, maternal and neonatal outcomes as compared to expectant management."
The nitty gritty of the arguments behind the aging placenta theory
Some of the technical terms I see bandied around a lot, and which bamboozle many of my colleagues because they do not understand their meaning, are morphological changes in the placenta such as apoptosis, autophagy, syncytial knots, reduction in telomere length and so on. In many papers, the authors claim that these are key features of aging, and observed in post-term placentas.
Yet there is more than one interpretation of these morphological changes so often lauded as proof of a placental 'sell-by date'. They do not automatically mean that there is a problem. In many ways, our understanding of this area is in its infancy, and we would do better to take a position of scientific humility while we try to determine the meaning of these findings.
One of the most striking examples of a study which makes suggestions that aging of the placenta at term is a fait accompli is this study, with its sensational title: " Evidence that fetal death is associated with placental aging" by Maiti et al.

I find one of the statements in this paper extremely concerning:
" The known exponential increase in unexplained intrauterine death that occurs >38 weeks of gestation may therefore be a consequence of aging of the placenta and decreasing ability to adequately supply the increasing needs of the growing fetus. This knowledge may impact on obstetric practice to ensure infants are born before the placenta ages to the point of critical failure"
I fear such a statement will be used to pressure yet more women into being induced earlier, without any concerns for their personal decision or well being. And yet, as I will keep saying, this is still an unproven theory and different experts have different opinions about whether it is true or not. The medical profession is based on the tenet of 'first do no harm' and my understanding is that this means that we should not intervene unless we have good evidence to support doing so.

I will go through clarifying the differential interpretation of some of the changes observed in the placenta.

One of the changes they observe in this paper is decreased autophagy. Autophagy is a kind of cellular recycling system. The authors infer that these changes are a proof of aging. Yes, autophagy decrease has been associated with aging in some studies. Some other authors, however, are suggesting that the reduction in autophagy in the placenta may be part of the process that actually starts labour and so it may be a normal and important part of a physiological process rather than a sign that something is 'wrong'.

Another placental change, quoted in the paper by Maiti cited above, is apoptosis (also known as programmed cell death). Apoptosis isn't just a proof of senescence (aging). Apoptosis also happens during fetal development and during adolescence. It is as much as sign of change as it is a sign of ageing, and of course change and growth are very important at this time; the whole point of pregnancy is that the baby grows and changes
"The role of apoptosis in normal physiology is as significant as that of its counterpart, mitosis. It demonstrates a complementary but opposite role to mitosis and cell proliferation in the regulation of various cell populations. It is estimated that to maintain homeostasis in the adult human body, around 10 billion cells are made each day just to balance those dying by apoptosis (Renehan et al., 2001"Trophoblast apoptosis is a physiologic event in normal pregnancy, increases with advancing gestational age and is higher in post- term pregnancies and therefore is considered as a normal process in the development and ageing of the placenta." Again and again we see that the processes which are claimed by some to be evidence of aging could also be interpreted to be signs of the normal growth and change which are the very function of pregnancy. " SNAs may form to structurally reinforce the placenta and minimise damage from shear stresses or other mechanical sources, reduce the proportion of nuclei in highly active vasculo-syncytial membranes or result from cell turnover in the placenta without an apoptotic trigger or shedding process. Ultimately, a better understanding of the processes leading to SNA formation will give insight into their significance in pregnancy complications." ). And that number can increase significantly when there is increased apoptosis during normal development and aging or during disease."
And during pregnancy
"Telomeres, the DNA-protein structures located at the ends of chromosomes, have been proposed to act as a biomarker of aging. In this review, the human evidence that telomere length is a biomarker of aging is evaluated. Although telomere length is implicated in cellular aging, the evidence suggesting telomere length is a biomarker of aging in humans is equivocal. More studies examining the relationships between telomere length and mortality and with measures that decline with "normal" aging in community samples are required. These studies would benefit from longitudinal measures of both telomere length and aging-related parameters."
Syncytial knots (SNAs, an accumulation of cell nuclei (the centre of cells) inside placenta cells) are another change quoted as a proof of ageing:
"Multiple studies have demonstrated that telomere length predicts mortality and that telomeres shorten with age. Although rarely acknowledged these associations do not dictate causality. In addition, the causality hypothesis assumes that there is a critical telomere length at which senescence is induced. This generates the prediction that variance in telomere length decreases with age. In contrast, using meta-analysis of human data, I find no such decline. Inferring the causal involvement of telomeres in aging from current knowledge is therefore speculative and could hinder scientific progress."
So again, what we are seeing could just as well be an adaptation rather than a sign of ageing.
" Placental senescence raises several important questions that need to be addressed experimentally. While fusion-induced senescence appears to be required for syncytiotrophoblast formation, it is likely that senescence of both fetal tissues and the maternal decidua play at least a part in determining timing of labour onset"
Telomere length :

In this paper called " Questioning causal involvement of telomeres in aging " the authors state:

What I find of particular interest, is that the authors of this paper also speculate that these cellular changes may form part of what starts labour:

So what if what is seen in the placenta and interpreted as a sign of aging, are in fact normal, healthy changes, which are a sign of healthy growth and development and which may also play a role in the start of labour?

Another "older" sign of placental aging is calcifications. I've been guilty myself of believing people who told me it was a sign of ageing and it was good that the baby had been born because the placenta was "old". I recently came across this blog (which has published references to back up all its claims):

So while calcification of a placenta at term - around 39-42 weeks is part of the normal appearance of a full-term placenta and has no clinical significance in a healthy pregnancy, the appearance of significant calcification earlier in pregnancy is associated with risks to both the mother and baby. Just like we would be concerned about a very young person with wrinkles - it could be a sign of something significant happening (...) So, in essence, when a mother is healthy and full term, calcification and infarcts are normal features of a healthy placenta - just like your healthy mother has some wrinkles and a few grey hairs.

Yet another myth blown out of the water.

In conclusion, whilst there is evidence of cellular changes in the placenta throughout the course of pregnancy, there still isn't any solid evidence to prove that it is indeed aging rather than an adaptation, or that these changes are truly accountable for the tiny rise in stillbirth when pregnancies continue beyond 42 weeks.

The concept of the aging placenta is still just that, a theory. Unfortunately the majority of the publications cited in this post fail to acknowledge this, and take this theory as proven.

What worries me even more, is that no consultation of women's view on the induction process usually takes place, and these publications will form the basis of the new NICE guidelines, then the local hospital guidelines, and therefore more and more women will be induced needlessly, and have negative or traumatising experiences.

This is underpinning a current trend towards inducing women even earlier, at 39 weeks instead of the current 41 to 42 weeks.
I am grateful to Maddie McMahon for editing this blog
Evidence based birth has produced an excellent review of the literature on this topic.

I hope that reading this blog will help women and their supporters make informed decisions.

I also would like to encourage scientists and policy makers to stay curious about the wider picture and to engage more with pregnant women and their views on the induction process.

If this resonates with you and you would like to work with me, head over here if you're an expectant or new mum, or here if you are a birthworker.

If you have found this blog helpful and would like to support my work and help me continue provide valuable free information to birthworkers and expectant and newborn families, you can donate to my paypal account paypal.me/SophieMessager.

Also feel free to signup to my mailing list to receive my newsletters by using the signup form at the bottom of this page

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The Myth of the Ageing Placenta | Sophie Messager

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I am a doula and birth educator. I also have a PhD in physiology of reproduction, and 20 years of research experience and I have a confession to make: I get REALLY irate when women get given poor quality evidence (or no evidence at all) in support of a recommendation for inducing labour.

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I'm pregnant through IVF. Should I have an induction? It is very common for women and people who became pregnant through IVF to be advised to have an induction of labour, usually around 38-40 weeks, if spontaneous labour hasn't started already.

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Here's WHY babies get nuchal cords, the associated RISKS, and YOUR OPTIONS when baby has his or her umbilical cord wrapped around their neck.

Pregnancy brings with it a veritable dictionary of new terms, and many of them sound ominous. ( Lochia, vernix, and port wine stains, oh my!) What about a nuchal cord, or when baby's umbilical cord is wrapped around their neck? What is it? Should you stress out over it?

Read on for info on babies get nuchal cords, the associated risks, and your options when baby has his or her umbilical cord wrapped around their neck.

What is a nuchal cord?

A nuchal cord is the official term for when a baby has his umbilical cord wrapped around his neck during pregnancy or delivery. As your baby's literal lifeline, providing him with oxygen, blood, and nutrients, any complications with the umbilical cord can seem critical and a cause of concern. But, thankfully, it turns out that most nuchal cords aren't dangerous at all.

Umbilical cords can be wrapped once, twice, or even multiple times around a baby's neck, but amazingly, it's usually nothing to worry about.

A healthy umbilical cord is protected from blood vessel compression by a soft, gelatinous filling called "Wharton's jelly". This jelly is designed to keep the cord free from knots, meaning that regardless of how many somersaults your baby does in-utero, they'll be safe.

How common are nuchal cords?

It turns out that nuchal cords are common and rarely dangerous - most doctors won't even mention them during delivery unless there is a complication with the cord.

In fact, about one in three babies are born (completely healthy) with the cord around their neck. (Source)

Furthermore, most practitioners can't tell if the baby has a nuchal cord even with an ultrasound.

What about a double nuchal or a knot?

Some babies even have the cord wrapped multiple times around their neck - this is called a double nuchal - and are completely fine thanks to the design of a healthy cord.

Only about one in 2,000 births will have a "true knot" in the cord, which does pose certain risks. However, in the majority of cases the cord won't tighten, even during delivery, to the extent that it becomes dangerous. ( Source)

Here's a pretty amazing video of a true knot in an umbilical cord

How do babies end up with a cord around their neck?

Pregnant mamas know better than anyone that unborn babies are essentially tiny acrobats, and their crazy moves are definitely a factor for nuchal cords. However, there are medical or biological reasons why a cord may end up around their necks or in loose knots:

Insufficient Wharton's jelly (Source)

Poor cord structure

Excessive amniotic fluid

Abnormally long umbilical cords

Having twins or multiples

Are there risks associated with a nuchal cord?

Usually, no. Other than increased stress levels and worry, there aren't generally any complications that will affect the mother or the baby. If the doctor detects a nuchal cord, they will closely monitor your baby during delivery, and that's usually all that needs to be done.

In some very rare cases, a nuchal cord does pose a risk to the baby. The most common complication with nuchal cords is decreased heart rate during delivery- a result of poor blood flow to baby due to a compressed umbilical cord during contractions.

If your baby is being properly monitored, the medical team should be easily able to detect this problem. In most cases, the baby is born fine, but if the heart rate continues to decelerate, you could try different laboring positions or an emergency c-section may be necessary. ( Source).

Other complications can include:

decreased fetal movement

decreased development (if the issue arises early on)

a more complicated delivery.

The good news is that any complications at all is rare.
Will I have to have a c-section if my baby has a nuchal cord?
Absolutely not.
The only reason for a c-section is extreme fetal distress. In rare cases, a nuchal cord can contribute to the distress of a baby during labor, and a c-section will be necessary. ( Source) But there's no reason why a healthy baby with a nuchal cord would need to be delivered by c-section.

(And if you do require a c-section, remember there are many ways to make it more natural. Read about gentle cesareans.)

In short, you don't need to make any special preparations if you learn that your baby has a nuchal cord.

Your birth plan can still be executed as planned. Home births and hospital births alike can be equally successful in delivering a baby with a nuchal cord (and even a lotus birth if you choose one).

Make sure that your birth team is skilled in this kind of delivery and won't make any premature interferences or jump to any unnecessary labor interventions.

What now?

Although it can be a lot to take in, remembering that nuchal cords generally aren't a big deal can put your mind at rest. In the weeks or days before your delivery, remember to take it easy. Rest when you need to.

Here are a few things to do in the meantime:

Now you know the 411 on one of pregnancy's most common misconceptions.

Birth is an incredible and yet normal biological process. Worrying about the things you have no control over certainly won't help, and it will always do more harm than good. Speak to your healthcare provider for reassurance about baby's nuchal cord if need be.

How about you?

Does your baby have a nuchal cord? Or have you delivered a baby with one? How did it turn out? Share with us in the comments below!

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The Truth About Nuchal Cords (Umbilical Cord Around Baby's Neck)

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Here's WHY babies get nuchal cords, the associated RISKS, and YOUR OPTIONS when baby has his or her umbilical cord wrapped around their neck. Pregnancy brings with it a veritable dictionary of new terms, and many of them sound ominous. ( Lochia, vernix, and port wine stains, oh my!)

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A graphic showing the statistical impact.

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Sarah Wickham article on why it's not a simple case of testing everyone and treating people who need treating

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Sarah Wickham article on why it's not a simple case of testing everyone and treating people who need treating

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Group B Streptococcus (GBS) are bacteria that live inside (or colonise) the gastrointestinal tract, bladder and / or throat of many people, including pregnant and labouring women. Estimates of the prevalence of colonisation range from 5% to 80% of the population (which shows, if nothing else, the difficulty with have with deducing some of these numbers). GBS is generally benign in adults, only posing a danger to people with compromised immune systems. It is also benign in most of the babies who pick up these bacteria during their birth, but can occasionally cause serious harm to others. Because of this, pregnant women may be offered screening and intervention - yet another pond of uncertainty to have to swim in, which is beset with complex numbers, difficult decisions and tiny chances of very serious conditions.

This is the introduction to an article that was first written in 2003 and, while some of the issues remain the same, some of the statistics have now changed. For instance, neonatal care has improved and the chance of a baby dying from GBS disease is lower than when this article was written. I know that older articles are still of interest to people and some of what it in here is still relevant, but I have now edited this article to remove the information that is no longer accurate. The latest data are included and discussed in my book on this topic and you may also like to search this site for other GBS-related resources on my website.

For several years, most areas in the UK have taken a "risk-based" approach to GBS screening, where practitioners attempt to identify the babies who are at increased risk of becoming infected with GBS. Risk factors (which vary between hospitals) include premature labour (before 37 weeks of pregnancy), a woman with a high temperature during labour or a woman whose waters have been broken for 18-24 hours (1). Where such a risk factor is identified, the woman will be offered intravenous antibiotics in labour. In these situations, swabs may be taken to see if the woman has GBS (or other bacteria), but it takes a while to perform the testing, so the results are usually only available after the birth. As a consequence of this, the woman is making a decision based on the possibility that, IF she has GBS, her baby might be more at risk of becoming infected, rather than knowing (from screening tests) THAT she has GBS.

By contrast, pregnant women in the USA, Australia and some other countries are offered routine screening for GBS at the end of pregnancy (2), and are offered intravenous antibiotics in labour if they are found to have GBS in their vagina or rectum. Some people have mooted the idea of replacing the current "risk-based approach" with the approach used in the US, termed "culture-based screening" (3). With culture-based screening, some of the women who have risk factors but not GBS may escape having unnecessary antibiotics (although some practitioners may recommend them anyway, in case other pathogens are present). However, hospitals will instead offer antibiotics to all of the 10-30% of women whose vaginas and rectums are colonised with GBS (4), even though only a tiny proportion of these babies will be affected with GBS disease (5,6).

GBS disease itself comes in two forms; early onset and late onset. Early onset GBS disease occurs within the first week of life; three quarters of babies who develop GBS disease will do so at this stage. Problems usually become apparent within a few hours of birth and can include generalised infection (sepsis), pneumonia or meningitis. GBS disease is termed "late onset" when it occurs between one week and a few months of age. Not all cases of late onset will occur because the baby's mother transmitted GBS during birth; some will occur from other (but usually unknown) sources. The impact of late-onset disease is usually less severe. Babies found to have GBS disease are treated with antibiotics and given whatever other support they need in Special Care Units.

As above, culture based screening would identify the 10 to 30% of pregnant women whose vaginas or rectums are colonised with GBS (4). The screening test involves taking swabs of the inside of a woman's vagina and rectum - not a particularly pleasant procedure, but not as invasive as some. Yet only 1 or 2 in every thousand of the women who have a positive result if we screen this way will have a baby who ends up with GBS disease (5,6).

It may be that, while policymakers are debating which of the two approaches to use, women might be better served by research which looked at the outcomes where the two were combined. Even this means that many more women would have antibiotics than needed them, but at least we are getting a bit more specific for the women who would prefer to take them if they were at risk.

Perhaps we could also see whether there are other factors that could help us be even more specific about who is at risk. While this might not be deemed cost-effective on a population basis, it may be more helpful for the women who want to avoid unnecessary intervention. There are, inevitably, a number of reasons why women may not want antibiotics in labour unless they are truly necessary. Apart from the side effects, and the discomfort of having movement hindered by an intravenous cannula in labour, there are more serious ramifications of policies advocating mass antibiotic cover. While penicillin (8) and ampicillin (9) are currently effective for treating GBS disease in babies, since antibiotics have been used to treat large numbers of women whose babies are deemed at risk of GBS disease (whether this is on a risk-based or culture-based policy), the rate of Escherichia coli infections in premature babies has more than doubled. Around 85 percent of the E. coli infections in one study were resistant to the drugs prescribed to treat GBS (10).

There is a huge debate about antibiotic resistant bacteria generally, and these policies involve giving antibiotics to a lot of women, which may have ramifications for the population as a whole. It has also been suggested that giving antibiotics while babies are still in their mother's uterus might delay the baby's gut being colonised with normal, "good" bacteria and allow dangerous penicillin-resistant bacteria to become established there instead (11).

There is also a need to find out whether giving antibiotics actually makes a difference to the outcome. The assumption that this is the case has long been just that - an assumption. Cochrane reviewers (12) who looked at the trials comparing women who had been given antibiotics with women who had not been given antibiotics found that, although antibiotics reduced the incidence of GBS infection in babies, there was no significant difference in the numbers of babies who died. They found the few trials that had looked at this area to be of poor quality, and called for further research - something which surely needs to be done before even more women receive unnecessary drugs in labour. Having said that, there is plenty of research to support the fact that midwifery and medical interventions in labour, such as vaginal examination, can increase the rate of infection (13-17), yet there is no evidence to suggest that hospitals are making attempts to limit these interventions. Added to the suggestion, from an American review of laboratory procedures (18), that these may not always be effective at detecting GBS in cultures, the decision can become fraught for some women.

Women looking for information about GBS on the Internet are likely to come across some of the most emotive websites in existence. Some are named for babies who died from GBS disease or who continue to suffer from the effects. While I have enormous sympathy for these families, this is only one side of the picture. The other, I hope, can be seen by looking at the actual risk. The available data show that there is no simple answer to this issue, and no way of screening for GBS in babies that doesn't lead to thousands of women having antibiotics they don't need.

It is appealing to want to reduce the rate of GBS infection; it is the commonest cause of infectious disease in babies, and it can be fatal. Yet, as with the issue of haemorrhagic disease, we are often using sledgehammers to crack nuts, potentially at the expense of future health. Antibiotics have been a marvellous and life-saving discovery. When used appropriately, they are truly useful to humanity. We are already suffering some consequences of our over-use of antibiotics, which is surely something we need to temper. GBS is increasingly seen as a public health issue. However, one's position on GBS (and many other birth interventions) really depends on two things. It depends on whether you are happy to be gathered together with all of the other Ms. Publics and be told what is best for your health (and that of your children), or whether you want to make the decisions that suit you as an individual.

And, perhaps more importantly, it depends on how you define health, on whether you are happy to accept the potential costs of medical technology, and how comfortable you are with the very unfashionable idea that nothing in life is certain.

References

1. Boyer KM, Gotoff SP. Strategies for chemoprophylaxis of GBS early-onset infections. Antibiotic Chemotherapy 1985; 35: 267-80.

2. Schrag SJ, Zell ER, Lynfield R and others. (2002) A Population-Based Comparison of Strategies to Prevent Early-Onset Group B Streptococcal Disease in Neonates. New England Journal of Medicine, July 25, 2002. 347: 4, 233-239.

3. Schrag S, Gorwitz R, Fultz-Butts K and others. (2002) Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from CDC. August 16, 2002 / 51 (RR11); 1-22.

4. Regan JA, Klebanoff MA, Nugent RP, Vaginal Infections and Prematurity Study Group. The epidemiology of group B streptococcal colonization in pregnancy. Obstetrics and Gynecology 1991; 77: 604-10.

5. Gilbert GL, Garland SM. Perinatal group B streptococcal infections. Medical Journal of Australia 1983; 1: 566-571.

6. Isaacs D, Royle JA. Intrapartum antibiotics and early onset neonatal sepsis caused by group B Streptococcus and by other organisms in Australia. Australasian Study Group for Neonatal Infections. Pediatric Infectious Diseases Journal 1999; 18: 524-528.

7. Oddie S Embleton ND. Risk factors for early onset neonatal group B streptococcal sepsis: case-control study British Medical Journal 2002; 325: 308.

8. Garland SM, Fliegner JR. Group B streptococcus (GBS) and neonatal infections: the case for intrapartum chemoprophylaxis. Australian and New Zealand Journal of Obstetrics and Gynaecology 1991; 31: 119-22.

9. Boyer KM, Gotoff SP. Prevention of early-onset neonatal group B streptococcal disease with selective intrapartum chemoprophylaxis. New England Journal of Medicine 1986; 314: 1665-9.

10. Stoll BJ, Hansen N, Fanaroff AA. Changes in Pathogens Causing Early-Onset Sepsis in Very-Low-Birth-Weight Infants New England Journal of Medicine 347: 4; 240-47.

11. Gilbert GL Preventing perinatal group B streptococcal infection: the jury is still out (Editorial) Medical Journal of Australia2002: 178: 5; 199-200

12. Smaill F. Intrapartum antibiotics for Group B streptococcal colonisation (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd

13. Yancey MK, Duff P, Clark P et al. Peripartum infection associated with vaginal group B streptococcal colonization. Obstetrics and Gynecology 1994; 84: 816-9.

14. Schuchat A, Zywicki S, Dinsmoor MJ, et al. Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicenter case-control study. Pediatrics 2000; 105: 21-6.

15. Gibbs RS, Jones PM, Wilder CJY. Internal fetal monitoring and maternal infection following cesarean section: a prospective study. Obstetrics and Gynecology 1978; 52: 193-7.

16. Soper DE, Mayhall CG, Froggatt JW. Characterization and control of intraamniotic infection in an urban teaching hospital. American Journal of Obstetrics and Gynecology 1996; 175: 304-10.

17. Seaward P, Gareth MB, Hannah ME, et al. International multicentre term prelabor rupture of membranes study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. American Journal of Obstetrics and Gynecology 1997; 177: 1024-29.

18. CD Laboratory Practices for prenatal group B streptococcal screening and reporting - Connecticut, Georgia and Minnesota. 1997-1998. MMWR 1999; 48: 426-8.

A version of this article was first published as Wickham S (2003). The War on Group B Strep. AIMS Journal 15(4): 7-9.

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Group B Streptococcus (GBS) are bacteria that live inside (or colonise) the gastrointestinal tract, bladder and / or throat of many people, including pregnant and labouring women. Estimates of the prevalence of colonisation range from 5% to 80% of the population (which shows, if nothing else, the difficulty with have with deducing some of these numbers).

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Info from Tommy's on testing and treatment

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Group B Strep (GBS) is a common type of bacteria; about 20% of women in the UK carry it. It is found in the vagina and bowel and is usually not harmful to women that carry it. It is very natural and normal to carry the GBS bacteria and it's not associated with any health risks for the carrier.

As the GBS bacteria can live in the vagina babies can come into contact with GBS after waters break and during the process of giving birth. Most will be unaffected, but a small number of babies (around 1 in 2000) can develop an infection as a result.

Symptoms of Group B Strep

The GBS bacteria do not produce any symptoms in women during pregnancy.

GBS infection in newborn babies

Most (two thirds) of the GBS infections in babies are early-onset, which means that the infection occurs in the first week of the baby's life, typically in the first 12 hours after birth. Late-onset GBS can occur seven days to three months after birth.

Most babies who become infected can be treated quickly and successfully. For some babies however, complications can develop as a result of the infection. These include blood poisoning (septicaemia), infection of the lung (pneumonia) and infection of the lining of the brain (meningitis). In the long term it can cause deafness, blindness, learning difficulties and cerebral palsy. Around 1 in 10 babies who have developed a GBS infection will die. Overall this is 1 in 17,000 babies born in UK and Ireland.

Is my baby at risk of GBS infection?

GBS infection is more likely if:

your baby is born prematurely, (before 37 weeks of pregnancy)

you have previously had a baby who developed GBS infection

you have a high temperature during labour

more than 18 hours have passed between your waters breaking and your baby being born.

Treatment for Group B Strep infection

Taking the risk factors above into account, NICE guidelines say that if you have any one of the following:

If you have had a baby before who has been infected with GBS

If you have had a test during any point in your current pregnancy that has shown you carry GBS

And/or if you have any two of the following:

If your waters break or you go into labour before 37 weeks of pregnancy

If your waters have broken for more than 18 hours by the time you have your baby

If you have a raised temperature in labour of more than 38⁰C during labour

You will be offered antibiotics during labour to help to prevent your baby from getting the infection. The antibiotics can't be taken before labour because the bacteria grows back very quickly and the protective effect may be gone by the time you give birth if you took them too soon. They are normally offered through intravenously (IV) for 15-30 minutes every four hours.

If your waters break after 37 weeks' of pregnancy then you will also be offered for your labour to be induced straight away rather than waiting for a period of time to see if you go into labour naturally.

Antibiotics specific to treating GBS are not offered if you are having a planned caesarean section because the bacteria lives in the vagina and the baby will not come into contact with it as long as your waters have not broken before the caesarean section.

GBS and water births

Water births have not been shown to make infection more likely and as the antibiotics are given every four hours it should be physically possible. However some hospitals are still reluctant to allow them, possibly because of the added complication of having a cannula in your arm for the IV. Therefore it will be highly dependent on your hospital and care team whether you can still have a water birth if you are being treated for GBS infection.

Find out more about having a water birth.

Treating GBS in a newborn baby

After your baby has been born they will be closely monitored for signs of infection. Most babies who are infected with GBS will show symptoms within 12 hours of being born. Your baby's heart rate, respiratory rate and temperature will be checked regularly. Your baby's general health will also be monitored. Health professionals will look at how well your baby is feeding, whether they are floppy or overly sleepy and how well they are breathing and settling. If there are any concerns about your baby's wellbeing then they will be seen by a neonatal doctor.

If GBS infection is suspected then tests will be carried out. These could be blood tests or testing some fluid from around your baby's spinal cord. They will be fully discussed with you at the time. It will be advised for your baby to have antibiotics straight away, even before test results are available. If the test results come back as negative or the baby no longer has any symptoms for 24 hours then the antibiotics will be stopped.
Whether or not your baby has a GBS infection, it is completely safe to continue to breastfeed.

Symptoms of GBS infection in babies

Some symptoms of GBS infection in babies include:

High or low temperature

Fast or slow heart rate

Not feeding well

Limpness or difficult to wake

Difficulty breathing

Grunting

Testing for GBS in pregnancy

At present, not every pregnant women in the UK is offered testing for GBS on the NHS. Only women who have risk factors above are offered testing and/or antibiotics.

If you are offered a test in pregnancy, then this is usually done by a vaginal swab, though it can also be detected in your urine.

If you have had a swab that shows that GBS is present, treatment (antibiotics) will still be held until labour. This is because the antibiotics in pregnancy will not reduce the chance of GBS being passed to your baby and GBS can return after the course of antibiotics has been finished. If, however, you develop a urine infection during pregnancy that has shown to be caused by GBS, then you will be offered antibiotics straight away to treat the infection.

Some women choose to pay to have a test privately if they don't meet the criteria to be offered it on the NHS. If you are thinking about this, talk with your midwife so you can discuss your options first. If you decide to go through with the test, the best time to have it done is between 35-37 weeks' of pregnancy. GBS can move around the gut and the test is only valid for about five weeks after it was taken. If the test is done earlier than this, it may not be valid by the time you go into labour.

Types of tests

There are different types of tests that can be used to detect GBS in pregnancy. The two main tests available in the UK are the Standard Direct Plating and the Enriched Culture Medium (ECM).

If you are offered testing through your NHS care it is likely to be the Standard Direct Plating test. A vaginal swab will be taken and sent to the laboratory, you should get results back a couple of days later.

A positive result is very reliable and will be recorded in your maternity notes; no matter how many weeks' pregnant you are when the test was done.
If you receive a negative result, no further action will be taken. It is possible to have a negative result but still be carrying GBS, but a repeat test would only be offered if you have developed risk factors in your pregnancy or labour.

The ECM test is not widely available on the NHS so most women would need to pay for this test privately. This test involves having two swabs taken, one vaginal and one rectal. These are sent away to a laboratory and you can expect to get the results back a few days later. This test is more sensitive at identifying GBS but it is not as effective at identifying other potential bacteria and viruses that maybe present and can still give a false result.

Why is GBS not routinely screened for?

Testing for GBS in pregnancy is often debated and these are the reasons given by the UK National Screening Committee and RCOG as to why testing is not currently offered as a routine to all pregnant women in the UK:

Currently there is no clear evidence that routine screening would do more good than harm

Many women carry the bacteria and, in the majority of cases, their babies are born safely and without developing an infection.

Screening all women late in pregnancy cannot predict which babies will develop GBS infection.

No screening test is entirely accurate. A negative swab test does not guarantee that you are not a carrier of GBS. In other words, you may be given a negative result when in fact you do carry GBS.

The majority of babies who are severely affected from GBS infection are born prematurely, before the suggested screening test would have happened.

Giving all carriers of GBS antibiotics would mean that a very large number of women at very low risk would receive treatment they do not need.

There is a risk to the general public from overuse of antibiotics leading to strains of bacteria becoming resistant.

The long term effects of antibiotic treatment in labour on the baby are unknown.

The amount of babies affected by GBS in the UK is the same as that in countries in which testing is a routine part of antenatal care.

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Group B Strep (GBS) is a common type of bacteria; about 20% of women in the UK carry it. It is found in the vagina and bowel and is usually not harmful to women that carry it. Find out how it affects your pregnancy.

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About Caesarean Birth

Caesarean surgery is lifesaving for some mothers and babies, and avoids problems for others. But in many cases it is not clear that the benefits outweigh the risks, particularly if the risks to any future pregnancies and births are taken into consideration. Across the country more than 1 in 4 babies are born by caesarean, and is some hospitals it is more like 1 in 3 women who will have surgery for the birth of their baby.

Most women do not want a caesarean unless it is clear that their baby really needs to be born that way, but other women know that a caesarean birth is best for them. Our national guidelines make it very clear that women's preferences need to be taken into account when a caesarean is being recommended to, or requested by, a pregnant woman.

What is the difference between a planned, elective and emergency caesarean?

Caesareans may be planned before labour starts and these can be referred to as planned or elective caesareans. Elective does not mean that the women has chosen or wants the caesarean; just that it is planned surgery.

Other caesareans may be unplanned. Unplanned caesarean are often also called emergency caesareans, this is because they had not been planned and the reason for them 'emerged' before or during labour. Only a small number of emergency caesareans are urgent and the term 'crash section' may be used to describe this urgent surgery. Most emergency caesarean are not urgent and there is time to agree what you want for the birth of your baby.

Can you make a caesarean birth plan?

As very few caesarean need to be done in a rush and many are planned well before the birth, there is usually time to consider what you want to happen when your baby is born. Most obstetricians are happy to work with women to make a caesarean birth a positive experience. It is usual for the baby's father and/or a birth supporter to be in theatre for the birth and for the parents to be able to greet their baby and have skin to skin contact, providing the baby is well.

Other options for the birth might include:

lowering the screen so the mother can see her baby born

the baby to be passed straight to its mother for skin to skin and breastfeeding

delaying cord clamping (usually about a minute, so less than optimal cord clamping)

facilitating resuscitation of the baby, if required, at the side of the operating table without cutting the cord

lotus birth may be supported

If you are having a planned caesarean and are not being supported with your birth plan you have a right to be referred to someone else who will. For more idea of what you might like for the birth see http://caesarean.org.uk/caesareanBirthPlan.html

Can you choose a caesarean birth?

Some women feel strongly that their baby should be born by caesarean and usually have a very good reason for why they feel this is best for them. Reasons may be psychological or physical, and both should be recognised as medical reasons for requesting the surgery. The NICE guidelines provide recommendations on how women who want a caesarean should be supported, including being referred for psychological support where there is a fear of birth, but ultimately being booked for a caesarean or referred to someone else who will. If you are struggling to get your needs for a caesarean respected then please see the page on {your right to specific treatment}, but you may also find this Birthrights fact sheet useful http://www.birthrights.org.uk/library/factsheets/Right-to-C-Section.pdf

Why might a planned caesarean be suggested?

Some reasons for caesarean to be suggested before labour are (and there are many others):

baby is in the breech position (bottom down)

twins or other multiples

previous caesarean(s)

placenta previa (placenta is over, or partly covering, the cervix at the end of pregnancy)

With the exception of placenta previa, which usually (although not always) means that a caesarean is the safest way to give birth, none of the above situations means that a caesarean is inevitable, and you do have the option to decline. This is the case for many situations where a caesarean is suggested. If you would prefer to explore your options, you are free to do so. The decision to accept the offer of a caesarean is always yours, and yours alone.

When a planned caesarean is recommended there is time to consider whether this is the best decision for you and your baby. This will be a very personal decision. Most women need not only to think about why the caesarean is being recommended, but also about the risk of the surgery and about what their personal priorities are for the birth of their baby. For some women a caesarean birth will be something they can accept happily, but for other they will need to explore every other option before they can agree to surgery.

Why might an unplanned caesarean be suggested?

A caesarean may be recommended before or during labour if an issue arises such as:

a baby is thought to be distressed

placental bleeding

the site of a previous uterine surgery may not be holding together well

Although you may have less time to consider your options when an issue of this sort arises you still have the right to make an informed decision. In order to give or decline consent, you should still be provided with information about:

why it is being recommended?

what are the risk of surgery?

what the options are if you decline?

What are the risks of a caesarean?

When a caesarean is suggested or requested information about the risks must be provided in order that you can give consent for surgery, just as it would be for any other surgery. Signing a consent form without this information makes that consent invalid, and there could be legal case to answer from any surgeon who has not obtained valid consent to carry out surgery. People will consider different risks or benefit to be more or less important when making their decision.

Caesarean surgery has risks that would be expected of any surgery such as:

bleeding

infection

blood clots

problems with the anesthetic

accidental and sometimes unavoidable damage to tissues and organs

In addition, caesarean births have other risks specific to a baby being born this way. Common post surgical problems include wound infections and adhesions. Less common ones include permanent nerve damage, bladder damage and hysterectomy.

Do babies miss out on being born vaginally?

When babies are born by caesarean they miss out on the journey through the birth canal. Often it is suggested that this is an advantage, but we now know that important things happen for the baby during this part of birth, including helping to prepare the baby to breathe and seeding the baby's gut with beneficial bacteria. Research has confirmed that babies born by caesarean are at greater risk of:

All of these issues seem to be related to missing this part of the birth process.

Can a baby be injured at a caesarean?

Is is uncommon for babies to be injured, but about 1 in 100 babies will be cut during a caesarean birth. Most these cuts are minor, though rarely babies have been seriously injured.

Might future pregnancies be affected?

When a caesarean is carried out the uterus will be damaged. Usually a small incision is made which is extended by tearing as tissue that has been torn apart and is a bit ragged heals better than a straight cut when it is stitched back together.

The scar on the uterus does not cause a problem for the majority of women, but it does increase the chance of some problems. It has been shown that it takes women longer to conceive another baby than women who have had vaginal births, and that more women will fail to conceive another baby.

Pregnancies following a caesarean have higher rates of placental problems such as placenta previa and an abnormally adherent placenta (placenta accreta, percreta and increta). These are serious issue increasing the risk for the baby and the women, and if an abnormally adherent placenta occurs then a highly skilled medical team will be required in order to minimise risk of bleeding and to try to avoid the need for a hysterectomy.
Uterine rupture is extremely rare when a woman's uterus has not been damaged, but after a caesarean a rupture occurs in about 1 in 500 [VBAC] labours.
What sorts of anesthetic would be used?

It is very rare today for a caesarean to be carried out under general anaesthetic and most are done using an epidural or spinal, or a combination of the two. You should be provided with printed information by your hospital about these anesthetics and what to expect. The following page gives information from the Obstetric Anaesthetists' Association about anesthetics used for caesareans http://www.labourpains.com/UI/Content/Content.aspx?ID=44

What sort of stitches will be used?

There are several different sorts of stitches used to close skin wounds. Dissolving and removal stitches or staples may be used, but the most common way caesarean scars are closed is with a single running stitch with a bead at each end. This is easily removed, usually about 5 days after the operation, by cutting a bead off one and pulling the stitch out in one piece. A midwife should be checking your wound until the stitches are removed and for longer if it has not healed completely when the stitches are removed. You wound should gradually feel less painful, but if it should become more red, sore or oozing, then you may have an infection and need to contact a doctor, as infections after a caesarean can become serious quickly. The following page has a collection of caesarean scar pictures http://www.caesarean.org.uk/ScarPics.html

There will also be internal stitches that have been used to repair your uterus and the tissue around it, these will dissolve in time and rarely cause women a problem, although some women may find that a stitch comes out in the lochia.

How long will it take me to recover physically?

How quickly women recover from a caesarean varies enormously and you are going to be the best judge of what you are ready to do. This will include when you are ready to leave hospital. Many women are very keen to get home, but other feel that they are being rushed to free up a bed. If you do not feel ready to go home then make sure that the staff know this whether it is because you are still in pain, feel unwell or have no one to help you when you get home.

Over the weeks after a caesarean you should gradually find you have less pain and are able to do more. However, it is quite common to find that bleeding or pain may increase following a sudden increase in how much you are doing. If you do not feel you are recovering properly then you have a right to see the midwife or your obstetrician even if it is weeks or months after the birth.

What are the emotional effects of a caesarean birth?

Most women struggle a bit emotionally after a caesarean even if they are very happy to have had a caesarean birth, but many women are left struggling with trauma or grief about the birth which can be very hard to reconcile with the delight with their new baby. Understanding what happened, why it happened to them, and what they might or might not have been able to do differently are often key to recovering. Postnatal depression is more common after a caesarean, and some {women suffer with PTSD}. You have a right to help from your health professionals, but women often find the women's support group are helpful in their recovery.

Women who have had an unplanned caesarean or a problem during the surgery may want talk to someone about what happened. You can make an appointment to see your obstetrician or one of the senior midwives. You may want to get a copy of your notes and if you are unhappy with your care then it is probably a good idea to do this before arranging a meeting. Some women prefer to talk through their birth with someone from outside the Trust, perhaps an independent midwife. AIMS will help to support you if you wish.

Articles that may be of interest
Journal Vol. 22, No. 2 Caesarean Birth
Further Reading
AIMS Birth after Caesarean Caesarean Birth: Your Questions Answered
Written by: Debbie Chippington Derrick
Reviewed by: Emma Ashworth
Reviewed on: 19/08/2017
Next review needed: 19/08/2019

AIMS does not give medical advice. Our website provides evidence-based information to support informed decision-making. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

If you found this information page helpful please consider making a donation to support the work of AIMS. We are a small charity that accepts no commercial sponsorship, in order to preserve our reputation for providing impartial, evidence-based information. You can make donations at Peoples Fundraising. To become an AIMS member or join our mailing list see Join AIMS
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
Published on 26th July 2017

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Caesarean birth - AIMS looks at the pros and cons and your rights around this form of birth.

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Considering a caesarean birth patient information leaflet | RCOG

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This information is for you if you are considering a planned (elective) caesarean birth for your baby. It may also be helpful if you are a partner, relative or friend of someone who is considering a caesarean birth.

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This guideline covers circumstances, methods and monitoring for inducing labour in pregnant women to avoid a pregnancy lasting longer than 42 weeks (known as a prolonged pregnancy) or if a woman's waters break but labour does not start. It aims to improve the advice and care provided to women considering and undergoing induction of labour in hospital-based maternity units, midwifery led units and at home.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals

Commissioners and providers

Pregnant women, their families and carers

Is this guideline up to date?

We checked this guideline in January 2017 and we are updating the recommendations on:

induction of labour in specific circumstances - suspected fetal macrosomia

recommended methods for induction of labour

methods that are not recommended for induction of labour

See the guideline in development page for progress on the update.

Guideline development process
How we develop NICE guidelines
This guideline updates and replaces NICE inherited clinical guideline D (June 2001).

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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This guideline covers circumstances, methods and monitoring for inducing labour in pregnant women to avoid a pregnancy lasting longer than 42 weeks (known as a prolonged pregnancy) or if a woman's waters break but labour does not start.

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The myth of cardiotocography

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Photo by Josh Willink on Pexels.com

Most of the focus of this blog is about the use of CTG monitoring during labour. A summary of the evidence about intrapartum CTG monitoring can be found here, here, here, and here. A summary of the evidence about admission CTGs can be found here. But what about using CTG monitoring during pregnancy? In this post I summarise the evidence which was systematically reviewed for Cochrane by Grivell et al. (2015).

Antenatal monitoring for women considered to be at risk

Research regarding the use of CTG monitoring in the antenatal period has focused exclusively on the use of CTG monitoring for women with pregnancy complications (such as pre-eclampsia) or women with other risk factors for poor perinatal outcome (such as reduced fetal movements or a suspected small baby). There have been six randomised controlled trials, including 2,105 women, which were conducted between 1982 and 1997. In two of these trials the comparison was between standard (clinician interpretation only) CTG and computer assisted CTG interpretation (Bracero et al., 1999; Steyn & Odendaal, 1997), three compared CTG monitoring with the findings revealed to the treating team against CTG monitoring with the findings concealed (Brown et al., 1982; Flynn et al., 1982; Kidd et al., 1985), and the remaining trial compared CTG monitoring with no CTG monitoring (Lumley et al., 1983). It is important to note that the comparator here was not intermittent auscultation, and the trials were conducted during a period where there was less use of ultrasound assessment of fetal wellbeing.

Placing the research into context

By 1982, when the first of the trials regarding antenatal CTG monitoring was published, five RCTs had been conducted examining the use of intrapartum CTG monitoring (Haverkamp et al., 1979; Haverkamp et al., 1976; Kelso et al., 1978; Renou et al., 1976; Wood et al., 1981), with four showing no benefit to the fetus. Despite this mounting evidence that CTG monitoring was not able to achieve the goals it seemed to promise, clinicians were expanding the use of CTG monitoring into the antenatal period. In 1983, Lumley et al., said that antenatal CTG monitoring "has become an established procedure for the management of the high-risk pregnant woman and has been extended to the entire obstetric population in a few centres" (p. 1018). There are many such examples of the triumph of hope over reality in relation to CTG monitoring research.

After a flurry of research activity over the three-year period of 1982 to 1985, the research comparing antenatal CTG monitoring with no monitoring (or where the results were blinded to clinicians) stopped and was not picked up again. The remaining two papers in the 90s didn't aim to demonstrate whether or not antenatal CTG monitoring was of benefit, but asked whether adding computer interpretation of the trace to CTG monitoring would improve outcomes.
How might antenatal CTG monitoring work?
Before examining the details of the research findings, it is worth stopping for a moment and asking about the mechanism by which antenatal CTG monitoring might be able to modify perinatal outcomes. Knowing this helps to understand what outcome measures to look at in the research. For example, a finding that women with abnormal fetal heart rate patterns experienced a poor perinatal outcome more often than women with normal patterns, while interesting, does not demonstrate that knowing that the fetal heart rate pattern is abnormal leads to a change in management, nor that changing her care ultimately leads to a better outcome.

The use of antenatal CTG monitoring is based on an assumption that there is a period of time preceding stillbirth or neurological injury in which the fetal heart rate pattern will be abnormal. By identifying fetuses with this particular abnormal pattern, prompt birth is recommended to prevent stillbirth or long-term neurological damage. This assumes that there is a predictable, meaningful, pattern of abnormality that reliably proceeds damage to the fetus (which is yet to be demonstrated in research).
Antenatal CTG monitoring with the findings revealed vs CTG monitoring with the findings concealed or no CTG
All the four studies that compared CTG use with no CTG, or concealed the findings from clinicians were considered to be of poor quality, and were small, with a total of 1,627 women in the studies. There were no statistically significant differences in the caesarean section rate, gestational age at birth, the use of induction of labour, low Apgar scores at five minutes of age, or in the rate of admission to a neonatal nursery. The absence of a difference in caesarean sections and inductions of labour might be because clinicians didn't act on the additional information available from the CTG, or (as is highly likely) the size of the research was simply to small to detect a difference if there actually was one. There was also no significant difference in the rate of seizures (occurring in 1 of 144 babies with CTG monitoring antenatally and 2 of 156 babies who were not exposed to CTG monitoring). The incidence of long term neurological outcomes were not measured, nor were women's experiences with antenatal CTG monitoring.

The perinatal mortality rate for babies who had received antenatal CTG monitoring was 23 per 1000 births and was only 11 per 1000 births when CTG monitoring was NOT used. CTG monitoring was therefore associated with a doubling of the perinatal mortality rate (RR 2.05, 95% CI 0.95 - 4.42), however the small number of babies in the population means that the research was underpowered and therefore not able to demonstrate a statistically significant difference, even if CTG use really does double the rate of deaths. When only babies without significant congenital abnormalities were considered, the mortality rate was two and a half times lower when CTG monitoring was NOT used (6 per 1000 compared to 17 per 1000 births when CTG monitoring was used). This once again came close to, but did not achieve statistical significance (RR 2.46, 95% CI 0.96 - 6.3).

Computerised vs standard CTG monitoring

It is worth first pointing out that the two studies which examined computer assisted CTG interpretation were both done in the 1990s, when the technology available was rather primitive compared to what is now commercially available for intrapartum use (Bracero et al., 1999; Steyn & Odendaal, 1997). In addition, while the quality of the studies was better (rated as moderate), the size of the studies was small, with only 469 women. As a consequence, caution should be taken in generalising these findings to current practice.

No significant differences were found in the caesarean section rate, low Apgar scores at five minutes of age, gestational age at birth, or the length of stay in the nursery. Again, no data were collected about long term neurological outcomes, or women's experiences of monitoring. The perinatal mortality rate was 9 per 1000 births in babies who had been monitored with the computerised CTG and 43 per 1000 for standard CTG monitoring, a statistically significant difference (RR 0.2, 95% CI 0.04 - 0.88). When babies with congenital abnormalities were excluded, the perinatal mortality rate was 4 per 1000 with computerised CTG monitoring and 26 per 1000 births for standard CTG monitoring, which was no longer statistically significant (RR 0.23, 95% CI 0.04 - 1.29).

Summing up

Rather than providing firm support for the use of antenatal CTG monitoring for women who are considered to be a high risk for a poor perinatal outcome, the research suggests that CTG monitoring may possibly cause harm. I find it curious that in the face of evidence suggesting a trend towards a higher mortality rate, further research was not conducted, and that antenatal CTG monitoring has continued to be used. The assumption that CTG monitoring works is so strong, it seems that researchers may have been anxious to avoid pursuing further research which might have definitively undermined this faith.

I am equally curious as to why computerised CTG monitoring for antenatal use was not mandated on the back of the evidence of a reduction in perinatal mortality rates, or at least provided the impetus for a large, multi-centre trial, adequately powered to address whether the findings from these small studies could be relied upon in practice. Given the obstetric love of all things technological, I am at a loss to explain why this has not been revisited in the past twenty years. The question of whether computer assisted CTG monitoring is associated with a reduction in perinatal mortality compared to no CTG monitoring also remains unanswered.

There is one particular corner of clinical practice where current antenatal fetal monitoring practices make me more uncomfortable than any other: the use of CTG monitoring for women who present with concerns about reduced fetal movements. Women with this concern were included within the populations studied in the RCTs summarised here. At best, CTG use in this population is useless at preventing harm, and at worst, might actually lead to higher rates of death. The mechanisms for this are not currently known. Perhaps women and their clinicians place misguided faith in the CTG output rather than taking more timely action? Any policies regarding the management of women with reduced fetal movements must require a comprehensive assessment of the woman, including ultrasound scanning. "I'll just pop on a quick CTG and see if the baby is happy" is not an evidence-based assessment approach, and may do harm.

Burying our collective heads in the CTG sand while pretending that CTG monitoring is an effective tool is preventing us from doing the research we need to address the really important questions of how best to care for women during the antenatal period and during labour to prevent the death or damage of their baby from low oxygen levels.
References
Bracero, L. A., Morgan, S., & Byrne, D. W. (1999). Comparison of visual and computerized interpretation of nonstress test results in a randomized controlled trial. American Journal of Obstetrics and Gynecology, 181(5 Pt 1), 1254-1258.

Brown, V. A., Sawers, R. S., Parsons, R. J., Duncan, S. L. B., & Cooke, I. D. (1982). The value of antenatal cardiotocography in the management of high-risk pregnancy: a randomized controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology, 89(9), 716-722.

Flynn, A. M., Kelly, J., Mansfield, H., Needham, P., O&apos;Conor, M., & Viegas, O. (1982, Jun). A randomized controlled trial of non-stress antepartum cardiotocography. BJOG: An International Journal of Obstetrics and Gynaecology, 89(6), 427-433.

Grivell, R. M., Alfirevic, Z., Gyte, G. M. L., & Devane, D. (2015). Antenatal cardiotocography for fetal assessment. Cochrane Database of Systematic Reviews, 9, CD007863.

Haverkamp, A. D., Orleans, M., Langendoerfer, S., McFee, J. G., Murphy, J., & Thompson, H. E. (1979). A controlled trial of the differential effects of intrapartum fetal monitoring. American Journal of Obstetrics and Gynecology, 134(4), 399-412.

Haverkamp, A. D., Thompson, H. E., McFee, J. G., & Cetrulo, C. (1976, Jun 01). The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy. American Journal of Obstetrics and Gynecology, 125(3), 310-320.

Kelso, I. M., Parsons, R. J., Lawrence, G. F., Arora, S. S., Edmonds, D. K., & Cooke, I. D. (1978). An assessment of continuous fetal heart rate monitoring in labor. A randomized trial. American Journal of Obstetrics and Gynecology, 131(5), 526-532.

Kidd, L. C., Patel, N. B., & Smith, R. (1985, Nov). Non-stress antenatal cardiotocography-a prospective randomized clinical trial. BJOG: An International Journal of Obstetrics and Gynaecology, 92(11), 1156-1159.

Lumley, J., Lester, A., Anderson, I., Renou, P., & Wood, C. (1983). A randomized trial of weekly cardiotocography in high-risk obstetric patients. BJOG: An International Journal of Obstetrics and Gynaecology, 90(11), 1018-1026.

Renou, P., Chang, A., Anderson, I., & Wood, C. (1976). Controlled trial of fetal intensive care. American Journal of Obstetrics and Gynecology, 126(4), 470-476.

Steyn, D. W., & Odendaal, H. J. (1997). Routine or computerized cardiotocography in severe preeclampsia? A randomized controlled tiral. Journal of Maternal Fetal Investigation, 7, 166-171.

Wood, C., Renou, P., Oats, J. J. N., Farrell, E.-M. E., Beischer, N., & Anderson, I. (1981). A controlled trial of fetal heart rate monitoring in a low-risk obstetric population. American Journal of Obstetrics and Gynecology, 141(5), 527-534.

Categories: Basics, CTG, EFM, Obstetrics, Perinatal brain injury, Perinatal mortality, Stillbirth

Tags: antenatal CTG, computerised interpretation

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Does antenatal CTG monitoring save lives?

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Most of the focus of this blog is about the use of CTG monitoring during labour. A summary of the evidence about intrapartum CTG monitoring can be found here, here, here, and here. A summary of the evidence about admission CTGs can be found here. But what about using CTG monitoring during pregnancy?

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Our panel of health writers

The Bishop score is used to assess the ripeness of your cervix. Your midwife will need to find this out before inducing labour because it helps to tell whether your body is ready to go into labour.

Your Bishop score is based on the findings of a vaginal examination by your midwife. With a gloved finger, she'll assess the condition and position of your cervix and work out where your baby is in relation to certain points on your pelvis. Your Bishop score is based on the following factors:

how dilated your cervix is (the more open the better)

how short your cervix is (the shorter the better)

how far down in your pelvis your baby's head or bottom is (the lower down the better)

the consistency of your cervix, whether it is firm or soft (the softer the better)

the position of your cervix, whether pointing backwards or pointing forwards (pointing forwards is better)

A score of eight or more indicates that your cervix is ripe and ready for labour.
A Bishop score of less than six indicates an unripe cervix. About 15 per cent of attempted inductions that start with an unripe cervix fail to work.

If you have a low Bishop score, you may decide you don't want to try any induction methods. You'll have the option to wait and see if labour starts naturally. Or you may opt for a caesarean. Your midwife or doctor will discuss your situation with you and your birth partner, to help you make the decision that's right for you and your baby.

You can also take this approach once the induction process has started. If prostaglandins (a hormone-like substance that causes your cervix to ripen) are used as a first step to get your labour started, your midwife will calculate your Bishop score again after a set time.

If your Bishop score is still low, and your labour hasn't started or progressed, you can decide whether you want to carry on trying with stronger interventions, such as a Syntocinon drip, or have a caesarean. Or, if it's safe to do so, you may want to give yourself some more time to allow your labour to start naturally.

References

Laughton SK, Zhang J, Troendle J, et al. 2011. Using a simplified Bishop score to predict vaginal delivery. Obstet Gynecol 117(4):805-11. www.ncbi.nlm.nih.gov [Accessed January 2015]

NCCWCH. 2008. Induction of labour. National Collaborating Centre for Women's and Children's Health, Clinical guideline. London: RCOG Press. www.nice.org.uk [Accessed January 2015]

NICE. 2008. Information for the public: induction of labour. National Institute for Health and Clinical Excellence. www.nice.org.uk [Accessed January 2015]

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Our panel of health writers The Bishop score is used to assess the ripeness of your cervix. Your midwife will need to find this out before inducing labour because it helps to tell whether your body is ready to go into labour. Your Bishop score is based on the findings of a vaginal examination by your midwife.

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Obstetric Anaesthetists’ Association Guide to types of pain relief available in labour

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Obstetric Anaesthetists’ Association Guide to types of pain relief available in labour

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NHS information about perineal tearing and episiotomy

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NHS information about perineal tearing and episiotomy

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Sometimes a doctor or midwife may need to make a cut in the area between the vagina and anus (perineum) during childbirth. This is called an episiotomy.

An episiotomy makes the opening of the vagina a bit wider, allowing the baby to come through it more easily.

Sometimes a woman's perineum may tear as their baby comes out. In some births, an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly.

If your doctor or midwife feels you need an episiotomy when you're in labour, they will discuss this with you. In England, episiotomies are not done routinely.

Up to 9 in 10 first-time mothers who have a vaginal birth will have some sort of tear, graze or episiotomy.

The National Institute for Health and Care Excellence (NICE) recommends that an episiotomy might be done if:

If you have a tear or an episiotomy, you'll probably need stitches to repair it. Dissolvable stitches are used, so you will not need to return to hospital to have them removed.

Recovering from an episiotomy

Episiotomy cuts are usually repaired within an hour of your baby's birth. The cut may bleed quite a lot at first, but this should stop with pressure and stitches.

Stitches should heal within 1 month of the birth. Talk to your midwife or obstetrician about which activities you should avoid during the healing period.

Coping with pain

It's common to feel some pain after an episiotomy.

Painkillers such as paracetamol can help relieve pain and is safe to use if you're breastfeeding.

It's also thought to be safe to take ibuprofen while you're breastfeeding, but check with your doctor first.

Aspirin is not recommended as it can be passed on to your baby through your breast milk. Your midwife will advise you if you're not sure what painkillers to take.

It may be necessary to treat severe pain with stronger prescription-only painkillers, such as codeine.

However, prescription-only medicine may affect your ability to breastfeed safely. Your GP or midwife can advise you about this.

To ease the pain, try placing an ice pack or ice cubes wrapped in a towel on the cut. Avoid placing ice directly on your skin as this could cause damage.

Exposing the stitches to fresh air can help the healing process. Taking off your underwear and lying on a towel on your bed for around 10 minutes once or twice a day may help.

It's unusual for pain after an episiotomy to last longer than 2 to 3 weeks. If the pain lasts longer than this, speak to a doctor, health visitor, or another health professional.

Going to the toilet

Keep the cut and the surrounding area clean to prevent infection. After going to the toilet, pour warm water over your vaginal area to rinse it.

Pouring warm water over the outer area of your vagina as you pee may also help ease the discomfort.

You may find squatting over the toilet, rather than sitting on it, reduces the stinging sensation when peeing.

When you're pooing, you may find it useful to place a clean pad on the cut and press gently. This can help relieve pressure on the cut.

When wiping your bottom, make sure you wipe gently from front to back. This will help prevent bacteria in your anus infecting the cut and surrounding tissue.

If you find pooing is particularly painful, taking laxatives may help. This type of medicine is usually used to treat constipation and makes poo softer and easier to pass.

For more information, read about treating constipation.

Pain during sex

There are no rules about when to start having sex again after you've given birth.

In the weeks after giving birth, many women feel sore as well as tired, whether they've had an episiotomy or not. Do not rush into it. If sex hurts, it will not be pleasurable.

If you've had a tear or an episiotomy, pain during sex is very common in the first few months.

If penetration is painful, say so. If you pretend everything is OK when it is not, you may start to see sex as a nuisance rather than a pleasure, which will not help you or your partner.

You can still be close without having penetration - for example, through mutual masturbation.

Pain can sometimes be linked to vaginal dryness. You can try using a water-based lubricant available from pharmacies to help.

Do not use an oil-based lubricant, such as Vaseline or moisturising lotion, as this can irritate the vagina and damage latex condoms or diaphragms.

You can get pregnant just 3 weeks after the birth of a baby, even if you're breastfeeding and your periods have not started again.

Use some kind of contraception every time you have sex after giving birth, including the first time (unless you want to get pregnant again).

You'll usually have an opportunity to discuss your contraceptive options before you leave hospital (if you've had your baby in hospital) and at the postnatal check.

You can also talk to a GP, midwife or health visitor, or go to a contraception clinic at any time.

Find sexual health services near you.

Infection

Look out for any signs that the cut or surrounding tissue has become infected, such as:

red, swollen skin

discharge of pus or liquid from the cut

persistent pain

an unusual smell

Tell a GP, midwife or health visitor as soon as you can about any possible signs of infection so they can make sure you get the treatment you might need.

Exercises

Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help with healing and will reduce the pressure on the cut and surrounding tissue.

Pelvic floor exercises involve squeezing the muscles around your vagina and anus as though to stop yourself from going to the toilet or farting.

A midwife can explain how to do the exercises. You can also read more about pelvic floor exercises on our page about exercise in pregnancy.

Scar tissue

For a few women, excessive, raised or itchy scar tissue forms around the place where a tear happened or where an episiotomy was done. If your scar tissue is causing problems for you, tell your doctor.

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Find out about an episiotomy (a cut between the vagina and anus), including why it might be done during childbirth, how long it takes to heal, and how to prevent a perineal tear.

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10 things every woman should know about induction.

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10 things every woman should know about induction.

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NCT's pages on C-Birth

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What is a caesarean birth?

Caesarean birth is when a baby is born by abdominal surgery. Around a third of babies in the UK are born by caesarean (NHS Digital, 2021). Some are planned, while others are unplanned caesareans.

To find about more about when a planned or unplanned caesarean may be offered and the different things you might want to consider, read our article.

Planning for a caesarean birth

A planned or 'elective' caesarean usually takes place after 39 weeks of pregnancy, when a baby's lungs are developed, to reduce the chances of your baby having any breathing problems immediately after birth (NICE, 2021). However, there may still be health factors to consider that will mean your midwife or doctor may suggest a planned birth earlier than 39 weeks (NICE, 2021).

If you are carrying twins or triplets, your doctor or midwife will discuss your particular circumstances, and the type and timing of the birth with you. This may include a planned caesarean as early as 32 weeks for the most complicated situations (NICE, 2019).

What will happen before my planned caesarean?

If you are planning to have a caesarean birth, you will have the opportunity to discuss your decision and birth preferences with your midwife and doctor.

You will be offered an appointment about a week before the planned date to discuss the procedure and you will be given medication to take before the operation. This could include antibiotics, anti-sickness medication, or anti-acid medication (NHS, 2019a).

You will also be offered a blood test to check for anemia and determine your blood group (NICE, 2019, 2021a).

You will be asked to sign a written consent form. The information should always be presented to you in a way which you can understand (NICE, 2021; RCOG, 2015). This is your chance to ask any questions, and have time to consider the answers, before you sign the consent form (NHS, 2019a).

You'll be given a time to arrive at hospital and asked not to eat for a few hours before the surgery, although isotonic drinks may be recommended (NHS, 2019a; NICE, 2021). Surgery may not take place for several hours after your arrival time, depending on how many other planned and unplanned caesareans are being performed that day. Some parents take things to keep themselves entertained in this time, and this is also an opportunity to ask any more questions you might have.

When you arrive at hospital, a midwife will check you have taken the medication given to you at your pre-operative appointment and may recommend pressure stockings to reduce the risk of deep vein thrombosis and pulmonary embolism (when an artery in the lungs is blocked by a blood clot that has travelled from elsewhere in the body).

You'll often meet the anesthetist first to discuss your options. A regional (spinal) anesthetic is most common (OAA, 2022) but some caesareans are performed under general anesthetic.

What happens just before I go into theatre?

You will be given a gown to put on for theatre, and a name band for your wrist or ankle. Your birth partner will be invited to change into theatre scrubs as well.

Once in theatre, your blood pressure, pulse and temperature will be checked, and your baby's heartbeat will be monitored. You will be asked to confirm your name and date of birth (OAA, 2022).

Your birth partner may be directed where to sit and asked to avoid certain areas of the room to minimise the chance of infections (OAA, 2022).

Regional (spinal) anesthetic is most commonly used during caesarean birth. You will be invited to sit or lie on your side, curling your back. The anesthetist will spray the area with a sterilizing solution before administering a local anesthetic to numb the lower back. The spinal anesthetic is then administered, but it may take a few minutes to get it in the right place.

Some people describe the sensation as tingly or like a small electric shock, and as the drug takes effect the legs and lower body begin to feel very heavy and warm. The anesthetist will be monitoring how you are feeling and can provide treatment if you feel sick or dizzy (OAA, 2022).

Once the anaesthetic has been administered in theatre, a catheter will be inserted into your bladder to drain urine away and a drip will be put into your arm to provide fluids and any medication, such as antibiotics.

The incision for your caesarean birth will be made around the area where pubic hair grows. If there is any hair in this area, it will be shaved off before the birth (NHS, 2019; OAA, 2022). It is not recommended to do this yourself in advance, as research shows this leads to a higher chance of wound infection (Ng et al, 2013).

Caesarean under general anaesthetic

Around 9 in 100 caesarean births are performed under general anaesthetic (Bamber et al, 2020). Some women chose this due to an extreme fear of needles (OAA, 2022) while medical reasons could include allergies, clotting issues, or spinal problems (OAA, 2022; NHS, 2019a).

A general anaesthetic might also be used if your baby needs to be born quickly (OAA, 2022).

During a general anaesthetic your birth partner may not be allowed to be present in the operating theatre (OAA, 2022). They can wait in recovery and will be able to look after the baby and have skin to skin contact while you come out of theatre. If your baby needs to be taken to special care for any reason, your birth partner may be invited to join them.

What happens during a caesarean?

The procedure is similar whether the caesarean is planned or unplanned.

Don't be surprised if there are a lot of people in the operating theatre. Depending on the reason for your caesarean, staff might include:

midwife(ves)

two obstetricians

a theatre nurse and an assistant

an anaesthetist and an assistant

paediatrician (a doctor specialising in children)

If you're awake during the procedure, a screen is usually put up so you and your birth partner can't see the operation. If you prefer, you can ask to have the screen lowered when your baby is being born.

Your birth preferences, like playing music in theatre, or silence so your voice is the first your baby hears, should be accommodated where possible.

During the procedure you will be slightly tilted on to your side and may be aware of the sounds of the instruments being moved around, and of the suction of fluids from around the baby. This is completely normal.

You shouldn't feel any pain during the operation, but you might feel some pressure. You might also feel some mildly uncomfortable, rather than painful, sensations. Some women have said it feels like 'having someone doing the washing-up in my tummy'. Generally, the anaesthetist will talk to you during the operation and give you more pain relief if you need it.

If you've had a general anaesthetic, you won't be aware of anything until you're awake. This will usually be in the recovery room rather than the operating theatre.

When will I meet my baby for the first time?

If you're awake and your baby is well, you can cuddle and have skin-to-skin contact straight away. Your partner can also do this if you prefer.

You can also choose delayed or optimal cord clamping. Waiting to clamp the cord can provide the baby with a higher iron level after birth. If possible, it's good to discuss your preferences with your obstetrician before your operation.

If you have a general anaesthetic and your baby is well, they might be given to your birth partner for skin-to-skin contact in another room near the operating theatre.

Sometimes you will be able to have assisted skin-to-skin contact in the operating theatre, even if you're not awake. Your baby can be placed on your chest and supported by a midwife while your wound is stitched.

If your baby needs any help breathing, or has other problems, they may be taken to the special care baby unit (Labour Pains 2018).

Will happens if I need an unplanned caesarean?

An unplanned caesarean (sometimes called an emergency caesarean) takes place during labour, or before labour starts if an unexpected medical problem comes up.

If there are immediate concerns for you or your baby, an emergency caesarean will usually be performed within 20-30 minutes, although this only occurs in around 1 in 10 unplanned caesarean births (NICE, 2021; OAA, 2022).

If there are no immediate concerns, it could take up to 75 minutes from when the decision is made, and the preparation will be very similar to that of a planned caesarean (NICE, 2021). You will be asked to sign a written consent form, but in an emergency, verbal consent is sufficient (NICE, 2021; RCOG, 2015). Partners cannot sign the form instead of the woman, even if she is unconscious (Birthrights, No date).

If your caesarean is unplanned and you've already had an epidural during labour, this is usually topped up. Occasionally, an epidural alone is not sufficient, in which case other options include a combination epidural and spinal block, or a general anaesthetic (OAA, 2022).

What happens after a caesarean?

While you're staying in hospital you will be given pain relief. You should also be able to have close contact with your baby and start breastfeeding, if you would like to - some people even start doing this in theatre or the recovery room. You should be offered infant feeding support as soon as possible after the birth of your baby.

You'll be encouraged to get out of bed when you feel able to and to eat and drink as soon as you want to. You won't be able to drive for a few weeks, so you will need to arrange transport home.

You should receive advice on looking after your wound at home, and on taking any painkillers you may need during the recovery period.

You can read more about other aspects of caesarean birth in some of our related articles.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

For statistics on your local hospital's caesarean section rates, see which birth choice.

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Having a caesarean: what to expect | Labour & birth, Different types of birth articles & support | NCT

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Knowing what happens during a caesarean and immediately after can help you feel more prepared. Here, we explain what happens before the operation, the difference between planned and unplanned caesareans, the anaesthetic used, and what happens afterwards.

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An exercise to help illustrate how one intervention can lead to another.

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Sometimes, when the second stage of labour is very long, an assisted birth is suggested because:

The baby needs a little help to move out of the birth canal, particularly if they are lying in the back-to-back position.

There are concerns about you or your baby.

You are exhausted.

You are unable to push, perhaps after an epidural, or because you have a condition that prevents you from doing so.

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Assisted birth: A helping hand - NCT Matters

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Sometimes, when the second stage of labour is very long, an assisted birth is suggested because: The baby needs a little help to move out of the birth canal, particularly if they are lying in the back-to-back position. There are concerns about you or your baby. You are exhausted.

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Why it might be offered and how it happens.

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You feel like you've swallowed a whole watermelon and getting anywhere feels like a feat of Herculean proportions. Your baby must surely be ready to come out, right?

You're definitely not alone if you've been focusing on your due date throughout your pregnancy and counting down to it in the latter stages. And it's understandable that you might feel disappointed or worried if you go past that date with no sign of your baby.

So when might you be offered treatment for an overdue baby and what happens? Well, the story starts with the due date...

When is a baby overdue or late?

Pregnancy normally lasts about 40 weeks, and that's when it's called a full-term pregnancy or term. This is calculated as 280 days from the first day of your last menstrual period (IQWiG, 2018).

A pregnancy that continues for longer than 42 weeks is called post-term, prolonged or overdue (IQWiG, 2018). Many heavily-pregnant, exhausted mums-to-be have a few choice names for it themselves!

How accurate are due dates?

It depends. Using early ultrasound scans rather than the date of the last menstrual period can be a better way to predict your due date (Whitworth et al, 2015). One study suggested that 55% of women gave birth within seven days either side of the due date predicted by ultrasound, and 70% of women gave birth within 10 days either side of that date (Mongeli et al, 1996).

When pregnancies are dated by ultrasound (and not induced), one study suggested that 7% of pregnancies progress beyond 294 days (42 weeks) and 1.4% beyond 301 days (43 weeks) (Mandruzatto, 2010).

Why are some babies overdue or late?

We don't fully understand why some babies are overdue. You might be more likely to have an overdue baby if you're older, heavier, more educated, expecting your first baby or having a boy (Oberg et al, 2013). You're also more likely to have an overdue baby if your mum or sister had this too (Oberg et al, 2013).

What is a membrane sweep?

If your baby is overdue, the first thing you might be offered is a membrane sweep. The membrane sweep makes it more likely that you will go into labour naturally. So it reduces the chances you'll need to have your labour induced by other means, such as oxytocin or prostaglandins.

If this is your first pregnancy, you should be offered a membrane sweep at your 40 and 41 week appointments. If you've already had a baby before, you will be offered a sweep at your 41 week appointment (NICE, 2008a).

Although a sweep is offered, you don't have to accept the offer. Healthcare professionals should support you in whatever decision you make (NICE, 2008a).

What happens during a membrane sweep?

During a sweep, the midwife will put a finger inside your vagina to reach the cervix. They will make a circular or sweeping movement with their fingers. The point of it is to separate the sac surrounding your baby from the cervix. Doing a sweep helps to release natural hormones that stimulate contractions, so it may get labour started. A membrane sweep can be uncomfortable for some women and there may be some vaginal bleeding afterwards (Tommy's, 2015).

Membrane sweeps have been shown to increase the likelihood of either spontaneous labour within 48 hours or delivery within one week. They are generally safe where there are no other complications.

Membrane sweeps can be uncomfortable, and can cause bleeding and irregular contractions. You have to consider these factors against being more likely to need a more formal method of induction later down the line.

How likely is a membrane sweep to start labour?

Just because you have a membrane sweep, it doesn't mean that labour will happen spontaneously. In fact, only one out of eight women who have a membrane sweep avoid formal induction of labour (Boulvain et al, 2005).

If labour doesn't start after this process, you can have multiple sweeps or you may be offered an induction of labour by other means.

Can I do anything to start labour myself?

For mums who'd prefer to have some control over the process, there are traditional ways of trying to induce labour at home. See more in our article about whether you can really kick-start your own labour or not.

What is induced labour?

Labour is a natural process that usually starts on its own. But sometimes labour needs to be started artificially. This is called 'induced labour' (NICE, 2008a).

When and why would I be offered an induction?

Induction of labour is offered in the following conditions:

If a pregnancy lasts longer than 42 weeks, because of the increased risk of stillbirth and complications of labour.

If an expectant mum's waters break but labour does not start.

If you have specific conditions, such as diabetes, high blood pressure, obstetric cholestasis or pre-eclampsia.

If there are concerns about the growth of your baby and your healthcare team feel this would be the safest option for you and your baby.

You are also likely to be offered an induction of labour in the tragic event of your baby dying in the womb.

In special circumstances, induction may be considered at the mum's request.

(NICE, 2008; Thomas et al, 2014).

Around 95% of women who are full term and whose waters break will go into labour within the next 24 hours (Middleton, 2017). If you're not in labour after 24 hours of your waters breaking, you should be offered a choice of induction or waiting for labour to start naturally (expectant management) (NICE, 2008a).

If after 24 hours you're still not in labour, your baby may have a lower risk of infection and of being admitted to a neonatal unit if you're induced (Middleton, 2017).

What happens in an induction of labour?

Induction of labour can be carried out in a hospital maternity unit in different ways.

One way is by inserting hormones such as prostaglandins as a tablet (pessary) or gel into the vagina. Prostaglandins are hormones produced in the body (Thomas et al, 2014). Prostaglandins are used in inductions to encourage the cervix to soften, shorten and open, and the uterus to start to contract regularly (Thomas et al, 2014).

Contractions after vaginal prostaglandins have been inserted usually begin within a few hours, reaching a peak after five to six hours (NICE, 2008a). They increase the likelihood of vaginal birth within 24 hours (Thomas et al, 2014).

Many hospitals may be happy for you to go home after the procedure if you are induced via a pessary, tablet or gel (Sharp et al, 2016). They should let you know who to contact if you have any concerns (NICE, 2014). If you don't begin to have contractions, you might be offered another tablet or gel (NICE, 2008a).

What happens if the prostaglandins don't work?

If labour doesn't start after you've been given prostaglandins, other hormones such as oxytocin may be used. Oxytocin is released naturally from the pituitary gland, stimulating the contraction of the uterus during labour (NICE, 2008a). An artificial form can be swallowed, inserted into the vagina in the form of tablets or fed into a vein using an IV drip (IQWiG, 2018).

Along with other methods of induction, your midwife might ask to break your waters themselves. This is called an artificial rupture of the membranes and its aim is to shorten your labour. Yet this should not be offered routinely as a primary method of induction on its own as there may be some risks (such as infections) (NICE, 2008a; Tommys 2019).

Double balloon catheters can also be used to safely induce labour in pregnant women who have not had a previous caesarean section. A double balloon catheter is another way to try to help the cervix to soften and dilate.

If a double balloon catheter is used to induce your labour, the catheter is inserted so that one balloon is in your uterus and one is in your vagina. The balloons are slowly and alternately inflated with saline. The device is left in place for up to about 12 hours and removed if labour begins, the device comes out, the waters break, or the baby seems to be in distress (NICE, 2015).

What happens once labour starts?

Once you're in labour, you'll be offered a check of your baby's heart rate every so often (NICE, 2008b). If you have certain risk factors, you'll be offered continuous electronic foetal heart rate and uterine contraction monitoring (NICE, 2008b).

Is it more painful to induce labour?

Induced labour is likely to be more painful than spontaneous labour. So you should be offered appropriate pain relief (Kelly and Tan, 2001; NICE, 2008a). This can range from simple pain relief, such as distraction, aromatherapy, hypnotherapy, acupuncture, to an epidural (NICE, 2014). You should be encouraged to use your own coping skills too, and birth attendants should offer support; ideally, you'd also be offered the opportunity to labour in water (NICE, 2008a)

Labour after induction may be more painful because a labour that starts spontaneously usually builds up gradually, giving you time to get used to each new sensation. You get used to the sensation because your body has the chance to release pain-relieving substances called endorphins.

How else does induction affect labour?

The amount of monitoring used in induced labour means that a woman's movement may be restricted. On the other hand, some women like induction because it enables them to have control over knowing roughly when their baby will be born. They also feel reassured that they'll be closely monitored throughout (Wickham, 2018).

Induction at or beyond term might lead to a reduced rate of caesarean section but a slightly higher rate of instrumental birth with forceps or ventouse.

What happens if labour induction doesn't work?

If your induction does not work, your midwife or doctor will discuss other options with you and support you. Other options include another attempt to induce labour or having a caesarean section (NICE, 2008a). Your wellbeing should be considered and the wellbeing of your baby should be assessed using electronic fetal monitoring (with your consent).
This page was last reviewed in June 2018.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about labour and life with a new baby.

Information from NHS choices on being overdue and on induced labour.

Find out more about NICE guidance on the induction of labour

Boulvain M, Stan M, Irion O. (2005) Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews. (1):CD000451. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000451.pub2... [accessed 2nd January 2019]

IQWiG (Institute for Quality and Efficiency in Health Care). (2018) Informed health online: pregnancy and birth: when your baby's due date has passed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK279571/. [accessed 3rd January 2019].

Kelly A, Tan B. (2001) Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. (3):CD003246. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003246/epdf... [accessed 2nd January 2019]

Middleton P, Shepherd E, Flenady V, McBain R, Crowther C. (2017) Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews. (1):CD005302. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005302.pub3... [accessed 2nd January 2019]

NICE. (2008a) Inducing labour [CG70]. Available at: https://www.nice.org.uk/guidance/cg70/resources/inducing-labour-pdf-975... [accessed 3rd January 2019]

NICE. (2008b) Antenatal care for uncomplicated pregnancies [CG62]. Available at: https://www.nice.org.uk/guidance/cg62/resources/antenatal-care-for-unco... [accessed 2nd January 2018]

NICE. (2014) Inducing labour (QS60). Available at: https://www.nice.org.uk/guidance/qs60/chapter/Quality-statement-2-Safet... [accessed 3rd January 2019]

NICE. (2015) Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section (IPG528). Available at: https://www.nice.org.uk/guidance/ipg528/ifp/chapter/The-procedure [accessed 3rd January 2019]

Oberg A, Frisell T, Svensson A, Iliadou A. (2013) Maternal and fetal genetic contributions to postterm birth: familial clustering in a population-based sample of 475,429 Swedish births. American Journal of Epidemiology. 177(6):531-537. Available at: https://academic.oup.com/aje/article/177/6/531/160108 [accessed 3rd January 2019]

Sharp A, Stock S, Alfirevic Z. (2016) Outpatient induction of labour in the UK: a survey of practice. European Journal of Obstetrics and Gynaecology and Reproductive Biology. 204:21-23 Available at: https://www.ejog.org/article/S0301-2115(16)30305-0/fulltext [accessed 3rd January 2019]

Thomas J, Fairclough A, Kavanagh J, Kelly A. (2014) Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database of Systematic Reviews. (6):CD003101. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003101.pub3... [accessed 3rd January 2019]

Tommy's. (2015) What is a membrane sweep? Available at: https://www.tommys.org/pregnancy-information/labour-birth/what-membrane.... [accessed 3rd January 2019].

Whitworth M, Bricker L, Mullan C. (2015) Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews. (7):CD007058. Available at: https://www.cochrane.org/CD007058/PREG_routine-compared-selective-ultra... [accessed 3rd January 2019]

Wickham S. (2018) Inducing Labour: Making Informed Decisions. 2nd ed. UK: Birthmoon.
Further reading
Caughey A, Stotland N, Washington A, Escobar G. (2007) Maternal and obstetric complications of pregnancy are associated with increasing gestational age at term. American Journal of Obstetrics and Gynecology. 196(2):155. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941614/ [accessed 2nd January 2019]

Decker R. (2019) The evidence on: due dates. Available at: https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-pas... [accessed 2nd January 2019]

Kavanagh J, Kelly A, Thomas J. (2005) Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. (3):CD003392. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003392.pub2... [accessed 3rd January 2019]

Mandruzzato G, Alfirevic Z, Chervenak F, Gruenebaum A, Heimstad R, Heinonen S, Levene M, Salvesen K, Saugstad O, Skupski D, Thilaganathan B. (2010) Guidelines for the management of postterm pregnancy. Journal of Perinatal Medicine. 38(2010):111-119. Available at: https://pdfs.semanticscholar.org/7e17/c75025c5476e37e98d9372605f026873f... [accessed 3rd January 2019]

Middleton P, Shepherd E, Crowther C. (2018) Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews. (5):CD004945 . Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004945.pub4... [accessed 2nd January 2019]

Mongelli M, Wilcox M, Gardosi J. (1996) Estimating the date of confinement: ultrasonographic biometry versus certain menstrual dates. American Journal of Obstetrics and Gynecology. 174(1):278-281. Available at: https://www.ajog.org/article/S0002-9378(96)70408-8/fulltext [accessed 3rd January 2019]

Morken N, Klungsøyr K, Skjaerven R. (2014) Perinatal mortality by gestational week and size at birth in singleton pregnancies at and beyond term: a nationwide population-based cohort study. BMC Pregnancy and Childbirth. 14(172). Available at: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-... [accessed 2nd January 2019]

NHS Digital. (2018) NHS maternity statistics, England 2017-18. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/nh.... [accessed 3rd January 2019].

NICE. (ND). Dinoprostone. Available at: https://bnf.nice.org.uk/drug/dinoprostone.html [accessed 3rd January 2019]

NICE. (NDb). Oxytocin. Available at: https://bnf.nice.org.uk/drug/oxytocin.html#sideEffects. [accessed 3rd January 2019].

Rosenstein M, Cheng Y, Snowden J, Nicholson J, Doss A, Caughey A. (2012) The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. American Journal of Obstetrics and Gynecology. 206(4):309. Available at: https://www.ajog.org/article/S0002-9378(12)00026-9/fulltext [accessed 3rd January 2019]

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Overdue baby - what happens if my baby is late? | Labour & birth articles & support | NCT

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You feel like you've swallowed a whole watermelon and getting anywhere feels like a feat of Herculean proportions. Your baby must surely be ready to come out, right? You're definitely not alone if you've been focusing on your due date throughout your pregnancy and counting down to it in the latter stages.

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© Sara Wickham and www.sarawickham.com 1998-2021 Unauthorised use and/or duplication of this material without express and written permission from this site's author and/or owner is strictly prohibited. A short (1-2 sentence) excerpt may be used, provided that full and clear credit is given to Sara Wickham and www.sarawickham.com with a link to the original content on this website.

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The impact of synthetic oxytocin on breastfeeding 

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The impact of synthetic oxytocin on breastfeeding 

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Synthetic oxytocin is used for labour induction and augmentation and also for speeding up the birth of the placenta.  This research shows how it negatively impacts breastfeeding success.

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In this preview of her 2018 Annual Conference talk, Karin Cadwell shares findings from her new research into the impact of synthetic oxytocin and other labour interventions on breastfeeding and infant health.
I've worked in the world of breastfeeding support for many years and have witnessed first-hand the effect of changes in birthing practices on breastfeeding. For example, I remember traveling to California in the early 80's and hearing about babies that wouldn't latch on. This was anathema to me in my Pennsylvania practice. We would see an occasional case of a baby who was early, jaundiced or otherwise weak who needed coaxing to latch, and often extraordinary measures to maintain sufficient milk production, but nothing like the wave of problems I learned about in California.

Then, one of our local hospitals hired a full time OB anesthesiologist and epidurals began. The nurses reported an immediate outbreak in flat nipples and babies who had trouble latching. One of the nurses told me that it was almost as though the baby didn't know that the breast was there! Now, epidurals, labor induction and augmentation with synthetic oxytocin, operative deliveries and elective cesarean births are widespread with ubiquitous breastfeeding problems. Whilst advances in labor interventions have helped reduce infant and maternal mortality during labor, it's crucial that we consider the other implications of these now widespread practices, particularly where the need for them is not clinically indicated.

What could the problem be?

I ask myself almost every day, how can something that is so fundamental to good health, in fact our survival as a species, be so difficult? How can it be that babies fail to latch when the characteristics of their mother's Montgomery gland secretions are analogous to their unique amniotic fluid flavor? What has happened to otherwise healthy, full term babies in the process of being born that they would deny themselves the ultimate pleasure nursing?

In the service of answering these (and other) questions, my colleagues and I have embarked on several well-received research studies with the finding that babies' behavior, especially in the critically sensitive period in the first hour after birth, is clearly affected by epidural administration that includes fentanyl and by labor induction and/or augmentation with synthetic oxytocin.

Synthetic oxytocin is chemically identical to the oxytocin that humans produce. We began to wonder, what was the range of potential physiologic effects on the mother and baby that could occur when the labor is induced or augmented with synthetic oxytocin? And, what does that mean for health outcomes for the mother and baby, even beyond breastfeeding?

We used a research technique that is more commonly used in social work and epidemiology to try to find hidden cases. The modified ascending, link tracing methodology, or snowball technique, identified studies about breastfeeding and human lactation which described physiologic pathways related synthetic oxytocin and breastfeeding outcomes.

Our findings

We then developed a way to think about these visually: a cascade model. We identified three physiologic pathways: dysregulation of the maternal OT system, crossing of the fetal blood brain barrier, and uterine hyper-stimulation. Downstream negative effects related to breastfeeding that we found include decreased maternal endogenous oxytocin, increased risk of negative neonatal outcomes, decreased neonatal rest during the first hour with the potential of decreasing the consolidation of memory, decreased neonatal pre-feeding cues, decreased neonatal reflexes associated with breastfeeding, maternal depression, somatic symptoms and anxiety disorders. No positive relationships between the administration of synthetic oxytocin and breastfeeding were found.

Given these findings, we need to look again at the nearly ubiquitous practice of inducing and accelerating labor with the use synthetic oxytocin, and consider how we can better support breastfeeding and protect the health of both baby and mother.

Read more: Cadwell, K, & Brimdyr, K, (2017). Intrapartum Administration of Synthetic Oxytocin and Downstream Effects on Breastfeeding: Elucidating Physiologic Pathways, Annals of Nursing Research and Practice, Vol. 2, Iss. 3.

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Guest blog: The impact of labour interventions on breastfeeding and infant health - Baby Friendly Initiative

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In this preview of her 2018 Annual Conference talk, Karin Cadwell shares findings from her new research into the impact of synthetic oxytocin and other labour interventions on breastfeeding and infant health. I've worked in the world of breastfeeding support for many years and have witnessed first-hand the effect of changes in birthing practices on breastfeeding.

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A look at the evidence around inducing labour vs waiting.

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Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions. The term 'augmentation' is often used instead of 'induction' for this procedure. Women who choose to wait are usually told their baby is at increased risk of infection and they are encouraged to have IV antibiotics during labour.

The rush to start labour and get the baby out after the waters have broken is fairly new. When I first qualified in 2001 the standard hospital advice (UK) for a woman who rang to tell us her waters had broken (and all else was well) was: "If you're not in labour by [day of the week in 3 days time] ring us back." Over the following years this reduced from 72 hours to 48 hours, then 24 hours, then 18 hours, then 12 hours and now 0 hours. You might assume that this change in approach was based on some new evidence about the dangers involved in waiting for labour. You would be wrong.

This post is mostly based on a couple of Cochrane Reviews because hospitals are supposed to base their policies/guidelines on research evidence. Obstetricians also tend to have great respect for research evidence - certainly more than other forms of knowledge midwives also use (experience, intuition, witchcraft etc.). However, please note that research reviews are only as good as the research reviewed. Research is not conducted in a vacuum, and the questions that are asked, and the methods used, tell us a lot about the social and cultural context of knowledge, and what is valued. For example in most trials the 'doing nothing' group is the experimental group and the 'routine intervention that was previously introduced without evidence' is the control group. You can read more about research bias in maternity care in this post.

Please note that this post is not about premature rupture of membranes (before 37 weeks)

The outcomes: induction vs waiting

A Cochrane Review comparing planned (induced labour) vs expectant (waiting) management concluded that neonatal infection 'may be' reduced. Unfortunately, the research reviewed was not great: "Only three trials were at overall low risk of bias, and the evidence in the review was very low to moderate quality." Indeed all of the evidence in the review was rated 'low quality' except the evidence demonstrating no difference in the rate of death for babies between inducing vs waiting (this was the only 'moderate quality' research).

Whilst the review reports a slight increase (less than 2%) in 'definite or probable' neonatal sepsis, this needs to be unpicked a little. Once the 'probable' portion was removed in the analysis the difference was no longer significant. It would be very interesting to know how many of the suspected (probable) cases of sepsis were merely care providers being cautious and making assumptions. For example, some symptoms associated with sepsis can be caused by other interventions - epidural increases the chance of a high temperature in both mother and baby; and a stressful labour (and syntocinon) can result in low blood glucose in the newborn. It is common practice to assume infection until proven otherwise and treat accordingly. The fact that there was no difference in Apgar scores between the groups increases my suspicions in this area. Infected babies are much more likely to have a poor Apgar score and require resuscitation at birth.

The review goes on to state that: "...evidence about longer-term effects on children is needed." And there is increasing evidence about the risks of the induction process for babies that needs to be considered by women when making a decision.

The Cochrane review did find a slight increase (1%) in the absolute risk of uterine infection for mothers who waited for labour. Bear in mind that these studies were done in hospitals which are not the best setting when attempting to avoid infection. If a uterine infection is identified early it can usually be effectively treated with antibiotics. I used to see quite a few uterine infections as a community midwife in the UK doing postnatal home visits - mostly after forceps or ventouse births. However, if the symptoms are missed, or the woman does not have access to antibiotics; or the infection is antibiotic resistant, a uterine infection can be life-threatening.

The report found no difference in the rate of caesarean sections. However, the stats for first-time mothers are not separated out. This is frustrating because induction increases the chance of caesarean significantly for first time mothers (see this post). Women who have previously given birth have no increased chance of caesarean with induction. When you mix the two groups together (like most research does) you miss the outcomes for those first-timers. Interesting only two of the studies in the review looked a uterine rupture during induction - a greater risk for women who have previously laboured.

The experience: induction vs waiting

Only one of the trials in the Cochrane Review bothered to ask women what they thought of their experience (no surprises there). In this trial, women who had their labour augmented were more likely to tick the box saying that there was 'nothing they disliked in their management'. There are huge limitations when using surveys to assess experiences, and a good qualitative study is needed here. For example, how can a woman compare one experience (induction) against an experience they did not have (physiological labour) - you don't know what you don't know. Also, if a woman believes she is protecting her baby against infection by inducing labour this may influence her perception of the management. The Cochrane Review states that no trials reported on maternal views of care, or postnatal depression.

Antibiotics - just in case?

A Cochrane Review of antibiotics for pre-labour rupture of membranes at or near term concluded that: "There is not enough information in this to assess the possible side-effects from the use of antibiotics for women or their infants, particularly for any possible long-term harms. Because we do not know enough about side-effects and because we did not find strong evidence of benefit from antibiotics, they should not be routinely used for pregnant women with ruptured membranes prior to labour at term, unless a woman shows signs of infection."

The National Institute for Clinical Excellence (UK) guideline states "If there are no signs of infection, antibiotics should not be given to either the woman or the baby, even if the membranes have been ruptured for over 24 hours."

So it appears that women and babies are being given high doses of antibiotics during labour without sufficient evidence to support the practice. In addition, these antibiotics may have short term, and long term side effects. As a student midwife I was asked by a mother what would happen if her unborn baby was allergic to antibiotics. I had no idea and asked the Consultant... after a long and complex answer I realised he didn't know either. I am guessing that most side-effects are more subtle than anaphylaxis. The effect I most often see is oral thrush in the baby and co-existing nipple thrush - and subsequent breastfeeding problems. However, more worrying are the potential long term problems associated with antibiotic exposure - most likely due to the disruption of gut microbiota and the integrity of the immune system. Another issue is the development of antibiotic resistant bacteria due to the overuse of antibiotics, which can result in infections (e.g. uterine) being difficult to treat.

Choosing to wait

Women need to be given adequate information so that they can make the decision that is right for them. I'm not sure most women are fully informed, and instead are told their baby is 'at risk'. As we know, you can get a mother to do anything if she believes it is in the best interests of her baby. So what happens if a woman chooses to wait for labour?

Most women (79%) will go into labour within 12 hours of their waters breaking and 95% will be in spontaneous labour within 24 hours ( Middleton et al. 2017). Ashlee whose birth I recently attended has given me permission to share her experience and photos here. Ashlee's daughter Arden taught both her family and her midwives about patience and trust. We waited 63 hours from waters breaking to welcome her into the world. After a 2 hour, 20 minute labour she was gently born through water and into her mothers arms (notice the nuchal cord). I wonder how different this birth would have been if Ashlee had chosen to follow hospital guidelines. Instead she weighed up the information for herself and chose to stay home amongst her own familiar bacteria, and let her daughter decide when she was ready to be born.
Suggestions for waiting:

View the situation positively - we are all getting time to prepare for the birth and the arrival of baby. She can use the time to relax, sleep and be pampered.

The vagina self cleans downwards. Reduce the chance of infection by not putting anything into the vagina ie. no vaginal examinations. If a vaginal examination is absolutely necessary sterile gloves must be used.

Some women like to boost their immune system with nutritional supplements (eg. vitamin C, echinacea, garlic).

Be self-aware, connect with your baby and let your midwife/care provider know of any changes eg. feeling unwell, a high temperature, if the amniotic fluid changes colour or smell, any reduction in the baby's movements etc.

I have observed Acupuncture and Bowen Therapy encourage contractions. However, if the cervix is not ready the contractions will fizzle out. If the cervix is ready, it may be enough to kick start labour. Nipple stimulation will also stimulate oxytocin (and clitoral stimulation will too).

Most importantly trust the process. Birth will happen.

Once the baby is born - keep baby skin-to-skin with mother to reduce the chance of infection by allowing the baby to become colonized by his mother's bacteria (this applies to all births).

After birth be aware of signs of infection. Mother: fever, raised pulse, feeling unwell, smelly vaginal discharge, uterine pain. Baby: fever, noisy breathing, change in colour (pale), listless.

Summary

The research evidence regarding induction for rupture of membranes is poor. Giving antibiotics in labour 'just in case' is not supported by current evidence, and may cause problems for baby and mother. Women need adequate information on which to base their decisions regarding the management, or not, of this situation. Women who choose to wait for labour should be supported and to do so.
You can read more about induction in my book Why Induction Matters

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Pre-labour Rupture of Membranes: impatience and risk

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Updated: July 2019 Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions.

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Link between epidural and further interventions

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Link between epidural and further interventions

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Objective

To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia.

Design

Prospective cohort study.

Setting

Two maternity hospitals in Ireland.

Population

A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section.

Methods

Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR). For dichotomous outcomes we used logistic regression, with results presented as odds ratios (OR).

Main outcome measures

Mode of birth, IV syntocinon use, pyrexia (≥38 °C), antibiotic treatment, first stage labour ≥10 h, second stage labour ≥2 h, blood loss (≥500 mls, ≥1000 mls), perineal trauma. Neonatal outcomes included APGAR score ≥7 at 1 min and 5 min, admission to neonatal intensive care unit, and infant feeding method.

Results

Women using EA were more likely to require a vacuum-assisted birth (RRR 3.35, p < 0.01) or forceps-assisted birth (RRR 11.69, p < 0.01). Exposure to EA was associated with significantly greater risk of ≥10 h first (OR 6.72, p = 0.01) and ≥2 h second (OR 2.25, p < 0.01) stage labour, increased likelihood of receiving IV syntocinon (OR 9.38, p < 0.01), antibiotics (OR 2.97, p < 0.01) and a greater probability of pyrexia (OR 10.26, p < 0.01). Women who used EA were half as likely to be breastfeeding at three months postpartum (OR 0.53, p < 0.01). No differences were observed between groups in neonatal outcomes.

Conclusions

Our data shows significant associations between EA use and several intrapartum outcomes.

To read this article in full you will need to make a payment

References

1. Epidural versus non-epidural or no analgesia for pain management in labour.
CD000331

2. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care.

Childbirth Connection Programs, National Partnership for Women & Families, Washington, D.C 2015

World Health Organization (WHO)

Care in Normal Birth.

World Health Organisation, Geneva 1996

4. Pain and women's satisfaction with the experience of childbirth: a systematic review.

: S160-S172

5. Women׳s experiences of coping with pain during childbirth: a critical review of qualitative research.

: 349-358

6. Stata Statistical Software: Release 14.

StataCorp LP, College Station, TX 2015

7. Institute of Obstetricians and Gynaecologists and Clinical Strategy and Programmes Division Health Service Executive Clinical Practice Guideline. Oxytocin to Accelerate or Induce Labour.

2016 ()

Herrera-Gómez A.

García-Martínez O.

Ramos-Torrecillas J.

De Luna-Bertos E.

Ruiz C.

Ocaña-Peinado F.M.

Retrospective study of the association between epidural analgesia during labour and complications for the newborn.

: 613-616

9. Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: a retrospective cohort study.

10. European Perinatal Health Report. Core Indicators of the Health and Care of Pregnant Women and Babies in Europe in 2015.

2018

11. Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.

: 275-277

12. Epidural analgesia during birth and adverse neonatal outcomes: a population based cohort study.

https://doi.org/10.1016/j.wombi.2020.05.012

13. Listening to mothers III: pregnancy and birth.

14. Women's experience of pain during childbirth.

: 105-110

15. Towards the Humanisation of Birth: Epidural Analgesia and Hospital Birth Culture.

Palgrave MacMillan, Basingstoke, UK 2018

Article Info

Publication History

Publication stageIn Press Corrected Proof

Identification

DOI: https://doi.org/10.1016/j.wombi.2020.09.001

ScienceDirect
Access this article on ScienceDirect

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Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study

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To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia. Prospective cohort study. Two maternity hospitals in Ireland. A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section. Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR).

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The information that was available in class on induction of labour

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NHS leaflet

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Reliable information about pain management and interventions

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel hongkong togel singapore togel sidney merupakan pasaran togel hari ini terpopuler yang memberikan hasil keluaran sdy pengeluaran sgp dan data hk hari ini.

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Information from the Royal College of Obstetricians and Gynaecologists about forceps and ventouse births.

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from NCT.org.uk

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What is an episiotomy?

An episiotomy is a cut to a woman's perineum (skin between the vagina and anus) made by a doctor or midwife during childbirth. Episiotomies help to make the vaginal opening wider to allow the baby through more easily. The procedure is only performed when there is a medical reason to do so (NICE, 2014).

What is the difference between an episiotomy and a perineal tear?

An episiotomy is a cut made by a health professional, while a perineal tear happens on its own during the second stage of labour. When a baby is being born, the perineum needs to stretch a lot and sometimes tears on its own.

How common are tears and episiotomies?

More than 85% of women who have a vaginal birth have some kind of tear or episiotomy (Frolich and Kettle, 2015). In first-time vaginal births, you're more likely to have worse injuries if the perineum tears on its own than if you get an episiotomy (NHS Choices, 2017).

At least one third of women in the UK and US have perineal tears that need stitches (Frolich and Kettle, 2015). About three in 100 women having a vaginal birth have the more severe perineal tears. Tears are slightly more common with a first vaginal birth than in women who have had a vaginal birth before (RCOG, 2015b).

Can perineal massage reduce my risk of tearing?

Some evidence suggests massaging the perineum in the last weeks of pregnancy might reduce the likelihood of tearing or needing an episiotomy or stitches (Beckmann and Stock 2013). For more information on how to do it, see our article on perineal massage.

What to expect during an episiotomy

If you need an episiotomy during childbirth, you will be offered pain relief and will be given stitches afterwards. It's usually a straightforward procedure.

For pain relief, you'll have local anaesthetic applied to numb the area. If you've had an epidural, the dose can be topped up as needed.

The cut your doctor or midwife makes will be small and diagonal. It'll go from the back of the vagina, down and out to one side.

The doctor or midwife will stitch up the cut after your baby is born. They'll use dissolvable stitches. (NICE, 2014; NHC Choices, 2017)

When might I need an episiotomy?

You might need an episiotomy if:

Forceps or ventouse are required to help you give birth to your baby.

Your baby is in distress (their heart rate gets much faster or slower) and they need to be born quickly.

You have been trying to give birth for several hours and are worn out from pushing.

You're having a breech birth - your baby is not head-first.

You have a serious health condition that requires your baby's birth to be as quick as possible to minimise risks to you. (NICE, 2014; NHS Choices, 2017)

An episiotomy might prevent more severe tears in some births, particularly in those where forceps are used (NHS Choices, 2017).

Recovery from episiotomy

Episiotomy cuts are usually stitched up within an hour of your baby's birth.

The cut might bleed quite a lot to start with, but this should stop with pressure and stitches.

Your stitches should heal within one month of your baby's birth. (NHS Choices, 2017)

Talk to your midwife or GP about which activities you should avoid during the healing period. Read more in our article on episiotomy recovery.

If you are concerned about how you are healing following a perineal tear or episiotomy, it's important to talk to a health professional. You can then get treatment if required.
This page was last reviewed in August 2018
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

The Royal College of Obstetricians and Gynaecologists (RCOG) has an information hub for perineal tears and episiotomies in childbirth. You can find out more about the types of tears that can occur during childbirth, how to minimise your risk of deeper tearing, and what can be done to help your recovery if you do tear. It also covers what to do if you have any concerns about your recovery, helping you feel better informed when discussing any topics with a healthcare professional.

Beckmann M, Stock O. (2013) Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. (4):CD005123. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005123.pub3/abstract;jsessionid=CF32264FB13246A8540B877017B34E8C.f02t04 [Accessed 1st September 2018].

Frolich J, Kettle C. (2015) Perineal care. BMJ Clin Evid. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356152/[Accessed 16th May 2017].

NHS Choices. (2017) Episiotomy and perineal tears. Available from: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/episiotomy.aspx [Accessed 16th May 2017].

NICE. (2014) Intrapartum care for healthy women and babies. Available from: https://www.nice.org. uk/guidance/cg190 [Accessed 16th May 2017].

RCOG. (2015a) The management of third- and fourth-degree perineal tears. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf [Accessed 16th May 2017].

RCOG. (2015b) A third of fourth degree tear during birth (also known as obstetiric anal sphincter injury - OASI). Available from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-third--or-fourth-degree-tear-during-birth.pdf [Accessed 16th May 2017].

RCOG. (2016) Patterns of maternity care in English NHS trusts 2013/14. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/maternity-indicators-2013-14_report2.pdf [Accessed 16th May 2017].

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Episiotomy during childbirth | Labour & birth articles & support | NCT

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Some women need an episiotomy when they give birth. Here we talk about what it is, when they're needed and what to expect if you have one.

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From NCT.org.uk

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When it comes to giving birth, most women want to know: how much is it going to hurt and will I be able to cope with the pain? Unfortunately, you can't answer either of these questions with certainty. But what you can do is improve your ability to cope with pain during labour, as well as understand your options for pain relief and their impact on you, your labour and baby.

Your birth partner(s) will make a huge difference to how you feel during labour. Emotional support, such as encouragement and reassurance from somebody you trust, can really boost your confidence and ability to cope with pain when you need it most.

Here we look at the different pain relief options that are available during labour.

Overcoming fear during labour

Labour is complex but, unfortunately, fear can affect this amazing process.

Fear makes you release adrenaline, which slows down the production of oxytocin and prepares your body to fight or run away (not helpful when you're trying to give birth). This makes your contractions less efficient and you focus on the pain and feel worse. So staying calm is the key to coping with pain.

To help you feel relaxed, it's good to read up on what happens during labour and choose a place to give birth where you feel safe.

It'll help to choose the right person to be your birth partner to help you cope with the pain and discomfort of labour more easily. It should be a person you trust, and who can give you encouragement, reassurance, listen to you and just be there. Research has shown that emotional support is important for women in labour.

Attending antenatal classes is also a really useful way of preparing for labour and gaining an understanding of what will happen on the day.

If it feels really tough, ask your midwife how you are getting on. Positive encouragement - knowing you are coping really well and making good progress - can make all the difference.

Position and movement in labour

Labour can last a long time so, at the beginning, try movement, upright positions, massage and water to help you cope. If you head straight for maximum pain relief, you'll never know how other things can help - plus your labour may end up being even longer.

Lying on your back can make your contractions slower and more painful. Different positions and movement, such as rocking, swaying and leaning forwards, maximises your body's ability to give birth as it helps ease your baby along the birth canal.

Pros

Maximises your body's ability to give birth.

No lasting side-effects for you or your baby

Cons

Try not to overdo it; saving energy is also important. Lying on your side for a while or sitting up supported by lots of pillows can help your body to work really well while you conserve energy.

Water and birthing pools in labour

Water soothes pain and, in a large birthing pool, supports you, enabling you to glide into any position. For more about water births and using water during labour, see here.

TENS (Transcutaneous Electrical Nerve Stimulation) machine in labour

A TENS machine transmits mild electrical impulses to pads on your back. These block pain signals and help your body to produce endorphins. For more about the pros and cons of TENS, see here.

Complementary therapies

Various complementary therapies are available, such as acupuncture, aromatherapy, reflexology, yoga, self-hypnosis and massage.

Pros

Some studies show acupuncture is helpful.

Massage or pressure on the lower part of your back can help reduce levels of stress and ease discomfort, too.

You can learn self-hypnosis techniques for labour by attending a course or using CDs; you don't have to have a hypnotherapist with you in labour.

Cons

There is little research proving the effectiveness of these treatments though lots of women say that they found these techniques useful.

Apart from massage and self-hypnosis, you will need a registered practitioner to perform the therapies.

Sterile water injections

Sterile water injections involve injecting a tiny bit of water into the skin of your lower back to help with back pain during labour. For more about sterile water injections, see here.

Gas and air (Entonox) in labour

Entonox is a colourless, odourless gas made up of half nitrous oxide and half oxygen. You'll probably be given gas and air through a mouthpiece and told how to breathe it in. Read more about Entonox here.

Painkilling drugs in labour (opioids such as pethidine, diamorphine, meptid and remifentanil)

Pethidine, diamorphine and meptid are pain relieving drugs given by injection into the thigh. Some hospitals offer remifentanil, which is a very strong, short-acting painkiller given via a drip that you can control yourself using a machine. For more details, see our articles about intramuscular opioids and remifentanil.

Epidural

Epidural analgesia is a local anaesthetic injected into the space between two vertebra in your back. It usually removes all pain and most feeling from the waist down.

The combined spinal epidural (CSE) injection contains a low dose of pain-relieving drugs and works more quickly than an epidural alone. Read more about their pros and cons in our articles about epidurals and CSEs.

Top tips for labour

The following tips have been found to be useful by women in labour:

1. Before labour, spend some time imagining having your new baby in your arms after the birth and that all is well. Imagining that you did it, and that you did it as you wanted, creates a positive picture to focus on.

2. Moving about helps labour to progress and women have said they were better able to work with the pain while rocking and leaning forwards (the pressure of the baby's head on the cervix will promote the release of oxytocin as well as endorphins - the body's natural pain relievers). Focus on letting go and relaxing any muscles that aren't needed to hold you in a position.

3. Focus on the out breath during a contraction. Keep the breathing calm and rhythmic.

4. Make a noise if you want to - be somewhere with people that are happy for you to moan, grunt, sigh or even swear if that helps.

5. Belly-dancing, hip-wriggling and stepping movements all help your baby settle into a good position to be born.

6. Massage or pressure on the lower part of your back just above the top of your bottom can help.

7. Water helps women relax and move more easily; being in a pool can give women a feeling of safety and security.

8. Positive, affirmative thoughts and supportive comments from birth partners help to promote confidence in the process. 'You are doing well - your body is made for this - feel the power of your body - your body knows how to do this - each pain is progress' are all positive and encouraging statements.

9. During labour, think about welcoming each contraction. As your contractions become stronger, longer and closer together your body is getting ready to give birth.

10. Rest, relax and conserve energy between contractions as labour progresses.

11. Have confidence in your own self-help resources.

12. Acknowledge that labour is unpredictable and that uncertainty is difficult to go along with. Try to go with the flow.

Recognising the point at which labour feels worst - when you have had enough - is often the point just before you are ready to start pushing your baby out. Having people with you who help you feel strong and capable can make all the difference.

Do what feels best for you

Every labour is different and each woman should choose whatever she needs to help her work with the pain of labour. Most importantly, have confidence that you can do it.
This page was last reviewed in August 2019.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about pregnancy and life with a new baby.

NHS Choices guide to pain relief.

Research from the Royal College of Obstetricians and Gynaecologists (RCOG) about the use of water as pain relief in labour.

Information from NHS Choices about complementary therapies during pregnancy and before birth.

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Pain relief in labour | Labour & birth articles & support | NCT

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Find out about the different options available for pain relief in labour and childbirth, including epidural, pethidine, TENS and other ways to reduce pain.

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The information that was available in class on assisted birth.