# data[].attributes.headline
Obstetric Anaesthetists’ Association Guide to types of pain relief available in labour

# data[].attributes.subject
Obstetric Anaesthetists’ Association Guide to types of pain relief available in labour

# data[].attributes.body
Why it might be offered and how it happens.

# data[].attributes.attachment_link.readable_text
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]

# data[].attributes.attachment_link.title
Overdue baby - what happens if my baby is late? | Labour & birth articles & support | NCT

# data[].attributes.attachment_link.description
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.

# data[].attributes.body
NHS leaflet

# data[].attributes.body
A look at the evidence around inducing labour vs waiting.

# data[].attributes.attachment_link.readable_text
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

# data[].attributes.attachment_link.title
Pre-labour Rupture of Membranes: impatience and risk

# data[].attributes.attachment_link.description
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.

# data[].attributes.headline
The impact of synthetic oxytocin on breastfeeding 

# data[].attributes.subject
The impact of synthetic oxytocin on breastfeeding 

# data[].attributes.body
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.

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.title
Guest blog: The impact of labour interventions on breastfeeding and infant health - Baby Friendly Initiative

# data[].attributes.attachment_link.description
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.

# data[].attributes.attachment_link.description
© 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.

# data[].attributes.body
Reliable information about pain management and interventions

# data[].attributes.attachment_link.provider_name
Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

# data[].attributes.attachment_link.authors[].name
Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

# data[].attributes.attachment_link.title
Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

# data[].attributes.attachment_link.description
Togel hongkong togel singapore togel sidney merupakan pasaran togel hari ini terpopuler yang memberikan hasil keluaran sdy pengeluaran sgp dan data hk hari ini.

# data[].attributes.body
From NCT.org.uk

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.title
Pain relief in labour | Labour & birth articles & support | NCT

# data[].attributes.attachment_link.description
Find out about the different options available for pain relief in labour and childbirth, including epidural, pethidine, TENS and other ways to reduce pain.

# data[].attributes.body
Information from the Royal College of Obstetricians and Gynaecologists about forceps and ventouse births.

# data[].attributes.body
An NCT article

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.title
Assisted birth: A helping hand - NCT Matters

# data[].attributes.attachment_link.description
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.

# data[].attributes.body
Why having the cord around your baby's neck is rarely a problem.

# data[].attributes.attachment_link.readable_text
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).

# data[].attributes.attachment_link.description
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...

# data[].attributes.body
from NCT.org.uk

# data[].attributes.attachment_link.readable_text
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].

# data[].attributes.attachment_link.title
Episiotomy during childbirth | Labour & birth articles & support | NCT

# data[].attributes.attachment_link.description
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.

# data[].attributes.body
NCT's pages on C-Birth

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.title
Having a caesarean: what to expect | Labour & birth, Different types of birth articles & support | NCT

# data[].attributes.attachment_link.description
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.