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Can I choose where to give birth?

Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives. It can be part of a hospital or completely separate.

Your NHS trust may automatically book you into a hospital or birth centre. You can ask to discuss this and make your own choice.

A healthcare professional may say you 'need' or 'have' to give birth in a hospital. You can ask them why they think this. What medical reasons do they have for this advice? You do not have to agree with them.

In some cases, there may be restrictions on your right to choose a hospital or birth centre. However, no-one can make you give birth away from home if you want to stay at home.

The only time someone else can decide for you about where you give birth, or your treatment, is if you lack mental capacity. This is very rare, but we describe what mental capacity is below.

Yes. You have a right to choose where you give birth. You cannot be made to go to hospital. Healthcare professionals may want to talk to you about your plans and any concerns they have. This should be an opportunity to have an open discussion and to share information. They should always respect your views and choices.

All NHS Trusts are expected to run a home birth service. This is not guaranteed in law, but the law says that your right to choose where to give birth should only be restricted when there is a good reason to do this, and where the decision is 'proportionate'.

This means that a Trust should only pause their home birth service if they have looked at all the options for keeping it going and they are still unable to.

If you are told you cannot give birth at home because of staff shortages, remind the hospital that it must make sure there are enough staff to provide the services it has promised. They should have plans for situations such as staff shortages. This could include providing an independent midwife.

If you feel that your choice to give birth at home is not being respected, you can contact Birthrights for advice using our contact form.

Yes. The Nursing and Midwifery Council's Code says that midwives must put your interests first and make your safety their main concern. This is their professional duty.

Midwives should respect your decision to give birth outside the hospital. They should attend you at home if you ask for this, even if they don't agree with your decision.

If you are in labour and the hospital tells you there is no midwife to attend you, (and that they will send an ambulance), you cannot be made to attend hospital if you do not want to. You or your birth partner can ask to speak to the Head of Midwifery and ask them to provide a midwife.

If a midwife - or any healthcare professional - has breached their duty of care, you can complain. Duty of care means that they must care for you and keep you safe. They can be referred to their regulatory body, which will investigate.

Yes. Only you have the right to decide where you give birth. No one can overturn the decision you have made. This is the law.

The only time that someone else can make decisions about your healthcare is if you lack mental capacity to make those decisions. This is very rare.

Even if healthcare professionals advise you not to give birth at home, no one can make you go to hospital.

Your midwife and hospital consultant (if you have one) should work with you to make a care plan for giving birth at home.

When professionals give you advice and information about where to give birth, it should be based on facts, not personal opinions.

Healthcare professionals must not put pressure on you, or threaten you, when you are deciding where to give birth. They must not threaten to involve social services. If you feel this has happened, you may not have given consent to the treatment you received. This could mean that the healthcare professional can be taken to court for failing to obtain your consent.

Yes. All people in the UK have a right to maternity care in hospital.

Your GP will tell you which hospitals have maternity services in your area, and you can choose which one to use.

You can ask to use a different hospital. If your GP will not refer you to the hospital you choose, you can refer yourself. Look on the hospital's website or ask its maternity team for the self-referral form.

Yes. The government says everyone in the UK should be able to choose between giving birth in hospital, in a birth centre, or at home. You should be offered a full discussion of the risks and benefits of the options you are considering.

If there is no birth centre in your area, or you want to use a different birth centre, you can ask your GP to refer you or you can refer yourself.

Birth centres often have rules, called admissions criteria, that say people with 'high risk' pregnancies cannot use the centre.

These are not legal rules and they cannot be applied in a blanket way. The centre should use them only to guide them when making a decision about who can use the centre.

The birth centre must only refuse to allow you to use the centre if they feel they cannot provide you with safe care. The centre must have a good evidence-based reason that shows you or your baby are at high risk of harm when giving birth without the support of a hospital obstetric ward. The centre must be able to show that it cannot safely manage that risk. They should consider the risk on a case-by-case basis, looking at what the risks are in your personal situation.
For example, a birth centre might say you cannot use the centre if your labour is being induced and where medical advice strongly recommends the monitoring of your contractions.
Or the birth centre's rules might say that you cannot use the centre if your body mass index (BMI) is above a certain level. However, they should look at what the specific risks are in your case and whether they can be safely managed. They need to have evidence for what they say. They need to discuss it with you, and if they think they cannot safely care for you in the birth centre they need to discuss what alternatives they can suggest (for example, offering similar support such as a birth pool on the labour ward).

Both hospitals and birth centres must make 'reasonable adjustments' so that anyone with a long-term health condition or disability has equal access to their services. This is law, under the Equality Act 2010.

These adjustments could be in the way the hospital or birth centre provides care, accessing and navigating the buildings, providing equipment, or providing services such as British Sign Language interpreters or extra support.

The Equality Act 2010 says the midwifery team should talk to you about what adjustments you need. Your midwife can also ask for help from other teams in the hospital, such as Occupational Therapy, if necessary.

They should talk to you from the start of your pregnancy so that together you can work out the best way they can support you throughout your pregnancy, in labour, and during your post-natal care.

Having a long-term health condition, disability or sensory impairment does not take away your right to choose where you give birth.
For example, a woman who uses a wheelchair should be given a room that she can access in her wheelchair as well as a bathroom that she can comfortably access. She should also be provided with appropriate aids such as a shower stool and toilet frame. An autistic person may ask for a familiarisation tour of the ward or have sensory considerations in their birth plan to make the environment accessible.
If you need help to communicate with healthcare professionals, ask as early in your pregnancy as possible so that you can make informed choices from the beginning.

This might be support with British Sign Language interpreters, large print materials or materials in a form that is suitable for your screen reader.

This might be access to an interpreter for your appointments and care.

Yes. A birth plan lets you tell healthcare professionals about the kind of treatment and care you want.

Your midwife or doctor should help you to make a birth plan (this may be called a personalised care and support plan) that will be included within your maternity records (your digital or handheld notes). If you choose care that is 'out of guidelines' then you may find it helpful to make your birth plan with a consultant midwife or doctor. Your plan should be recorded so that any doctors or midwives who care for you can find it. You might also want to print a copy so that you can give it to your doctor or midwife when you are in labour.

This can include where you want to give birth, so thinking about your birth plan will help you to explore the options and decisions you might make.

You may find it useful to think about what is important to you before you make your birth plan. This can help you to think of the questions you want to ask the healthcare professionals who are supporting you. It can help you have a clear and respectful discussion with them about where you want to give birth and what care you want during and after the birth. You can read more about birth plans on our factsheet Consenting to treatment.

Your midwife and doctor should provide you with information and personalised discussions to help you make informed choices about your care.

When you make your decision, your midwife should support you. They should listen to you and respect what you say. They should help you to get the maternity care you choose.

If you are struggling to find this support, contact the Director or Head of Midwifery at your hospital. If you don't know the details for the Head of Midwifery, you can ask your midwife and/or the Patient Advice and Liaison service (PALS) (in England and Wales) to put you in touch. The Trust website will have a page with PALS details on it. If you are worried, you can look these details up in case you need them.

The Nursing and Midwifery Code says that all midwives must treat people as individuals and respect and uphold their rights. Your midwife is your advocate. They should support you even if your decision doesn't fit the hospital or birth centre's guidelines.

You may want to choose a hospital or birth centre in another area, for example to be near family support. Or you may need to change to a Trust if your circumstances change, for example if you move to a new area during your pregnancy.

If you move, you can book with a hospital or birth centre in your new area for care. You can do this directly by looking on the hospital's website or asking its maternity team for the self-referral form. Alternatively, your GP in your new area can help. You should be able to do this even if you are very late in your pregnancy. You can also ask to book with the home birth team, although they may have a limit on numbers of people they can book or how late they can accept bookings, depending on how they are staffed.

If you are having trouble booking for care after a move, you can contact us for support.

If you are told that you cannot choose the hospital or birth centre you want because you do not live in the right area, you can ask for an exception to be made. Ask:

Even if their policy says you cannot use the services you have asked for, you can ask them to look at the reasons why you want this hospital or birth centre. They need to give you a good reason if they say no.

Wherever you give birth, your postnatal care will be provided in your home area.

Many NHS Trusts now offer only online video tours, photographs or leaflets about their maternity wards and birth centres. These can help you familiarise yourself with the maternity unit. You do not have a right to an in-person tour.

However, if you have a disability or health condition that means you may need reasonable adjustments, ask to visit the hospital or birth centre so that you and the healthcare professionals working with you can plan ahead.

You might want to look at physical adjustments that will be needed, such as a hoist. If you have a visual impairment, the position and nature of the lighting could be important. Autistic people often want to visit ahead so that they know what to expect and can ask for changes that will make their birth experience easier. The key is that everyone is different so you need to visit in order that you and the healthcare team can plan your individual care.

You have the right to ask for a water birth. The hospital or birth centre may have rules about who can have a water birth but these are not legal rules. You can ask how many rooms have a pool in the birth centre or hospital.

If your care team has concerns about whether a water birth is safe, they should offer you a respectful discussion on the risks and benefits in your situation so that you can make an informed decision.

The hospital or birth centre should only say that you cannot access a water birth if they have a good reason based on clinical evidence.

Your midwife and doctor should also help you consider other options, such as using water for pain relief in labour but not for the birth itself.

If you choose a water birth at the birth centre or hospital, you may not be able to access a pool if there is not one free when you arrive. If you are unsure whether a pool will be available, some people decide to hire their own pool for use at home and then transfer when they are ready. If you have a home birth, you can buy or hire a pool to use at home.

Mental capacity means that you can understand the choice you need to make about treatment and can make a decision.

In law, everyone has mental capacity unless it can be shown that you do not.

Very rarely, someone may not be able to give consent to treatment because they are unable to make a decision that they need to make, even when it is very clearly explained and they are given lots of support.

It is very rare to not have mental capacity.

The people caring for you cannot say you do not have mental capacity simply because you do not agree with them.

Most people do not have to pay for their care. The NHS provides free care to those who are 'ordinarily resident' in the UK. If you are not 'ordinarily resident' then you may have to pay for your care. If this applies to you, then this includes maternity care in hospital, in the community and at home. Your NHS Trust must tell you if you will be charged for your care.

Even if you have to pay for your care and cannot afford to do so, you must still be given maternity care. You cannot be told that you have to wait until you can pay.

The rules about who has to pay for care, and how charging works are very complicated.
Guidance giving you the choice of where to give birth
The 2016 Better Births report for NHS England set out that women should be able to decide where they want to give birth; whether this is at home, in a midwifery unit or in an obstetric unit. This also applies to birthing people who do not identify as women.

The other nations of the UK have the same expectations of maternity services in their areas. Here is their guidance:
Guidance on home births
The legal position is that you have the right under Article 8 of the Human Rights Act to a private and family life which includes the right to choose where you give birth and who is present.

However, this is a qualified right which means that the rights can be restricted where there is a legitimate aim such as protecting the health of others, and the restriction is 'proportionate'.

This means that the Trust should only suspend their home birth service if they have looked at all the options for keeping it going including using local Independent Midwives or bringing back retired midwives to supplement their team, and looking at alternative ways to transfer into hospital if the ambulance service is under pressure (this last realistically applies only in times of severe crisis such as a pandemic).

The UK's guidance is set out in:

In 2016 the NHS Ombudsman accepted that an NHS Trust that suspended its home birth services and refused to make contingency plans was acting unreasonably. They were told to start providing the service again and to work with other Trusts to provide support for home birth in the meantime.
The Nursing and Midwifery Council Code
The Nursing and Midwifery Council Code sets out professional standards of behaviour for nurses, midwives and nursing associates in the UK. It says that midwives need to put the interests of people using maternity care first.
About Birthrights
Birthrights factsheets give you information about your human rights when you are pregnant and giving birth.

Birthrights champions respectful care during pregnancy and childbirth by protecting human rights. We provide advice and information to women and birthing people, train doctors and midwives, and campaign to change maternity policy and systems.

We are a charity, independent of the government and the NHS.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
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Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Can I choose where to give birth? Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives.

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This page is intended to explain in outline the situations where induction of labour might be offered, what it might involve and what options you have. There is a lot more detail on all these topics in our book AIMS Guide to Induction of Labour(principal author Nadia Higson.)

What is induction of labour?

There is increasing evidence that babies send chemical signals when they are ready to be born, and in particular when their lungs are ready to start breathing. This causes the mother's body to produce chemicals called prostaglandins that start the physiological process of labour.

Inducing labour means taking action to bring forward the start of labour rather than waiting for this physiological process to begin. It is often understood to mean medical methods, but self-help methods or complementary therapies when used to start labour are also a form of induction. All these methods are trying to stimulate or mimic the physiological process of labour and this can have consequences.

Why might I be offered an induction?

According to NHS Maternity Statistics the proportion of labours in England that are induced has increased from 21% in the year to March 2010 to 34% in the year to March 2021.

There are many different situations in which induction is offered. The point in pregnancy at which it is suggested will depend on the reason for suggesting it. It might be because there is a cause for concern about the wellbeing of you and/or your baby. Depending how far advanced your pregnancy is, your decision on the timing of an induction may need to be a trade-off between the risk to your baby of being born too soon, and the risk of continuing your pregnancy.

More often induction is offered because of a concern that problems might develop or some risks to you or your baby (including stillbirth) might increase if the pregnancy were to continue beyond a certain number of weeks. The quality of the evidence about whether there really is an increased risk in these situations, and if so whether induction would reduce it, varies a lot. In some cases there is good evidence that induction can reduce the chance of harm to you and/or your baby, but often the evidence is limited, of poor quality and even contradictory, and sometimes it is virtually non-existent. It's also usually the case that the actual risks remain low, whether or not labour is induced.

Due to the limitations of the evidence, it's often a case of considering which view you feel more comfortable with: "Induction might help, so why not do it just in case?" or "There's no evidence that induction does any good, so why do it?"

Below is a brief discussion of some of the common reasons for induction to be offered, but there are many others, and a full discussion of the evidence about induction in various situations is beyond the scope of this article. For more details of situations in which you might be offered induction, a review of the evidence for each and a list of things that you may want to consider, see the AIMS Guide to Induction of Labour, or contact the AIMS Helpline for information and support.

Your waters broke before your labour started: The NICE guideline recommends offering a choice of induction either after 24 hours or straightaway if your waters break after 37 weeks of pregnancy (though it's up to you if you want to wait longer than this). This is to avoid an increased risk of infection for you or your baby. Most labours will start naturally within 24 hours of the waters breaking. The evidence review 'Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)' suggests that induction may reduce your chance of developing an infection yourself, but there may be no difference in the chances that your baby will. None of the evidence is of high quality, and any additional risk appears to be small.

If your waters break earlier in pregnancy there is evidence that it may be better to wait for your labour to start at least until 37 weeks if there is no other cause for concern, to avoid the risks to your baby of being born prematurely.

Your pregnancy has lasted 41 weeks: The NICE guideline recommends that you should be told that "some risks associated with a pregnancy continuing beyond 41+0 weeks may increase over time" and induction from 41 weeks "may reduce these risks", but that you "will also need to consider the impact of induction on [your] birth experience when making [your] decision". The risks they list are: a higher chance of a caesarean birth; your baby being admitted to a neonatal unit; and stillbirth or neonatal death. However, they say that the evidence that induction reduces these risks is not "definitive" and "the absolute risk remains low" whether or not labour is induced after 41 weeks. In fact, the evidence from different types of study is contradictory. One recent review suggests that about 500 inductions of pregnancies that have lasted 41 weeks would be needed in order to avoid one baby dying.

There are guidelines that recommend offering induction or a planned caesarean earlier than 41 weeks if you have any of the following risk factors. Please see the relevant guideline or the AIMS Guide to Induction of Labour for details.

You have Type 1, Type 2 or Gestational Diabetes Mellitus[9] especially if your baby is also predicted to have a high birth weight

You have high blood pressure that can't be controlled with drugs, or develop

You develop severe Intrahepatic Cholestasis of Pregnancy[11]

You are expecting twins or triplets[12]

You might also be offered induction before 41 weeks for various other reasons (such as your age or the fact that you conceived through IVF), but you should be aware that there is no good evidence to support this.

Your baby is expected to have a high birth weight but you don't have diabetes: The NICE guideline says that in this situation "there is uncertainty about the benefits and risks of induction of labour compared to expectant management". For this reason they have not made a recommendation about offering induction earlier than 41 weeks.

Your baby seems to be growing slowly but is otherwise well: A package of measures designed to address the national stillbirth rate (the Saving Babies' Lives Care Bundle) recommends induction between 37 and 38 weeks for the smallest 3% of babies (below the 3rd centile), and at 39 weeks for babies between the 3rd and 10th centiles. However, the majority of these small babies are born in good health and being born early also carries some risks. At present, we do not have enough evidence to show whether it is always better to induce labour when a baby seems small, or to wait and monitor the baby's growth and well being.

Can I decline an induction?

It is your right to decide whether to accept the offer of induction and no-one should try to pressure or bully you into it. The new NICE guideline on inducing labour makes it very clear that your midwife or doctor should "recognise that women can decide to proceed with, delay, decline or stop an induction. Respect the woman's decision, even if healthcare professionals disagree with it, and do not allow personal views to influence the care they are given". For more about your rights to make decisions, and your care team's duty to give you information to help you decide, see our webpage Making decisions about your care and our book AIMS Guide to Your Rights in Pregnancy & Birth (principal author Emma Ashworth.)

Can I request an induction?

Although you have the right to decline an induction, you do not have the right to insist on one, but your doctor should at least be prepared to consider your request. The NICE guideline says, "Consider requests for induction of labour only after discussing the benefits and risks with the woman, taking into account the woman's circumstances and preferences". If you feel strongly that this is the right thing for you, or are worried about you or your baby's well being if they are not born soon, and feel that you are not being heard, you have the right to ask for a second opinion from another doctor.

When should I not be offered induction?

The NICE guideline says that induction "is not generally recommended" for babies in the breech position (bottom down) but could be considered if your baby needs to be born soon and you don't want a caesarean. It also says that labour should not be induced if a baby has very poor growth and is also showing signs of distress, but a planned caesarean should be offered. You should not be offered induction just because of a previous very fast labour.

What is involved in an induction?

Non-medical methods of induction

Unfortunately, very little research has been done on the effectiveness or safety of these methods and most of the studies that have been done were small.

There is some limited evidence that nipple stimulation, acupuncture or acupressure, and eating dates in the last few weeks of pregnancy can help to bring on labour. There is a lack of clinical evidence about whether other self-help methods (such as eating curry or pineapple, or having sex) or using complementary therapies (such as hypnotherapy, homeopathy, reflexology or aromatherapy) work. However, people do report finding them helpful, and trying them may make you feel more in control and able to relax. This could in itself make it more likely that your labour will begin without the need for medical induction.

Raspberry leaf (as tea or tablets) is often suggested but there is no evidence that this helps to start labour, and it may have potential adverse side-effects or interact with other medications such as insulin, so check with your midwife before taking it.

Methods of medical induction

This section gives a basic outline of the methods that you may be offered, but for details of the evidence on the effectiveness, benefits and risks of these please see the AIMS Guide to Induction of Labour.

The methods that you are offered will depend on how far your body has progressed in its preparation for labour (your Bishop's score). To assess your Bishop's score a midwife or doctor would need to perform a vaginal examination to feel how much your cervix has softened, thinned and started to dilate. A high Bishop's score makes it more likely that an induction will be successful, so before making decisions about induction you might want to ask what your Bishop's score is.

A membrane sweep involves a midwife or doctor carrying out an internal vaginal examination, and at the same time passing a finger inside your cervix and moving it around to loosen the membrane. The NICE guidelinerecommends you should be offered a sweep at an antenatal appointment after 39 weeks if you want it.

Evidence suggests that a sweep makes it about 20% more likely that you will go into labour without further interventions, but you are no more likely to avoid a caesarean or assisted birth. A sweep may be more painful than a regular vaginal examination and can cause bleeding.

If you have decided to proceed with an induction and your Bishop's score is still six or less, the NICE guidelinerecommends that you should be offered the choice of either artificial prostaglandins or a mechanical method to encourage your cervix to ripen further.

There is evidence that prostaglandins are effective at bringing on labour, but they can cause severe pain and nausea, and sometimes very strong, frequent contractions (hyperstimulation), which can be stressful for the baby.

The evidence about mechanical methods is more limited but they do not seem to carry the same risk of hyperstimulation and one type (called a balloon catheter) has been shown to be effective.

With both methods it could take 24 hours (sometimes much more) before you are in active labour.

Once your Bishop's score is above six, the NICE guidelinerecommends having your waters broken artificially (called amniotomy or ARM) and then being given a synthetic version of the hormone oxytocinthrough a drip to encourage strong labour contractions, either at the same time or a bit later.

There is no direct evidence for the effectiveness of either of these methods if labour has begun but is progressing slowly following induction with prostaglandins or a mechanical method. There is some evidence that synthetic oxytocin helps to shorten a labour that started naturally so it may have a similar effect in an induced labour. Both methods have potential risks which include more pain and increased stress on you and your baby.

How might having an induction affect my choices for the birth?

Agreeing to an induction could affect your other choices and your experience of birth.

You would be asked to agree to repeated vaginal examinations to assess your Bishop's score and check progress.

Your choice of birthplace is likely to be limited to a hospital labour ward as procedures like breaking your waters or giving a hormone drip would not be done at home or in a birth centre.

It may mean spending several days in hospital before getting into active labour.

You may not be able to have a partner or supporter present throughout the early stages of induction

You may have limited options for pain relief especially in the early stages, and may find it harder to get agreement to use a birth pool.

An induced labour may be more painful, especially if you have your waters broken or use a hormone drip.

Continuous monitoring is likely to be recommended for an initial period after the insertion of prostaglandins or a mechanical induction device. It may also be offered if you have your waters broken and is usually recommended if you use a hormone drip.

If the induction fails to work you may need to consider having an unplanned caesarean.

What can help me make decisions about induction?

The NICE guidelinerecommends that you should have a chance to discuss your options for the birth early in your pregnancy and again later on. You may find it helpful to have this conversation early so that you can start thinking about your preferences, especially if you know you are likely to need to consider an induction. Alternatively, you may prefer to focus on positive preparation for labour and not think about induction unless a reason arises. This could happen late in your pregnancy, and mean that you do not have very long to think about it.

Depending on your circumstances and how things develop, there are various decisions you might want to make including:

Whether you want to bring forward the time of your baby's birth or wait for labour to start naturally.

If you decide to bring your baby's birth forward, whether to have an induction or a planned caesarean and at which week of pregnancy to do this.

If you decide to have an induction, which methods you want to use to try to start your labour, including whether to have one or more membrane sweeps in late pregnancy, and whether you prefer prostaglandins or a mechanical method.

If you would like to go home in the early stages of induction if all is well.

If the ripening methods fail, whether to try again (e.g. have another dose of prostaglandin), try ARM and an oxytocin drip, wait a while, or request a caesarean instead.

What methods of pain relief you'd like to use (See our webpage Ways of managing your labour)

You may find it helpful to look at our webpage Making decisions about your care and the section in the AIMS Guide to Induction of Labour called 'Discussing induction with doctors and midwives'. This includes a list of questions that you might want to ask your carers. There are also sections on what may help an induction to work and things to consider if you are planning an induction.

References

[1] Higson N. (2020) AIMS Guide to Induction of Labour. shop.aims.org.uk/products/aims-guide-to-induction-of-labour

[2] Gao L. et al Steroid receptor coactivators 1 and 2 mediate fetal-to-maternal signaling that initiates parturition J Clin Invest 2015 Jul 1;125(7):2808-24. www.jci.org/articles/view/78544

[3] NHS Maternity Statistics, England - 2020-21 - NHS Digital, November 2021 digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2020-21

[4] NICE Guideline 'Inducing Labour', November 2021 www.nice.org.uk/guidance/ng207

[5] Middleton P et al Cochrane review 'Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)' January 2017 www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005302.pub3/full

[6] RCOG 2019 "Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation (Green‐top Guideline No. 73 ) obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.15803

[7] Chippington Derrick D. & Higson N 'Labour Induction at Term - How great is the risk of refusing it?' AIMS Journal, 2019, 31:1 www.aims.org.uk/journal/item/induction-at-term

[8] Middleton P et al Cochrane review 'Induction of labour at or beyond 37 weeks' gestation' July 2020 www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004945.pub5/full

[9] NICE guideline 'Diabetes in pregnancy', December 2020 www.nice.org.uk/guidance/ng3

[10] NICE guideline 'Hypertension in pregnancy', June 2019 www.nice.org.uk/guidance/ng133

[11] ICP support 'Guideline for managing ICP', August 2019 www.icpsupport.org/protocol.shtml

[12] NICE guideline 'Twin and triplet pregnancy, September 2019 www.nice.org.uk/guidance/ng137

[13] Editor's note: The term 'expectant management' means waiting to see or waiting for labour to start.

[14] Saving Babies' Lives Care Bundle: www.england.nhs.uk/mat-transformation/saving-babies

[15]Making decisions about your care. AIMS 2020. www.aims.org.uk/information/item/making-decisions

[16] Ashworth E. (2020) AIMS Guide to Your Rights in Pregnancy & Birth. shop.aims.org.uk/products/aims-guide-to-your-rights-in-pregnancy-birth

[17] Raspberry leaf tea during pregnancy www.babycenter.com/pregnancy/diet-and-fitness/red-raspberry-leaf-tea_40007946

[18] Raspberry Leaf and Hypoglycemia in Gestational Diabetes Mellitus
pubmed.ncbi.nlm.nih.gov/27824754
[19] Finucane E.M. et al Cochrane review 'Membrane sweeping for induction of labour', February 2020 www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000451.pub3/full

[20] Editor's note: ARM stands for Artificial Rupture of the Membranes. AIMS has a useful glossary of terms here: www.aims.org.uk/general/glossary

[21] Editor's note: Ripening refers to the measures taken to soften the cervix in preparation for the further stages of the induction process. Ripening happens naturally in the days before the spontaneous onset of labour.

[22] Ways of Managing Your Labour. AIMS 2018 www.aims.org.uk/information/item/managing-labour

Written by: Nadia Higson
Reviewed by: Debbie Chippington Derrick and Julie Milan
Reviewed on: 01/02/2022
Next review needed: 01/02/2024

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. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

Published on 9th March 2022

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information for parents about induction of labour and the decisions that are theirs to make

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Induction of Labour/C-Birth & Other Stories Gloucester

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Induction of Labour/C-Birth & Other Stories Gloucester

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We have been working with women and their families to share their experiences of having a baby in Gloucestershire. Thanks go to all those that have kindly shared their stories with us and have agreed to appear on camera, we hope you enjoy watching them. If you are affected by any of the films here and need some support then please contact your midwife, health visitor or GP.

If you have a story you would like to share with us then please email glicb.glosmvp@nhs.net

Coping in early labour

Reduced Fetal Movement

Pregnancy and my mental health - Jenni's story

First few weeks

My postnatal mental health experience - Charlie's story

Vaginal Birth After Caesarean (VBAC)

Induction of labour

Having a caesarean

Ambulance transfer

My Choice - Philippa's Breech Delivery

My experience of labour and birth - Helen's story

Aquanatal

Yoga in pregnancy

Jenni's experience of Cognitive Behavioural Therapy (CBT)

The Birth Unit at Gloucestershire Royal Hospital

Having a baby at Aveta Birth Unit, Cheltenham

Giving birth at Stroud Maternity

Having a natural birth on delivery suite at Gloucestershire Royal Hospital

S.H.E.D (Support and Help for Every Dad)

In the past 10 years, approximately 5,000 fathers have had a child on Gloucestershire Royal's Neonatal Unit. Here are some of their stories.

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We have been working with women and their families to share their experiences of having a baby in Gloucestershire. Thanks go to all those that have kindly shared their stories with us and have agreed to appear on camera, we hope you enjoy watching them.

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Induction of labour care in the UK: A cross-sectional survey of maternity units

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To explore local induction of labour pathways in the UK National Health Service to provide insight into current practice. National survey. Hospital maternity services in all four nations of the UK. Convenience sample of 71 UK maternity units. An…

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If you're induced it means your labour is started artificially. Labour is usually induced when doctors think it's safer for your baby to be born sooner rather than continuing with your pregnancy. This may be because you are overdue, your labour is taking longer to start, or you have medical conditions, such as gestational diabetes or pre-eclampsia. You will have a choice about whether or not to have an induction, and about which methods are used.

What does being induced mean?

Your labour is described as "induced" when it's started artificially. You'll be offered an induction of labour if your doctor thinks that it is safer for your baby to be born sooner rather than continuing with your pregnancy (NICE 2021).

Though most labours begin naturally, you may need a little help to get started.

Why might my labour need to be induced?

You're likely to be offered an induction if:

Your pregnancy has gone beyond 41 weeks (NICE 2021), though the exact timing may depend on your hospital's policy. Being overdue is the most common reason for induction (NICE 2008).

Your waters have broken, but labour hasn't started. If you don't go into labour within a day or so, there is an increased risk that you or your baby could develop an infection. So you'll be offered an induction about 24 hours after your waters break (NICE 2021, NICE 2014).

You have diabetes, which means there's a small risk that your baby will be larger than normal. If you have type 1 or type 2 diabetes and your baby is growing as expected, your doctor will recommend you have an induction between 37 weeks and 38 weeks of pregnancy. If you have gestational diabetes and your pregnancy is going well, your doctor will advise induction no later than 41 weeks (NICE 2015a). If there are signs that your baby is big, your doctor may recommend a caesarean as the best option for you.

You have a chronic or acute condition, such as pre-eclampsia or kidney disease, that threatens your wellbeing, or the health of your baby (NICE 2019).

You are 40 years of age or older, which can carry a higher risk of stillbirth. Being induced at 39 weeks to 40 weeks of pregnancy may reduce the risk, particularly if you have other complications (RCOG 2013).

You may have your own reasons for wanting an induction. For example, you may be worried about pregnancy complications, or if you've previously had a baby who was stillborn. Or you may want your labour to be induced if your partner would otherwise miss the birth.
What your doctor and midwife advise will be based on your individual circumstances, as well as checks to see if your body is ready for labour (NICE 2008, 2021).

There should be time to ask questions, and time to talk to your partner, so that you come to a decision that feels right for you (NICE 2021). Induction interventions are "offered" to you, which means that you can refuse if you want to, and your midwife or doctor should respect your decision (NICE .

How will my labour be induced?

There are a few methods your midwife can use to try to get your labour started. They'll use a vaginal examination first, called the Bishop score, to assess how ready your cervix is for labour. Depending on your Bishop score, some induction methods may need to be repeated, or you may need to try more than one before your labour progresses well.

Here's the order in which you're likely to be offered particular methods of induction and what they mean:

Membrane sweep

A membrane sweep is when a midwife or doctor sweeps their finger around the opening of your cervix. This can encourage labour to start. Your midwife may offer you a sweep if you're full term. They'll suggest a sweep at your 40-week appointment and again at 41 weeks if this is your first baby. If you've had a baby before, you should be offered a sweep at your 41-week appointment (NICE .

If your waters have broken but labour hasn't started, membrane sweeps are not recommended, as they can increase your risk of infection (NICE 2014).

The membranes are the sac that surrounds your baby and that holds the amniotic fluid in. During a sweep, your midwife tries to separate them from your cervix, to directly stimulate the production of prostaglandin, which may help to kick off contractions and labour. If your cervix is not dilated enough to do a sweep, your midwife may stretch or massage your cervix instead. This is why the procedure is sometimes called a stretch and sweep.

You may be offered several membrane sweeps before labour starts. It can be uncomfortable and even painful while you're having this done, and afterwards you may have some cramps and bleeding (Mozurkewich et al 2011, NCT 2018, NICE 2008). If you are unclear about anything, ask your midwife to explain. If you decide against a membrane sweep, you can wait for labour to start naturally or use a more formal method of induction, if it's offered to you.
Prostaglandin
Prostaglandin is a hormone-like substance that causes your cervix to ripen, and which may stimulate contractions. Before using it, your baby's heartbeat needs to be continuously monitored for 30 minutes and your Bishop score assessed (NICE .

Your midwife will insert a tablet, pessary or gel containing prostaglandin into your vagina. The slow-release pessary, Propess, looks a bit like a tampon. If you're given Propess, you have to lie on your side for 30 minutes so the pessary has time to absorb moisture and swell (EMC 2018a) . You'll then be able to move about.

While you wait for prostaglandins to work you can usually go for a walk. Depending on why you're being induced, you may even be able to go home while you wait for your contractions to start (NICE . You'll need to be examined after six hours with a tablet or gel, or after 24 hours with a Propess pessary (NICE 2008) unless your contractions start sooner.

Prostaglandins may make you feel feverish, nauseous, be sick or give you diarrhoea and they can make your vagina feel sore, although these side effects are less common with Propess (EMC 2018a,b,c).

If prostaglandins don't work at all, you may be offered induction again at a later date (NICE . If your doctor thinks that it may be safer for your baby to be born sooner, you may be offered a caesarean instead (NICE 2008, 2021).

There's a very small risk that using vaginal prostaglandins may cause your womb (uterus) to become overstimulated (NICE . This means that you may develop very intense, frequent or long-lasting contractions, which could be stressful for your baby. This is known as hyperstimulation.

If your womb does start to hyperstimulate, you can be given medication to stop or slow down your contractions. As Propess is similar to a tampon, it can simply be pulled out by your midwife. This alone can help your womb to settle (NICE .

Balloon catheter or other mechanical methods

Depending on where you live in the UK, your midwife may offer to induce your labour by inserting a balloon catheter into your womb. A balloon catheter helps to open your cervix using gradual physical pressure. The catheter is inserted into your womb while deflated, then slowly inflated with a little saline solution (Ezakoff and Kilpatrick 2013). As the balloon fills, it puts pressure on your cervix and encourages it to dilate, stimulating your labour to start.

Sometimes the catheter has a second balloon which is inserted in your vagina and inflated in the same way, gently applying pressure on both sides of your cervix. If you've had a previous caesarean section, however, you won't be offered a double balloon catheter (NICE 2015b,c).

Balloon catheters are left in place, usually for up to about 12 hours, while you are monitored. If your labour starts, your waters break, or your baby shows signs of distress the device will be removed (NICE 2015b).

Having a balloon catheter inserted may be uncomfortable but it should not be painful (Ezakoff and Kilpatrick 2013). Most women give birth within 24 hours of having a balloon catheter inserted (NICE 2015b,c).

Other mechanical methods involve dilators that swell as they absorb cervical and other fluids, putting pressure on your cervix and encouraging it to open (de Vaan et al 2019, Ezakoff and Kilpatrick 2013).

These methods appear to work just as effectively as prostaglandins and carry a lower risk of over-stimulating your womb (de Vaan et al 2019, NICE 2015b,c).

If your labour does not start using a balloon catheter, your doctor may recommend that you move on to other methods of induction (NICE 2015b).

Artificial rupture of membranes (ARM)

Also called breaking the waters, ARM is used by your midwife or doctor to speed up your labour if it's not progressing. ARM is also occasionally used earlier as part of the induction process if you're having problems with the vaginal prostaglandins, such as very frequent or very long contractions (NICE 2008).

Your midwife or doctor will make a small break in the membranes around your baby. They'll use either a long thin probe (amnihook) or a medical glove with a pricked end on one of the fingers (amnicot). It can be quite uncomfortable, so you may be offered gas and air to help you relax.

ARM is no longer recommended as a method of induction on its own as it doesn't always get labour started, and once your waters have been broken, your baby could be at risk of infection (NICE . If your midwife or doctor suspects an infection, you'll be given antibiotics.

Syntocinon

Syntocinon is a synthetic form of the hormone oxytocin, which your body releases to help labour progress. You'll only be offered Syntocinon if a membrane sweep or prostaglandin hasn't started your labour, or if you're having contractions but your labour isn't progressing.

You'll have Syntocinon through an intravenous drip. Once your contractions have begun, the rate of the drip can be adjusted. This allows contractions to happen often enough to make your cervix dilate, without becoming too powerful.

Syntocinon is started at a very low dose and increased gradually to prevent it from over-stimulating your womb or causing stress to your baby. Don't worry, your midwife will ensure that your baby is monitored continuously to make sure all is well (NICE 2014).

The contractions brought on by Syntocinon tend to be more intense than natural ones. So you should be offered an epidural for pain relief (NICE .

The risk of Syntocinon causing your womb to become overstimulated or hyperstimulated is low (NICE . If this does happen, and turning down or stopping Syntocinon isn't enough, you'll be given medication to slow your contractions.

How can I prepare for my induction?

You have a choice about whether or not to have an induction, and about which methods are used. Your midwife or doctor may suggest that one method is better than another, depending on how soft and ready for labour your cervix is.

There's some evidence that if your labour is induced, you may be slightly more likely to need instruments such as forceps or ventouse to help your baby to be born (Middleton et al 2018, NICE . However, if you are near to term, being induced should not increase your chance of needing a caesarean and may even make a caesarean less likely (Middleton et al 2018, NICE 2014, RCOG 2013, Thomas et al 2014).

Before you go into labour, you may want to consider what pain relief you may want if the induction works and makes your contractions very strong and difficult to cope with.

Find out more about how induced labour is different and what it might mean for you by reading other BabyCentre parents' tips based on their experience.

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You're offered an induction if you need help getting labour started. Get more information about what do inductions mean, why you might be induced, the methods...

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The natural caesarean - a woman centred technique

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Cwm Taf Morgannwg University Health Board

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A caesarean birth is when the baby is born by abdominal surgery. One in every four women in the UK will have a caesarean birth. Some will be planned while others will undergo an emergency caesarean. This will be undertaken by an obstetrician (Pregnancy Doctor).

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Third Stage of Labour

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Choosing between Active and Physiological Delivery of the Placenta
Whether you plan to give birth at home or in hospital, you can choose to have drugs to help you deliver the placenta, or to go for a 'natural' third stage.

'Active management', or a 'managed third stage', means that you have an injection as the baby is born, or shortly afterwards, which makes your uterus contract strongly to push out the placenta quickly, and then makes it clamp down tight to reduce bleeding after the placenta is delivered. In the UK, the drug most often used is Syntometrine - a combination of Syntocinon, to bring on strong contractions, and Ergometrine, to make the uterus clamp down tight afterwards.

The advantages of an actively managed third stage are that the third stage is usually over quickly, and average blood loss is lower. The mother does not usually have to 'do' anything - she just waits, while the drugs and the midwives do the work!

The disadvantages of an actively managed third stage for the mother are:-

some women feel sick, dizzy or faint or have a headache after the drug is injected, and some vomit and are unable to hold the baby for a while after birth because they feel so bad. Estimates of the proportion of mothers so affected vary from 1 in 8 to 1 in 3, so while the majority of mothers will feel fine after Syntometrine, the risk of 'minor' side-effects is appreciable.

Blood pressure changes can be significant for some women -

There is thought to be a higher risk of trapped placenta, where the placenta is stuck inside the uterus, if it is not delivered before the ergometrine component of the drug makes the uterus clamp down. If a trapped placenta occurs, it usually has to be manually removed in an operating theatre.

Active management has serious drawbacks for the baby IF the cord is clamped before it has ceased pulsating. It is not necessary for Syntometrine to be given this quickly, but usual practice in the UK is to give the injection as the baby's shoulders are born, or immediately after the birth. The cord is usually clamped before the injection is given, because of theoretical concerns about the powerful shunt of blood from the induced contractions causing an 'overtransfusion' - the baby getting too much blood, which could lead to polycythaemia (causing a serious form of jaundice). Current evidence appears to suggests that neither of these is a real risk. The downside of early cord clamping is that the baby does not get the benefit of the oxygen-rich blood in the cord and placenta which would come to it in a natural third stage. This is now known to increase the baby's risk of becoming anaemic in infancy. Moreoever, the oxygenated blood in the cord and placenta would normally tide the baby over for the few minutes while the cord pulsated, providing extra oxygen while the baby established breathing. This cord blood is rich in stem cells, and we do not yet know if these have a role to play in recovery from birth.

Delaying cord clamping for a few minutes after the baby is born is now becoming rather mainstream, thankfully; the Daily Mail has even published an article on it!

Another recent article by a US obstetrician, Nicholas Fogelson MD, discusses ' Why delayed cord clamping should be standard practice in obstetrics'. The comments section is extensive and well worth a read, containing input from midwives, doctors and birth supporters from varied backgrounds. Follow-up articles and video presentations are also available.

See also the Facebook page - Delayed Cord Clamping UK.

For more discussion of the effects of early clamping on the baby, see Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping.

Much of the research on cord clamping is fairly recent and practices in obstetrics are only just starting to change. It is now being questioned whether early clamping is indeed necessary after an injection of syntometrine, but as early clamping is currently standard practice, you may find that your caregivers are either not up to date with the latest research, or disagree with it. This is changing rapidly in the care of premature babies, and is starting to filter through to the mainstream.

Here, for example, is a quote from a letter to the BMJ from a consultant obstetrician, explaining why his unit has changed arrangements so that they can resus after caesareans with the cord still attached:

From http://www.bmj.com/cgi/eletters/333/7575/954 "Fetal distress is a common reason for instrumental delivery or caesarean section. The fetal compromise is often due to cord compression associated with a nuchal cord. A nuchal cord results in compression of the low pressure venous return of oxygenated blood from the placenta. Blood continues to be pumped out by the fetal heart and the obstructed return from the placenta results in a congested placenta and a depleted fetal blood volume.
If the cord is clamped immediately at delivery, although the return from the placenta is now relieved, the excess blood, which is oxygenated blood, never has any opportunity to return to the newborn.
In these circumstances it is particularly important to be able to resuscitate the baby with the cord return still intact. Preparation for neonatal resuscitation needs to be made at the same as preparation for the caesarean section. Every maternity unit in the UK needs to adopt these guidelines.
David Hutchon

There are quite a few other interesting letters on that BMJ letters page, with a number of references to research on cord clamping and anaemia etc..
The Journal of American Medical Association published a meta-analysis of early versus late cord clamping in full-term newborns, which you can read in full here:http://jama.ama-assn.org/cgi/reprint/297/11/1241
They found that there was no increase in the incidence of clinical jaundice or need for phototherapy with 'late' cord clamping, although there was some increase in neonoatal polycythaemia. In the higher-quality studies this association did not reach statistical significance.

What they DID find was that late clamping was associated with better iron status, as measured by serum ferritin levels, to six months and beyond, and also with less anaemia in the newborn periods. The babies who were breastfed and who experienced 'late' cord clamping had proportionately higher iron stores at six months than the babies who were no longer breastfed.

Abstract copied below.
See also NHS electronic library for health discussion of the paper
http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=12007008099

This subject is returned to in the section below on resuscitation with the cord intact.

'Physiological management', or a 'natural' third stage, means that drugs are not automatically administered to deliver the placenta, but that the woman waits for it to arrive naturally, and drugs can be given at any time if blood loss seems worrying or if she decides she has waited long enough. If, at any stage, the woman's blood loss worries her or her midwives, she still has the option of having drugs to push out the placenta and control bleeding.

The downside of a 'natural' third stage is that it takes longer to deliver the placenta, on average, and that average blood loss is higher. The Hinchingbrooke trial of active management versus physiological third stage found that 16.5% of women had a clinically significant blood loss of 500mls or over with physiological management, against 6.8% with active management. But when you look at the overall difference in blood loss, as opposed to the number of women who passed that threshold, it was only an average of 80mls approximately (if I recall correctly - will confirm that soon) [Rogers et al, 1998]

How long does a physiological third stage take?

Perhaps not as long as you might think. Research suggests a physiological third stage takes only 9.7 minutes longer than active management, on average [4, Cochrane review]. Yet it is quite common for a natural third stage to take half an hour or an hour or more, although ten minutes is also perfectly normal. Why should it have a reputation for taking so long? In a discussion on third stage [LINK currently DOWN while that site is restructured], a UK midwife commented:

In most normal cases, a placenta will detach from the wall of the uterus within ten minutes (whether you give an oxytocic or not.) Ultrasound studies show this. Sitting around for a couple of hours waiting for the thing to fall out after it has separated is dull, and can be dangerous.

What almost always happens, if you watch carefully and disregard the things you think you know about third stage, is this. The baby is born and the cord pulsates forcefully. The mother greets the baby and gives him or her her full attention. Within three to five minutes she will have a contraction and will usually look up and go 'ooh.' Within five to ten minutes she will have another, nasty contraction and go 'ow,' and whatever she is doing she'll normally shift around uncomfortably. This is because the placenta has hit her cervix. If you feel the cord, then, it may be pulsating, but the pulsation will be weak and thready. If she is in, or gets in an upright position, the placenta will normally plop out. Well within fifteen to twenty minutes.

So what is different about a natural third stage? The mother has to be actively involved in the birth of her placenta; she must push it out herself, and sometimes this involves moving around, and trying different positions and techniques, although, as the experiences below show, it often takes no more than standing up as the placenta slips out. Your baby can be close to you while you are doing this, of course, and for many women a physiological third stage means no more than sitting down,and cuddling the baby for ten minutes or so until she feels the urge to push the placenta out.

While you are waiting, your midwives should observe carefully and may offer advice on techniques to help push the placenta out. For instance, some women find that if they push as if they were trying to do a poo (bowel movement), the placenta rapidly appears. Some midwives recommend that women blow into a bottle to help push the placenta out. A full bladder can make it difficult to pass the placenta; if you find it difficult to urinate, you could try a warm shower or bath, or your midwives may catheterise you.

If you do not have drugs to aid delivery of the placenta, you can choose to either have the cord cut when it has stopped pulsating, or to wait until the placenta is delivered. This last choice is a great excuse to keep your baby 'velcroed' to you straight after birth, rather than having him whisked off to be weighed and measured while you get on with delivering the placenta. On the other hand, some women feel they can't concentrate on delivering the placenta while still attached to their baby. There is some speculation that leaving the cord uncut until the placenta is delivered might somehow help speed up the delivery of the placenta, but I am not aware of any strong evidence for or against this.

I have had physiological third stages for all of my five babies, but while the cord was cut when it stopped pulsating after the first, I left it intact until the placenta was delivered for the others. Personally I really valued the peaceful bonding time this latter choice gave me and my babies. The first time it took about an hour and a quarter and was unpleasant - the cord was cut when it stopped pulsing, and I spent ages sitting there, cold, trying to push the placenta out, while clots built up behind it. The midwives were very relaxed about natural third stages and believed that it was normal for them to take an hour on average. The placenta was separated but I could not feel any contractions to push it out, and eventually passed a large amount of blood clots which had built up inside me behind the placenta, before the placenta came out. After that I swore that I would choose a managed third stage next time, because I felt that precious first hour with my baby had, instead, been spent trying to have a placenta. However, after reading about different approaches to a physiological third stage I decided to be more proactive next time, and it worked beautifully; none of my subsequent third stages took more than 20 minutes, several less than 10, and during that time I was snuggled up with baby having a nice cup of tea! Blood loss was minimal. I had decided that, if the placenta did not arrive within 15 minutes or so, I would ask the midwife for help delivering it and, if that did not get results quickly, have the injection. What worked for me was pushing as if I was having a bowel movement, as soon as I started to feel anything at all!

Michel Odent apparently teaches that it is important to keep oxytocin production up in the third stage, in order to help push the placenta out and contract the uterus down. Things which help this:

Keep warm - ideally mum and baby wrapped up together under a duvet or blanket

Keep the room calm, quiet, low lights

Personally I worry about staying in a birth pool for the third stage because I believe that we hear about more long and difficult third stages when this happens. It may be that the birth pool relaxes some women too much and it is difficult to get strong enough contractions for the third stage. It can be hard for the midwife to keep an eye on blood loss, particularly if the room is dark. A third stage in water can be hassle for other reasons; it can certainly be difficult to keep both mum and baby at a comfortable temperature and to give the baby its first feed, while ensuring that both water level and water temperature are perfect. There is some discussion about this on the page about waterbirth, but I plan to expand on it soon. I am not aware of any research evidence on the safety of conducting the third stage in water, and while certainly many women do it with no problems, it seems reasonable to question it; it's certainly not something we have evolved to do.

Please see the section above on ' Cord clamping - issues for the baby'.

If the baby needs some form of resuscitation, this can be administered while the baby is still attached to the cord - giving it the benefit of all the oxygenated blood in the placenta, as some still pulses down the cord for a few minutes after birth - if the midwife has her equipment near the mother, or if the mother can move to the resus area. If the mother cannot move to the resus area then the midwife can quickly clamp and cut the cord, just as she would in a managed third stage. However, the disadvantage of this is that the baby is deprived of the oxygenated blood which is already in the cord and placenta, and which would be transfused to the baby over the next few minutes - buying it vital time to establish breathing. Increasingly, experienced midwives and obstetricians are resuscitating with the cord attached wherever possible.

The British Medical Journal's editorial on 18 August 2007 focussed on this issue, and concluded:

"Early clamping and cutting of the umbilical cord is widely practised as part of the management of labour, but recent studies suggest that it may be harmful to the baby. So should we now delay the clamping? ..."

"How should we approach cord clamping in practice? In normal deliveries, delaying cord clamping for three minutes with the baby on the mother's abdomen should not be too difficult. The situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. Nevertheless, it is these babies who may benefit most from a delay in cord clamping. For them, a policy of "wait a minute" would be pragmatic.11 Indeed, this first minute is already largely spent on neonatal assessment. This could be done in warmed towels on the birthing bed or the mother's abdomen after vaginal delivery, or on the mother's legs at caesarean section. Cord clamping need only take place when transfer to the resuscitation trolley is required.... "

"There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful. Both the World Health Organization and the International Federation of Gynecology and Obstetrics (FIGO) have dropped the practice from their guidelines. It is time for others to follow their lead and find practical ways of incorporating delayed cord clamping into delivery routines. In these days of advanced technology, it is surely not beyond us to find a way of keeping the cord intact during the first minute of neonatal resuscitation. "

You can read the full text of the BMJ Editorial on Cord Clamping online: BMJ Cord Clamping editorial - pdf
BMJ Cord Clamping editorial - .rtf
Please see Links section below for more links to the original editorial, and to responses from midwives and obstetricians.

More information on resuscitation at homebirths, and birth stories where resus has been given in different ways, can be found on What if your baby needs resuscitation at home?

An excellent article explaining many of the arguments against routine intervention in the third stage is: Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

Here is an extract from the page on Birth Plans, about choices for third stage:
There are four main variations to choose from, but of course if the midwife is worried about your blood loss then (with your permission or without, in an emergency) drugs may be needed, whatever your plans.
I plan to have an actively managed third stage and understand that the midwife will administer syntometrine/syntocinon/whatever drug is used in her practice, when she feels it appropriate, and that the cord will be clamped and cut soon after the baby's birth.

Or: I would like an actively managed third stage, but with cord clamping and cutting delayed until the cord has stopped pulsating. After this, I would appreciate it if you could administer drugs to help me deliver the placenta.

Or: I would like a physiological third stage with the cord clamped and cut when it stops pulsating. I wish no drugs to be used unless specifically indicated. It is important to me that you do not clamp the cord until it has stopped pulsating, unless you need to take emergency steps which preclude this. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.

Or: I plan to have a fully natural (physiological) third stage, and to cut the cord only after the placenta is delivered. I want to allow the placenta to turn up in its own time. It is important that the cord is not clamped or cut until the placenta is delivered. Please do not administer any drugs unless you feel there is a real need. I would appreciate your advice to help me deliver the placenta naturally. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.
Here are some birth stories from women who chose various approaches to the third stage of labour at home births:
Helen H started off with a physiological third stage but opted for the injection after 20 minutes or so - her placenta came quickly. Her second baby was born before the midwife arrived after a rapid labour, and "We were just about to discuss 3rd stage labour when nature answered the question for us. Plop! Out came the placenta and sploshed onto the floor."

Gina R had a 5-hour third stage after a long, tough labour with her first baby. After trying various positions and homeopathy, she delivered the placenta with syntometrine. She went on to have a Lotus third stage, with the placenta separating after two and a half days.

Lynne D had a long third stage in a birth pool and moderate blood loss.

Emma Barrett had 'expectant management'; she hoped for a physiological third stage, but the midwife was worried about her bleeding shortly after the baby's birth, and so switched to a managed third stage.

Amanda B: While Dennis was in my arms, the I received the injection and the midwife tugged on the cord. I felt really scared at this point as it was the only part of the labour that I didn't feel I was in control. However, the placenta just slid out easily and I didn't feel a thing.

Brenda: "I decided to get out of the pool for the third stage, and wobbled to the sofa to gaze in besotted admiration at my baby, and await the placenta while Henry latched on. Then - oh, bum! More contractions. "Why am I having a physiological third stage again?" I wondered. However, I knew perfectly well why I was having one - and about one contraction later, I realised it might help if I moved my big bottom off the sofa, as sitting down was probably not the most conducive position. Sure enough, the moment I moved, out it came - masterfully caught by a midwife with a kidney dish and reflexes a rattlesnake would be proud of."

Rosie Evans wanted to wait and see how the third stage went, before deciding on a management plan. Her daughter's cord was clamped and cut after a minute or so because the midwives wanted to give her some resus out of the pool, and after that: "After a few minutes holding her in the water I decided to have the injection for third stage because I wanted to get out of the pool and into bed ... Six or seven minutes after the injection nothing had happened so with a little help I stood up, and just as I did the placenta fell out.."

Rebecca had wanted the cord left to pulsate, but the midwife didn't realise this and clamped it immediately. Her daughter was a little slow to get going, but was OK in the end. Rebecca writes: "I waited 10 minutes or so for the placenta then took the syntocinon injection to bring it on. Out it came, whole and fine. I lay with my baby and sang a song to her we'd shared when I was pregnant."

Emma: We waited for the cord to stop pulsing, and whilst waiting mummy cuddled and tried to feed. Daddy then cut the cord, after which Daddy had a chance to have a cuddle, after the vitamin K injection had been administered. I was told I would have to get out of the pool for the third stage. And although I had decided not to have the injection, I did change my mind, I was so tired and just wanted it over with. This again was relatively painless and then I was given my baby back and I was a mummy.

Joy bled heavily as her baby was born, but she wanted her baby to benefit from a physiological third stage. She stopped the midwife from clamping the cord, waited for cord to stop pulsing then had syntometrine, which was very effective.

Donna Cummings had a managed third stage in an unhurried way - her baby was born, they said hello, the midwives rubbed him down and then she had the injection.

Amber: "I wanted a physiological third stage, so after about half an hour the midwife asked if I could stand up to see if the placenta would arrive with the help of gravity, but it was a bit more stubborn than that and didn't arrive for another half an hour with a bit more pushing from me. I wasn't concerned but the midwife was getting a bit edgy, and at one point after examining me said she could see the placenta just sat waiting for me to give a shove, and she tugged a bit on the cord. This was naughty as with a natural third stage she should have been hands-off had the cord come away this could have caused complications, but as it was everything was fine and I had estimated blood loss of 300ml."

Kate Marshall waited for the cord to stop pulsing, then had the jab: "I had initially planned to try for a physiological third stage with the cord to be cut once it has stopped pulsating but had indicated that I would be willing to have the injection if required. Given the epic duration of the stop start labour and my general exhaustion the midwife had already asked me earlier if I would consider the injection once the cord had stopped pulsating and I had agreed that things had really gone on long enough. Once the cord stopped pulsating my husband cut it. ..The midwives administered the injection to deliver the placenta and asked me to lay down (as it later transpired they were concerned about the bleeding). The third stage took a total of 5 mins."

Rachel White had a homebirth after two caesareans: "We waited for the cord to stop pulsing before Curtis cut it. We tried for a physiological third stage but blood was gushing so had the injection and delivered the placenta."

Victoria Whitworth chose a physiological third stage; her midwives said they would like her to have syntometrine after an hour, but the placenta turned up after 59 minutes.

Kirsty Crowther had a natural third stage but her placenta was a bit slow, so on her midwife's advice, she delivered it by pulling on the cord herself.

Fiona's placenta took over an hour to arrive naturally with both of her babies. Her midwife encouraged to stand up and try a soothing shower, which did the trick.

Debbie Dooley chose a physiological third stage partly because she is diabetic and her research suggested this would help to stabilise her baby's blood sugar levels. The delivery of the placenta took some time but was not a problem: "We left his cord to stop pulsing and he had his first feed whilst he was still attached to me. Daddy cut his cord around 15 minutes later and had his first cuddle whilst I started pushing again to deliver the placenta. It took about an hour for the placenta to come out naturally, and Caiden fed wonderfully and helped it to detach."

Jem had an unusually painful third stage after the birth of her fourth baby. She did not have syntometrine, and "the midwives said later that it was just as well I hadn't had it, if anything had caused my uterus to contract down any harder I would have been in far more pain, which really doesn't bear thinking about."

Melanie Renowden chose a managed third stage: "I lay down on the bed and had a lovely cuddle while the midwife gave me the injection for the placenta. It was delivered very quickly and easily."

Sally Paech picked up her baby to give her her first cuddle. "I think time stood still while we all marvelled at what had just happened. What seemed like ages after I felt something "drop" from inside me. I again went up on my knees only to have the placenta drop out. Apparently it was only minutes."

Kirsty Nicol gave her body a chance to deliver the placenta on its own, but after waiting a while she moved to a managed third stage: "the placenta just didn't seem to want to budge, and after kneeling up at one point, I suddenly felt hot and dizzy. Quickly the midwives had me lying down, and I was feeling willing to go for the assisted 3rd stage after all." - after which her placenta arrived quickly and easily.

Jeanette was keeping an open mind about her third stage, and after the birth she started to bleed heavily so her midwife suggested an injection of syntometrine, which she had and which worked well. When she had her next baby, Sidney, she was again keeping an open mind, but felt so rotten after the birth that she couldn't stand the thought of waiting for a physiological third stage, and so chose syntometrine again.

Rebecca planned a physiological third stage but, after over an hour "In the end I decided that I had had enough, wanted to get into bed and lie down so I asked for a shot of syntometrine. After this the placenta came out very easily"

Gillian chose physiological management for her third stage, but her midwives were not experienced in hands-off approach, and started hassling her to deliver it in strict time limits. When an hour was up, she used homeopathic remedies, apparently to great effect.

Lonnie Fletcher chose active management after the birth of her second baby, Eloisa, and physiological third stage after the birth of her fourth baby, Aoife.

Sarah Sadler had a home birth and wanted a physiological third stage, but after waiting for the placenta for an hour, decided to use Syntometrine instead.

Brigett English said "I had planned to deliver the placenta naturally, but all I wanted to do was to be with my baby. So the placenta is delivered with the help of an injection.."

Christine chose to have Syntometrine for the third stage of her twins' waterbirth, but it made her sick.

Catriona considered a natural third stage for her third and fourth babies, after unmedicated labours, but each time chose to have syntometrine to get the delivery of the placenta over quickly.

Karen had a natural third stage with her second baby, Lewie, after having had a retained placenta with her first baby.

Kedi had planned to delay cutting the cord until the placenta was delivered, after Beth's home waterbirth, but in the event she wanted to get it over with, so chose to have the cord cut when it stopped pulsating. When her third baby, Isaac, was born, she again wanted to delay cord cutting, but this time the delivery of the placenta took two hours and was quite difficult.

Helen
was just getting bored waiting for her placenta to turn up, when it decided to co-operate.
Vivienne writes that " I'd asked for a physiological third stage and amazingly, it was all over and done with just five minutes after Gabriel was born"

Emily had a fully physiological third stage, minimal blood loss, and cut the cord after the placenta was delivered.

Sarah Calvert waited half an hour for the cord to stop pulsating before cutting it, and then her placenta arrived naturally one hour later.

Emma planned a homebirth for her twins, but transferred to hospital for slow progress. Her waters were broken in hospital, then she gave birth to her twins under her own efforts and had a physiological third stage with very little blood loss.

Tric was dreading the third stage after finding the delivery of the placenta difficult in her three previous hospital births, but with the encouragement of her confident midwife, she delivered it very easily after her waterbirth. She did not have syntometrine for the delivery of the placenta, but because of heavy bleeding she was given the drug afterwards - a "wait and see" third stage.

Carrie planned a physiological third stage but consented to syntometrine when there was a gush of blood after her baby's birth - another good example of "expectant management".

Aida chose a 'lotus' third stage for her baby - the cord was left uncut, with placenta attached, until it separated naturally from the baby. Baby Maia was born in poor condition and needed resusctiation, but this was done with her still attached to her mum.

Sara Gonzales had hospital births with managed third stages for her first two children, and chose an injection of syntometrine for her homebirth as well, as she did not want to wait for the placenta or have to push it out. She had no problems and did not experience any pain when her midwife used cord traction to help her deliver the placenta.

Helen O'Donnell had a physiological 3rd stage with no problems: " I just squatted and I think it just fell out!"

Alicia waited until her first baby's cord stopped pulsating before clamping and cutting. "About ten minutes later I stood up and delivered the placenta, no problem at all. "

Sarah H writes: "My contractions completely stopped once the baby had arrived. I had chosen to have natural third stage and wanted to have time to cuddle my baby, but the midwife was very keen that I get on and finish the job. As there did seem to be a lot more blood in the pool after this birth than the last, I did eventually agree to stand and try pushing the placenta out which worked fine.

Fiona B's second baby arrived very quickly, but her placenta was not in such a hurry: "This took just over an hour, which was starting to worry us, but the threat of a transfer to hospital gave me the incentive to push harder, and it was all fine."

Willow says that immediately after her daughter's birth, "I asked for the injection to speed up the delivery of placenta. I had romantically hoped to breastfeed instantly and slip it out like a real mammal, but in reality I just wanted birth over with.". She had no problems with her managed third stage and it took 13 minutes.

Jessica B: "I intended to get out of the water to have a physiological 3rd stage but I was enjoying cuddling this wailing child and didn't want to leave the pool. ...I was just planning on getting out when I had 3 strong but painless convulsions in quick succession & the placenta fell out to the bottom of the pool. James' cord was subsequently clamped and cut and we got on to dry land again."

Rosie had a 'wait and see' third stage: "I had wanted a natural third stage, but the placenta didn't want to shift. The MW's encouaged me to go to the loo..I sat there for ages, but it really wasn't happening, so I then shuffled back to my bed and had the injection. The placenta followed a couple of minutes later."

Miriam had a home waterbirth with her first baby, and ten minutes later stepped out of the birth pool and delivered her placenta with "no fuss whatsoever"; she had a natural third stage and the midwife simply pulled gently on the cord. Her estimated blood loss was 250mls, which is about average.
Angela Horn
Postpartum Haemorrhage - how would PPH be treated at a home birth? (on this site)

The Third Stage of Labour, from the UK Midwifery Archives - active versus physiological management, and other topics (www.radmid.demon.co.uk/pph.htm)

Review of the Literature on Umbilical Cord Clamping - by Judith Mercer
Journal of Midwifery and Women's Health, November 2001

Why early cord clamping at birth must stop now! By Dr David Hutchon (a UK obstetrician)

Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping. His site is now archived on Dr Hutchon's site - this is the direct link to it.

Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
Fab article drawing together the evidence and arguments in favour of a physiological third stage.
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

You can read the full text of the BMJ Editorial on Cord Clamping online:
BMJ 2007;335:312-313 (18 August), doi:10.1136/bmj.39282.440787.80
Late vs Early Clamping of the Umbilical Cord in Full-term Neonates
Systematic Review and Meta-analysis of Controlled Trials
Eileen K. Hutton, PhD; Eman S. Hassan, MBBCh
Editorial on the BMJ Website - subscribers only until August 2008 (http://www.bmj.com/cgi/content/extract/335/7615/312)
Responses to BMJ - includes interesting comments from midwives and obstetricians - free to all on the BMJ website. Copy of BMJ Cord Clamping editorial - pdf
Copy of BMJ Cord Clamping editorial - .rtf

Delayed clamping of the umbilical cord does no harm and reduces anaemia in newborns
BMJ 2006;332 (13 May), doi:10.1136/bmj.332.7550.0-e

Journal of the American Medical Association
JAMA. 2007;297:1241-1252.
Context
With few exceptions, the umbilical cord of every newborn is clamped and cut at birth, yet the optimal timing for this intervention remains controversial.

Objective
To compare the potential benefits and harms of late vs early cord clamping in term infants.

Data Sources
Search of 6 electronic databases (on November 15, 2006, starting from the beginning of each): the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Neonatal Group trials register, the Cochrane library, MEDLINE, EMBASE, and CINHAL; hand search of secondary references in relevant studies; and contact of investigators about relevant published research.

Study Selection
Controlled trials comparing late vs early cord clamping following birth in infants born at 37 or more weeks' gestation.

Data Extraction
Two reviewers independently assessed eligibility and quality of trials and extracted data for outcomes of interest: infant hematologic status; iron status; and risk of adverse events such as jaundice, polycythemia, and respiratory distress.

Data Synthesis: The meta-analysis included 15 controlled trials (1912 newborns). Late cord clamping was delayed for at least 2 minutes (n = 1001 newborns), while early clamping in most trials (n = 911 newborns) was performed immediately after birth. Benefits over ages 2 to 6 months associated with late cord clamping include improved hematologic status measured as hematocrit (weighted mean difference [WMD], 3.70%; 95% confidence interval [CI], 2.00%-5.40%); iron status as measured by ferritin concentration (WMD, 17.89; 95% CI, 16.58-19.21) and stored iron (WMD, 19.90; 95% CI, 7.67-32.13); and a clinically important reduction in the risk of anemia (relative risk (RR), 0.53; 95% CI, 0.40-0.70). Neonates with late clamping were at increased risk of experiencing asymptomatic polycythemia (7 studies [403 neonates]: RR, 3.82; 95% CI, 1.11-13.21; 2 high-quality studies only [281 infants]: RR, 3.91; 95% CI, 1.00-15.36).

Conclusions
Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.

Author Affiliations: Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario (Dr Hutton); and The Child and Family Research Institute (Dr Hutton), Western Regional Training Centre for Health Services Research (Dr Hassan), and Department of Health Care and Epidemiology (Dr Hassan), University of British Columbia, Vancouver.

[4] The Cochrane review of active management for third stage says physiological third stage takes an average of 9.7 minutes longer than active management. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000007/frame.html
This page updated 22 January 2010.
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Home Birth Reference Page
Site Contents

www.homebirth.org.uk

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Choosing between active and physiological delivery of the placenta

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Delivering the placenta

After your baby is born, your midwife should check how you are. The placenta (which is also known as the afterbirth) will be delivered or pushed out. This is called the third stage of labour. You can usually hold your baby during this stage if you want to.

When you were pregnant, a midwife should have explained to you about the 2 options for the third stage, and about the pros and cons of each. They are called active management and physiological management.

Injection of a drug called oxytocin into your thigh, usually as you give birth

No injection is given

The cord is clamped and cut between 1 and 5 minutes after the birth

The cord is clamped and cut once it has stopped pulsing

The placenta is pulled out by the midwife once it has separated from the wall of the uterus (womb)

You push the placenta out with contractions, which can take up to 1 hour

Active management speeds up delivery of the placenta, which will usually happen within 30 minutes, and lowers the risk of heavy blood loss (haemorrhage). But the injection does increase the chances of nausea and vomiting.

Your midwife should discuss these options with you again in the early stage of labour. You should be advised to have active management of the third stage, but should also be asked about your preferences. If you have a low risk of heavy blood loss, you may opt to have physiological management.

If you choose physiological management but your placenta is not delivered within 1 hour, or you have heavy blood loss, you will be advised to change to active management. You can also choose to change from physiological to active management at any time.

See later for what should happen if the placenta is not delivered.

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Intrapartum care for healthy women and babies

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This guideline covers the care of healthy women and their babies, during labour and immediately after the birth. It focuses on women who give birth between 37 and 42 weeks of pregnancy ('term'). The guideline helps women to make an informed choice about where to have their baby.

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Assisted Delivery
Ventouse and Forceps

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Find out about assisted birth or assisted delivery, which uses forceps or vacuum (ventouse) to help deliver the baby.

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Caesarean 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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Monitoring

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Just weeks after the publication of two articles in the BJOG that questioned electronic fetal heart monitoring, a freely available article in the Journal of Child Neurology does an absolutely stellar job of bringing together the case against the use of this technology. The authors begin their paper - Cerebral Palsy Litigation: Change Course or Abandon Ship - by explaining that, in the last half-century, the response to the frequency of litigation and the increasing value of damages relating to birth-related cerebral palsy 'was abandonment of the venerable ''first do no harm'' principle, replacing it with the expedient self-serving ethics of ''do whatever is necessary to keep trial lawyers at bay.''' (Sartwelle and Johnston 2014)

The paper then goes on to describe the effects of this litigation and the way in which it is based on erroneous beliefs about electronic fetal monitoring:

"Electronic fetal monitoring precipitated, nurtured, and continues to be the primary cudgel against defendant physicians in the world's courtrooms. But electronic fetal monitoring is based on 19th-century childbirth myths. Its scientific foundation is almost nonexistent. Its false positive rate exceeds 99%. It does not predict cerebral palsy. After 40 years of continuous use and supposed improvements, electronic fetal monitoring has not reduced the cerebral palsy risk. It has, however, increased the cesarian section rate, with the expected increase in mortality and morbidity risks to mothers and babies alike." (Sartwelle and Johnston 2014)

It gets even better, as the authors explain how a courtroom evidence rule could be used to turn this situation around. I thoroughly recommend reading this article, as it brings together a number of key areas of evidence, and is one of the clearest and most quotable pieces I have ever read on this topic.

"It is far past time for birth-related professional organizations to confront electronic fetal monitoring reality, abandon the electronic fetal monitoring ship, and start over. Birth-related professional organizations must come to grips with the undeniable evidence that electronic fetal monitoring is an epic medical ethical dichotomy-it harms mothers and babies in direct opposition to the long-made promise not to do so. The time to act is now. If not now, when?" (Sartwelle and Johnston 2014).

Sartwelle TP and Johnston JC (2014). Cerebral Palsy Litigation: Change Course or Abandon Ship. Journal of Child Neurology. DOI: 10.1177/0883073814543306

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The case against electronic fetal monitoring

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Just weeks after the publication of two articles in the BJOG that questioned electronic fetal heart monitoring, a freely available article in the Journal of Child Neurology does an absolutely stellar job of bringing together the case against the use of this technology. The authors begin their paper

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Inducing Labour Guidlines

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Overview | Inducing labour | Guidance | NICE

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This guideline covers the circumstances for inducing labour, methods of induction, assessment, monitoring, pain relief and managing complications. It aims to improve advice and care for pregnant women who are thinking about or having induction of labour

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Writing a Birth Plan

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Birth Plan for C-Birth

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One of our BWF moms was kind enough to share her cesarean birth plan with us! Sometimes, due to the fast and surgical nature of a cesarean, many doctors and hospitals forget to include the family, and especially the mother, in the birth. A cesarean is a birth, and needs to be treated as one - this includes the creation of a birth plan. If you are in the position of needing a cesarean, please know that you can still make choices in your birth and have the birth you desire. I highly suggest that every mother have a cesarean birth plan - just in case. Birth, like life, is unpredictable but you can still have an empowering experience if you go in with knowledge and not fear.

Thank you so much Rachel for sharing this!
Rachel's Birth Plan
My fiancé and I are looking forward to sharing our first birth experience with you. We have created this birth plan in order to outline some of our preferences for birth. We would appreciate you reviewing this plan, and would be happy to do so with you. We understand that there may be situations in which our choices may not be possible, but we hope that you'll help us move toward our goals as much as possible to make this birth a sacred experience. We would like to be informed of any procedures or medications in advance, and to be allowed the chance to give our informed consent. Please feel free to ask if you have any questions or comments. Thank you!
During Surgery

Please ensure all medications are suitable for breastfeeding

I'd like a non-drowsy, anti-nausea med if possible (Zofran)

Please explain the surgery to me as it happens

No sedatives after birth. I want to remember my baby's first day of life.

Please reinforce my uterus and use dissolvable stitches for closing me up (double suture on my uterus and suture on the outside instead of staples.)

Warm blanket during surgery if possible

Baby

Please lower the screen just before delivery so I may see the birth of our baby.

I ask that the surgery be performed slowly and if possible allow the cord to continue pulsing after the birth so Baby may start breathing on her own while still attached to the placenta

Please allow for skin-to-skin contact immediately after delivery and evaluate Baby on my chest, (If this is not possible - then father would like skin-to-skin contact)

Keep cord long for daddy to cut while baby is in my arms

No Eye Gel, No Hep. B vaccine. I will sign the waiver ahead of time.

I would like to see and touch the placenta and cord

Recovery

Once back in our room to recover and been checked as stable, we would like to be alone with Baby to nurse.

We would like to keep Baby with us at all times. If Baby must go to the NICU due to medical reasons, my fiancé will follow.

If someone arrives to visit, please check with my husband or I as to whether we are ready for company before allowing them in our room.

Delay Baby's bath until the evening after Baby is born rather than bathing Baby right after birth.

I am willing to be up and walking as soon as possible

I would like my Catheter out early the morning after surgery

I would like to eat and have the IV removed as soon as possible after surgery

I will be nursing on demand and whenever Baby is fussy to help stimulate my milk to come in and to soothe Baby.

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One of our BWF moms was kind enough to share her cesarean birth plan with us! Sometimes, due to the fast and surgical nature of a cesarean, many doctors and hospitals forget to include the family, and especially the mother, in the birth.

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Packing Your Hospital Bag

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What is the issue?
Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently?
Why is this important?
Monitoring babies' heartbeats is used to check wellbeing during labour. Listening and recording the baby's heartbeat aims to identify babies who are becoming short of oxygen and may benefit from an early delivery by caesarean section or instrumental vaginal birth.

A baby's heartbeat can be monitored intermittently using a special trumpet-shaped device, or hand-held Doppler device. The heartbeat can also be checked continuously using a CTG machine. Continuous CTG produces a paper recording of the baby's heart rate and the mother's labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.
What evidence did we find?
We searched for evidence on 30 November 2016, but found no new studies for this update. We included 12 trials that compared continuous CTG monitoring with intermittent listening, and one trial compared continuous CTG with intermittent CTG. Together, the trials involved over 37,000 women. No trial compared continuous CTG with no monitoring. Most studies were undertaken before 1994, and apart from two, were not high quality. The review was dominated by one large, well-conducted trial from 1985 which involved almost 13,000 women who received one-to-one care throughout labour. The mothers' membranes were ruptured artificially as early as possible and about a quarter received oxytocin to stimulate contractions.

Overall, there was no difference in numbers of babies who died during or shortly after labour (about one in 300) (low quality evidence). Fits in babies were rare (about one in 500 births) (moderate quality evidence), but occurred less often when continuous CTG was used to monitor the baby's heart rate. There was no difference in the rate of cerebral palsy (low quality evidence); however, other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with significantly more deliveries by caesarean section (low quality evidence) and instrumental vaginal births (low quality evidence). Although both procedures carry risks for mothers, these were not assessed in the included studies.

There was no difference in numbers of cord blood acidosis (very low quality evidence), or women using any drugs for pain relief (low quality evidence) between groups.

Compared with intermittent CTG, continuous CTG made no difference to how many women had caesarean sections or instrumental births. There was less cord blood acidosis in women who had intermittent CTG but this result could have been due to chance.
What does this mean?
Most studies were undertaken many years ago and showed benefits and problems with both methods of monitoring the baby's wellbeing in labour. Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women's coping strategies. Women and their doctors need to discuss the woman's individual needs and wishes about monitoring the baby's wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

If you found this evidence helpful, please consider donating to Cochrane. We are a charity that produces accessible evidence to help people make health and care decisions.

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.

The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).

Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Read the full abstract...

Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

Data collection and analysis:

Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

We included 13 trials involving over 37,000 women. No new studies were included in this update.

One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.

Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).

Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).

Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.

Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

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Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

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What is the issue? Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently? Why is this important? Monitoring babies' heartbeats is used to check wellbeing during labour.

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Vaginal Examinations in Labour - why are they offered and do we need to have them?

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Updated: June 2023
Big babies are normal in well resourced countries. Over 10% of babies born in the UK and Australia weigh 4kg (8lb 13oz) or more. Healthy well nourished women grow healthy well nourished babies. Genetic factors also influence the size of babies (big babies run in families); and each baby a woman has usually weighs more than the last. Babies also continue to grow at the end of pregnancy (because placentas continue to nourish them rather than switch off) - so a baby will be bigger at 42 weeks than they were at 40 weeks.

However, abnormal blood glucose levels (BGLs) - with uncontrolled gestational diabetes (GD) - can also cause a baby to grow big. Babies who are big because of high BGLs are a different shape to 'normally' large babies. In particular, their shoulders and chest are larger and fatter, and they are more likely to encounter complications at birth. Unfortunately, research into big babies usually combines the outcomes for GD babies with non-GD babies.

Estimating size

The only way to accurately assess the weight of a baby is to weigh them after birth. Clinical assessment ie. palpating and measuring pregnant bumps is incorrect more than 50% of the time ( Chauhan et al. 2005). Measuring the baby's abdomen with an ultrasound - only predicts the weight of the baby within 15% of their actual weight ( Rossi et al. 2013). Around half of the babies estimated to be over 4kg via ultrasound are not over 4kg when born ( Relph et al. 2023). Therefore, lots of women are being incorrectly told that their baby is 'big'. A US study found that one out of three women were told their baby was 'too big' based on ultrasound ( Cheng et al. 2015). In this study the average birth weight of the group of babies suspected of being big was 7lb 13oz - ie. not big at all. Being diagnosed with a 'big baby' impacts on women's experiences of their pregnancy. A study by Baddington et al. 2023 explored women's experiences of 'navigating an ultrasound prediction of a large baby in pregnancy' and concluded that: 'The prediction of a 'large' baby in pregnancy has undeniably negative impacts on women. We encourage midwives to scrutinise the dominant discourses of authoritative scans and problematic large babies, becoming vectors for critical thinking and resistance'.

Another US study concluded that 'fetal biometrics [ultrasound assessment of size] had limited ability to predict SD [shoulder dystocia] and lack clinical usefulness' ( Newman et. al. 2022). So, predicting a large baby is inaccurate, does not improve outcomes and instead negatively impacts on women's experiences.

Birth complications?

Giving birth to a big baby is associated with an increased chance of particular outcomes - notice I am using the term 'associated' not 'caused'. The main complication associated with big babies is shoulder dystocia. The incidence of shoulder dystocia increases with the size of the baby. For example, it occurs with around 1% of babies weighing less than 3.9kg (8lbs 8oz), compared to 5-9% of babies weighing between 3.9kg and 4.5kg (9lb 9oz) ( Politi et al. 2010). Other, less likely complications associated with big babies are severe perineal tearing (0.6%) and postpartum haemorrhage (1.7%) ( Weismann-Brenner et al. 2012). I have previously written about how to reduce the chance of these complications:

Care provider fear

However, research suggests that the complications associated with big babies may be due to interventions carried out when a baby is suspected to be big. Care providers are more likely to diagnose slow progress during labour and recommend a caesarean if they suspect the baby is big ( Blackwell et al. 2009). Women who are told that they have a 'big baby', and are counselled about potential complications, are significantly more likely to choose a planned caesarean ( Peleg et al. 2015). One study compared the outcomes of a group of women with suspected big babies with a group of women who unexpectedly gave birth to a big baby ( Sedah-Mestechkin et al. 2008). Women who were suspected of having a big baby were three times more likely to have an induction or caesarean, and were four times more likely to have complications such as severe perineal tearing and postpartum haemorrhage. In this study there were no differences in the incidence of shoulder dystocia between the two groups.

Therefore, when a baby is suspected of being big, a woman has an increased chance of interventions during birth, and of experiencing complications caused by those interventions, even if the baby is not actually big.

The perception of a baby's size influences outcomes more than the actual size of the baby

Induction?

A Cochrane Review comparing induction of labour before 40 weeks for a suspected big baby with waiting for spontaneous labour, found that induction decreased the incidence of shoulder dystocia from 68 in 1000 to 41 in 1000. However, the review also found an increased rate of perineal tearing in the induction group of 26 in 1000 compared to 7 in 1000 in the spontaneous labour group. The review also notes that "antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed." There are a number of risks associated with inducing labour (see this post and this post) that need to be considered against the potential risks of of birthing a big baby.

NICE guidelines and World Health Organisation guidelines both state that induction of labour should not be carried out simply because a baby is suspected of being big. Interestingly, Queensland Health induction guidelines do recommend induction if a baby is estimated to be big via ultrasound. Yet the Queensland Health gestational diabetes guidelines state that "estimation of fetal weight by clinical assessment or USS can have significant margins of error".

Summary

The estimation of a baby's size via ultrasound is inaccurate. The complications associated with big babies may reflect care provider fear and practice. International guidelines do not recommend induction for a suspected big baby. Women need to be given this information before agreeing to an ultrasound scan aimed at estimating the size of their baby. Once the 'big baby' label is applied it cannot be removed and may alter the birth experience and outcome.

About Dr Rachel Reed

Doctor of (Birth) Philosophy * Author * Educator * Researcher

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Big Babies: the risk of care provider fear

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Isla Miller (and cheeks) Updated: June 2023 Big babies are normal in well resourced countries. Over 10% of babies born in the UK and Australia weigh 4kg (8lb 13oz) or more. Healthy well nourished women grow healthy well nourished babies. Genetic factors also influence the size of babies (big babies run in families); and each...

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One concern many people have about having their labour induced is that it might increase their chance of having a caesarean. Reasons for this could be that induction puts a baby under more stress, or because the induction fails to progress to the birth of the baby within a reasonable time.

The research evidence about the impact of induction on caesarean rates is contradictory and has been much debated by experts.In formal randomised controlled trials (RCT) it looks as though induction does not significantly increase the chances of having a caesarean, but population studies suggest that in real life it's likely that it does. For an explanation of these different types of research see ' Understanding Research Evidence'

Below we explore what some of the reasons behind this might be.

What evidence is there that induction might reduce your chance of a caesarean?

RCTs (which compare two groups who have been randomly allocated to have different treatments) often find that induction makes no difference or reduces the chance of a caesarean. For example, a recent study combined the results of many RCTs of induction at term, 40 weeks or beyond. It concluded that there were slightly fewer caesareans amongst the women who were randomised to be induced. The figures were around 15 fewer caesareans, but 13 more births assisted with forceps or ventouse for every 1000 women in the induction group, compared to those randomised to expectant management (waiting for labour to start).
Issues with this type of research
In the review discussed above, the findings are dominated by one large study of induction for length of pregnancy beyond 41 weeks (the Hannah trial). This study has been criticised for several reasons which are also likely to apply to a greater or lesser extent to other RCTs, so we will use this as an illustration.

RCTs report their findings by what is called 'intention to treat'. This means that if a woman was randomly allocated to have her labour induced, she will be counted in the induction group whether she actually had an induction or went into spontaneous labour before the planned induction. Similarly, a woman who was randomly allocated to wait for her labour to start spontaneously (called 'expectant management') will be counted in that group even if she later went on to be induced for some other reason. The random allocation is done to try to ensure that the groups are as similar as possible, so that differences between them do not affect the results. Analysis by 'intention to treat' is designed to avoid ending up with groups that are not similar, which could happen if the people who do not get their intended treatment are different in some way from the rest of their group.

This approach give good results providing the 'cross over' (the proportion who had the treatment they were not intended to ) remains small, but not when the cross over is large. In that case, it is desirable to also do the analysis based on the treatment actually received (induction or not). Another way to look at this is that 'intention to treat' shows whether planning an induction makes a difference to the chances of having a caesarean, rather than whether having an induction does.

The Hannah trial found that 21.2% of women who were in the induction group and 24.5% in the expectant management group had a caesarean . What these figures don't show is that over a third of the expectant management group had their labours induced. Also around a third of the induction group went into labour spontaneously or had a caesarean before they were induced. So, more than 1 in 3 women allocated to not be induced were induced and nearly 1 in 3 women allocated to be induced were not induced.

It would therefore have been more useful if the authors had also compared caesarean rates in all the women who had their labours induced and all those who laboured spontaneously, in order to see whether induction at 41 weeks alters the caesarean rate, or has any other benefits or risks.

Difference in methods of induction

An RCT can only produce valid findings if the two groups differ only in the treatment of intervention being tested, in this case whether labour is induced at a specified numberof weeks of pregnancy compared to waiting for spontaneous labour. Also, those in the expectant management group who do go on to have their labours induced need to be treated using the same methods as those in the planned induction group. In the Hannah trial women in the induction group were given prostaglandin if their cervix was not already dilated to 3cm or more. Those in the expectant management group who had induction went straight to having their waters broken or a Syntocinon drip, and this may have made it less likely that the induction would be successful, and so more likely that the baby would be born by caesarean. As the authors of the study say "One can only speculate about what the results would have been if prostaglandin gel had been used for women in the monitoring group or for all women who had evidence of fetal compromise".

Ideally in an RCT those providing and receiving treatment are not able to tell which group they are in, which is refer to as blinding. In studies of induction blinding is not possible - women and their carers inevitably know which group they are in. If women, midwives and doctors believe that pregnancy carries an increasing risk to the baby the longer it goes on beyond 41 weeks this could affect their decision-making. It has been questioned whether this made the people in these studies more ready to request or offer a caesarean if labour has not begun by 41 weeks, or if an induction was tried for some reason and failed to bring on labour quickly. As the authors of the Hannah study say "Because our trial did not use blinding, the differences in the rates of cesarean section may have been due to differences in the interpretation of fetal heart-rate tracings."

It's also quite likely that there is 'observer bias' with doctors involved responded differently to any worrying signs either before or during labour depending on whether the mother is having induction or expectant management. Something that they might egard as insignificant in the induction group might lead them to suggest a caesarean to a woman in the expectant management group simply because of their own belief that a longer pregnancy puts these babies at higher risk. As the authors of the Hannah study say "A physician may be more likely to perform a cesarean section at 43 weeks of gestation than at 41 weeks, or when labor has been induced."

RCTs looking at the effect of induction often seem to find caesarean rates for both induction and expectant management groups which are well above what would normally be expected, which casts doubt on the relevance of the findings. For example, a recent study of induction at 39 weeks in women aged 35 or over (the so-called "35/39 trial") reported no difference in caesarean rates, but the figures were 32% for the induction group and 33% for the expectant management group. These are extraordinarily high rates for first-time mothers with no known pregnancy complications. The National Maternity Statistics for England in 2017-18 showed an unplanned caesarean rate for first-time mothers of 21% and that is including mothers who had known complications.

A recent randomised controlled trial in the USA which compared induction at 39 weeks with expectant management for first time mothers who had no risk factors (the ARRIVE trial) found a slightly lower rate of caesareans in the induction group (19% vs 22%). These again are high ceasarean rates for a group of first time mothers who were considered to be at low risk. There are many unanswered questions about this trial. In particular it is not clear how many women in the expectant management group actually had their labours induced, but there is reason to think that "a large percentage of women in the expectant-management group underwent unnecessary induction with an unfavorable cervix" which would have increased the chances of them needing a caesarean.

What evidence is there that induction might increase your chance of a caesarean?

In contrast, numerous population studies, which look back at what happened in a large group of mothers, have reported higher caesarean rates when labour is induced. These studies typically show the caesarean rate to be twice as high when labour is induced.

Part of the problem may be that if an induction is done when a mother is not ready to go into labour the process is more likely to fail or cause the baby to become distressed. These factors would make a caesarean more likely. One study found that after adjusting for how close mothers were to going into labour there was no difference in caesarean rates with or without induction. This was probably because induction is more likely to work if the mother is already close to going into labour. In that situation, it's worth asking whether the induction is really needed.

The National Maternity Statistics for England in 2017-18 show that when labour started spontaneously, 75% of mothers had a straightforward vaginal birth, but when labour was induced only 61% of mothers did so. Also, the women who had an induced labour were twice as likely to have an unplanned caesarean as those whose labours started spontaneously. We can't be certain why this is, as the statistics do not include the reasons for induction, or caesarean. However, failure of the induction or distress to the baby as a result of the induction are likely to be factors.

Does simply planning an induction increase the chance of a caesarean?

Inducing labour means giving birth in a hospital consultant unit. There is good evidence that planning to birth at home or in a birth centre significantly reduces the chance of a caesarean from16% to 7-9%.Agreeing to induction will therefore increase the risk of having an unplanned caesarean compared with planning to birth in an out-of-hospital setting just because of the 'being in hospital' factor.

RCTs will not have been able to account for this difference in caesarean rates as all women agreeing to be included in a study will have been expected to birth in hospital, and this may also have contributed to the high caesarean rates.

In summary the research evidence about the impact of induction on caesarean rates is contradictory and has been much debated by experts. In formal RCTs it looks as though induction does not significantly increase the chances of having a caesarean, but population studies suggest that in real life it's likely that it does.

References

1. Middleton P. et al Cochrane review: "Induction of labour in women with normal pregnancies at or beyond term" (2018) www.cochrane.org/CD004945/PREG_induction-labour-women-normal-pregnancies-or-beyond-term

2. Hannah M.E. et al "Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group." N Engl J Med. 1992 Jun 11;326(24):1587-92 www.nejm.org/doi/10.1056/NEJM199206113262402?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov

3. Menticoglu S.M. and Hall S.F. "Routine induction of labour at 41 weeks: nonsensus consensus" BJOG 109 (5) May 2002 pp485-491 obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/j.1471-0528.2002.01004.x

4. Walker K.F. et al "Randomized Trial of Labor Induction in Women 35 Years of Age or Older" (The "35/39 trial") N Engl J Med 2016; 374:813-822 2016 www.nejm.org/doi/full/10.1056/NEJMoa1509117

5. Roberts A. "Informed Decision Making - does research help us?" AIMS Journal, 2019, Vol 31, No 1 www.aims.org.uk/journal/item/35-39

6. NHS Maternity Statistics, 2017-18 http://digital.nhs.uk/pubs/maternity1718

7. Grobman W.A. et al "The ARRIVE Trial (A Randomized Trial of Induction Versus Expectant Management)" N Engl J Med 2018 379:513 -523. www.nejm.org/doi/full/10.1056/NEJMoa1800566

8. Goer H. "Parsing the ARRIVE Trial:Should First-time Parents be Routinely Induced at 39 weeks?" 2018 www.lamaze.org/Connecting-the-Dots/parsing-the-arrive-trial-should-first-time-parents-be-routinely-induced-at-39-weeks

9. Vrouenraets F.P. et al "Bishop score and risk of cesarean delivery after induction of labor in nulliparous women" Obstet. Gynecol. 2005 Apr;105(4):690-7 www.ncbi.nlm.nih.gov/pubmed/15802392

10. Vardo J.H. et al "Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor." J. Reprod. Med. 2011 Jan-Feb;56(1-2):25-30. www.ncbi.nlm.nih.gov/pubmed/21366123

11. Jacquemyn Y. et al "Elective induction of labour increases caesarean section rate in low risk multiparous women" Journal of Obstetrics & Gynecology Volume 32 (3), 2012 www.tandfonline.com/doi/abs/10.3109/01443615.2011.645091?journalCode=ijog20

12. Davey M. and King J. "Caesarean section following induction of labour in uncomplicated first births- a population-based cross-sectional analysis of 42,950 births" BMC Pregnancy & Childbirth, April 2016, 16: 92 bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0869-0

13. Birthplace in England Collaborative Group "Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study" BMJ 2011;343:d
7400www.bmj.com/content/343/bmj.d7400

Written by Nadia Higson
Date: 03/2020
Reviewed by Emiko Priest & Debbie Chippington Derrick
Review needed: 03/2022

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. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

Published on 18th March 2020

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One concern many people have about having their labour induced is that it might increase their chance of having a caesarean. Reasons for this could be that induction puts a baby under more stress, or because the induction fails to progress to the birth of the baby within a reasonable time.

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Shoulder dystocia during delivery | BabyCenter

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Shoulder dystocia means that a baby's shoulder or shoulders get caught behind the mother's pubic bone during a vaginal delivery. During delivery, the "turtle sign" is an indication that the baby's shoulders may be stuck. When this happens, the baby's head emerges but then retreats without the shoulders following.

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Induction of Labour Warwick

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Delayed Cord Clamping

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Thoughts on Induction

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"Overdue" - but still want a home birth?

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Assisted vaginal birth (ventouse or forceps) | RCOG

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An assisted vaginal birth (ventouse or forceps) patient information leaflet

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This information covers:

There can be many reasons for needing help with the birth of your baby. The main ones are:

there are concerns about your baby's wellbeing during birth

your labour is not progressing as would usually be expected

you are unable to, or have been advised not to, push during birth

Overall about 1 in 8 (10-15%) births in the UK will be an assisted vaginal birth although this is much less common in women who have had a vaginal birth before. 1 in 3 women having their first baby will have an assisted vaginal birth. Your healthcare professional will discuss ways to reduce your chance of needing an assisted vaginal birth during your pregnancy.

If you have someone supporting you throughout your labour, you are less likely to need an assisted vaginal birth, particularly if the support comes from someone you know, in addition to your healthcare professional.

Assisted vaginal births are less likely if you do not have any complications in your pregnancy and plan to have your baby in a midwife-led unit. Using upright positions or lying on your side after your cervix is fully open in labour can reduce the need for an assisted vaginal birth. Having an epidural for pain relief in labour may increase the chance of you needing an assisted vaginal birth, but this is less likely with modern epidural anaesthetics.

The need for an assisted vaginal birth may be reduced by not starting to push too soon after your cervix is fully open. You may be advised to wait until you have a strong urge to push, or to try and delay pushing by 1-2 hours depending on your individual situation.

A ventouse (vacuum cup) is an instrument that uses suction to attach a plastic or metal cup on to your baby's head. Your healthcare professional will wait until you are having a contraction and then ask you to push while they pull to help you give birth. This may happen over several contractions. Sometimes the cup can detach itself, making a "pop" sound. If this happens your healthcare professional may need to re-apply the cup to your baby's head before continuing.

Forceps are smooth, curved metal instruments. They are made to carefully fit around your baby's head. Your healthcare professional will wait until you have a contraction and then ask you to push while they pull with the forceps to help you give birth. This may happen over several contractions.

Ventouse and forceps are both safe and effective. Choice of instrument depends on factors including how well your epidural is working (if you have had one), the wellbeing of your baby and the position of your baby's head. If you need an assisted vaginal birth at less than 36 weeks of pregnancy, forceps may be preferred over ventouse. This is because they involve less risk of injury to your baby's head which is softer at this stage of pregnancy.

Your healthcare professional will recommend the method most suitable for your individual situation. If you have any concerns around the use of ventouse or forceps you should discuss this with your healthcare professional at any time during your pregnancy or labour.

If one instrument has been chosen and is not effective, your healthcare professional may then either recommend using the other instrument to help you have a vaginal birth or offer a caesarean, depending on your individual circumstances.

If neither instrument is effective in helping you give birth, your healthcare professional will recommend an emergency caesarean birth.

Forceps and ventouse will only be recommended if they are thought to be the safest way to help you give birth. The reasons for recommending an assisted vaginal birth, the choice of instrument and the procedure will be discussed with you at the time. If you are in labour and choose not to have an assisted vaginal birth, the alternatives are to wait for your baby to be born without assistance or to have an emergency caesarean. Your healthcare professional will discuss your options depending on your individual circumstances.

A caesarean in the late stage of labour is a more complex operation than a planned caesarean and in some circumstances may increase the risk of harm to both you and your baby.

Decision making in labour can be difficult which is why it is important to explore any concerns you may have with your healthcare professional before you go into labour.

If you are certain you would not want an assisted vaginal birth, one option is to choose a planned caesarean birth before you go into labour. If you are considering a planned caesarean you should discuss this with your healthcare professional during your pregnancy. For more information, refer to the RCOG patient information on caesarean birth.

With your consent, your healthcare professional will examine your abdomen and perform an internal examination to confirm that an assisted vaginal birth is safe for you and your baby. You will usually be asked to sit with your legs supported and your bladder will be emptied by passing a small tube (catheter) into it.

Pain relief for the birth may be either a local anaesthetic injection inside the vagina or a regional anaesthetic injection into your back (an epidural or a spinal). For more information about pain relief during labour see the Labour Pains website ( labourpains.com) from the Obstetric Anaesthetists' Association.

You are more likely to need to have a cut (episiotomy) to enlarge your vaginal opening and allow your baby to be born.

A healthcare professional who specialises in the care of newborn babies may be there when you give birth in case your baby needs some extra help after birth. If your baby is well you may choose to have immediate skin to skin contact and/or delayed cord clamping.

After your baby is born you will be given some antibiotics through a drip to reduce the chance of you developing an infection.

If your healthcare professional expects your assisted vaginal birth to be straightforward, they will recommend that you give birth in the same room where you have been in labour. If they think that the assisted vaginal birth may be more complicated or that there is a chance that it might not work, you will be advised to give birth in the operating theatre. This is so that you can have an immediate caesarean if necessary.

Assisted vaginal birth is less likely to be successful if:

you are overweight with a body mass index (BMI) over 30;

you are less than 161cm in height

your baby is estimated to be more than 4kg in weight

your baby is lying with its back to your back at the end of your labour

your baby's head is not low down in the birth canal at the end of your labour

You may need to stay in hospital for longer than originally expected after the birth of your baby.

A third- or fourth-degree tear (a tear which involves the muscle and/or the wall of the anus or rectum) affects 3 in 100 women (3%) who have a vaginal birth. It is more common following a ventouse birth, affecting up to 4 in 100 women (4%) and following a forceps birth, affecting between 8 and 12 women in every 100 (8-12%).

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Assisted vaginal birth (ventouse or forceps)

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This information covers: There can be many reasons for needing help with the birth of your baby.

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Regional Anaesthetia for Caesarean Birth

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Breech Birth

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Bottom first! What to expect if your baby is breech

What is a breech baby?

A breech baby is one that is born bottom first rather than the usual head first. Most breech babies will have straight legs going up past their ears (a "complete breech"), or bent legs in the usual foetal position (a "flexed breech"). Some will have one bent and one straight leg. Others have their legs curled up beneath them, so that their feet are born first, and even more rarely can have their legs in a kneeling position and be born knee first. In most cases there is no obvious reason why a baby is breech.

Typically 3-4% of babies will be breech at full-term. This is an awkward statistic - not frequent enough for midwives and doctors to see them regularly, and frequent enough that most people know someone who has had a breech baby. Even more awkwardly, approximately 1 in 4 of all babies will be breech at 30 weeks, and most of those will turn into a head-down position by themselves with no intervention. However, the details matter. First-time babies are less likely to turn, as are babies in women who have already had a previous breech.

Undiagnosed breeches

Some breech babies always go undiagnosed until labour has commenced, either because the baby turns breech very late in pregnancy, or because it felt like a head-down baby to the midwife. It can be quite a difficult experience for women to be told in advanced labour that their baby is breech, and especially difficult at that stage to make a logical informed decision about the birth.

Ante-natal care

Usually a breech baby is first recognised by your community midwife at a regular antenatal appointment. Addenbrookes is currently running a major study of first time pregnancies, which includes regular ultrasound scans, and these will also show if a baby is breech. In my own limited experience, women with breech babies often describe a hard round "bum" digging into their ribs. Not all breeches are spotted in pregnancy, especially if the baby's legs are straight so that the kicks are high up towards your ribs, just as they would be in a head-down baby.

A suspected breech pregnancy should be referred for an ultrasound "positional" scan at 36 weeks, and anyone planning a home birth should also be offered a scan at that time. If the scan shows that the baby is breech, then the hospital midwives will explain a procedure called ECV (external cephalic version) which aims to turn the baby, and book an appointment for you straightaway. There are some cases (for example low fluid levels) where an ECV will not be offered. However, ECVs can usually be offered to women who have had previous Caesareans. If the baby remains breech, then you will have a "clinic appointment" with a hospital consultant to discuss your birth options.

Turning methods

The first focus in a breech pregnancy is always to try to encourage the baby to turn head-down. A turned baby is no longer breech, and the pregnancy and birth can then proceed just like any other, allowing you to have your baby at home or in the Midwife-led Birthing Unit if you wish to.

There are several "alternative" turning methods, which can be started as early as 34 weeks, as well as the ECV offered by the NHS. If you try the alternative approaches it is worth checking whether or not your particular practitioner has successfully turned breech babies before.

Most of the turning methods are combined with positional exercises. The formal positions are the "knee/chest" position, where you kneel with your shoulders resting on the floor (or a cushion) and your bottom in the air, or a reclining position where you lie on your back with your legs up against the wall and cushions supporting you under your bottom. The aim is to have your pelvis higher than your shoulders to encourage the baby to move out of your hips. This gives the baby room to move into a head-down position, which usually happens after the exercises rather than during them. Lots of "floor-scrubbing" is also meant to help - one breech mum I spoke to bought gardening knee pads to make this more comfortable!

The alternative methods include an acupuncture technique called moxibustion, which involves burning moxa sticks over a certain acupressure point on your little toe every day for 10 days. If the first course of treatment is unsuccessful, then a second can be tried after a gap of 4-5 days. Success rates of 50-80% have been reported, although formal published studies show insufficient evidence of benefit to recommend the use of this method within the NHS.

Other methods include a chiropractic method called the Webster Technique, which ensures that the mother's pelvis is straight and aligned, a cranial osteopathy method and homeopathy using pulsatilla.

ECV is offered in the NHS at 36 or 37 weeks. There is a formal study underway looking at using ECV at 33-35 weeks, but this will not become standard practice unless the study shows good results. An ECV is done by one of the Rosie consultants, several of whom regularly carry them out. The doctor uses their hands to push the baby around into a head-down position, following the same path that a baby would take if she turned by herself. Ultrasound scan is used to check the baby's heart beat and position during the procedure. Although women often say that ECVs are "uncomfortable", this means "uncomfortable but not so painful that I needed to ask the doctor to stop". Roughly half of all ECVs are successful, meaning that from then on the pregnancy is treated as normal.

If the first ECV is unsuccessful, then a second one can be attempted. One aspect which always worries people is that you are asked to skip breakfast before an ECV and to bring a hospital bag. This is in case the ECV triggers a labour or upsets the baby and requires you to stay in for a Caesarean. However, in reality, this happens very rarely, less than once a year at Addenbrookes, so is an example of the hospital being highly cautious.

Many breech mums try several turning methods, to give themselves the greatest possible chance of turning their babies. You should always tell each practitioner if you are using other methods, to ensure that they don't counteract each other.

Birth options

If your baby refuses to turn then you should be given an appointment with a hospital consultant to discuss the birth. You should take advantage of this to ask all the questions you want, which people are often nervous to do!

Although many pregnancy books will list "breech" as one of the conditions that "requires" an elective Caesarean, this is not actually the case, and breech babies have been born safely throughout history. Addenbrookes are supportive of women who ask for a vaginal breech birth, though will ask you to labour in the delivery unit, rather than in the Midwife-led Birthing Unit or at home. As with many aspects of pregnancy and birth, their approach is to give you information about the risks of the different options, and allow you to make your own choice.

If you decide to have an elective Caesarean, then this will be scheduled for approximately 39 weeks. The doctors should go through all the risks of a Caesarean with you, which are the same as the risks for a head-down Caesarean. If you go into labour before 39 weeks then your Caesarean will be classed as an "emergency Caesarean" even if you are only in early labour when it is carried out.

If you choose a vaginal birth, then you will be recommended to use the hospital delivery unit, and have constant monitoring of your baby's heartbeat. The delivery will be supervised by the most senior doctor on duty, ie a consultant during the day or a senior registrar at night, all of whom have delivered vaginal breech babies as part of their required training. First time mums will be encouraged to have an epidural and intravenous access in case labour does not progress and a Caesarean becomes necessary. The key criteria for proceeding with a vaginal breech birth will be that the labour progresses steadily. If labour slows for any reason then that is taken as a sign that a Caesarean is needed. For this reason they will not induce a breech baby, which means that if you develop a condition which would usually be a reason for an induction (for example, gestational diabetes, low fluid levels or slow growth of your baby), the doctors will recommend that you have a Caesarean instead. In fact breech labours will often progress more quickly and intensely than a head-first labour (although for me my bottom-first labour took exactly the same time as my head-first one).

Different practitioners have different approaches to breech birth. All doctors and midwives in the UK have annual training on how to deal with a breech baby, though very few have the opportunity to deliver breech babies in practice. One key rule is "hands off the breech", which is Addenbrookes standard practice. Doctors in Addenbrookes will deliver the baby with the mother in the lithotomy position, ie lying on your back, since this is how they are trained to help the baby out if needed. In Germany and at The Farm in Tennessee, breeches are generally delivered in a standing position, while midwives trained by Mary Cronk and Jane Evans (the UK breech experts) encourage women to use an all fours position, leaning further and further forward as the baby emerges.

In cases of undiagnosed breeches, the staff will move you to the delivery unit and turn you onto your back for delivery, if it is safe to do so. In practice some breech labours progress so quickly that all they can do is catch the baby from whatever position the mother happens to be in, whether that is upright, or on all fours, or leaning on a table.

Concerns are usually around babies "getting stuck", though everyone is trained in simple manoeuvres to help a breech baby out. Jane Evans always says that in a normally-developed baby there is not much difference between the size of the hips and the head, so if the hips can come out then so can the head. The other practical concern is that an individual doctor does not deliver many breech babies, so some are more confident than others. Typically Addenbrookes has between 2 and 5 vaginal breech births each month.

The alternative is to use an independent midwife with breech experience, which will ensure that the person delivering your baby is confident of their own breech skills. The most experienced breech midwife local to Cambridge is Valerie Gommon, now that Jane Evans has moved to the west country. This would mean that you have a home birth, since independent midwives cannot practise in the hospital.

If you go ahead with a vaginal breech birth, then it can take up to 5 minutes from the baby first being visible (which is called "rumping" rather than "crowning"), to her being born. This amusingly means that your doctor or midwife will know the sex of the baby long before you do. Usually the bottom comes out first (except for in a footling breech when the feet come out first), then the legs come out and unfold, then the arms, and finally the head. The umbilical cord is visible once the hips have been born, which means you can see it pulsing throughout the birth. Breech babies have a higher chance of needing help to take their first breath than head-first babies, so you may not get to hold your baby straight away, until she has good APGAR scores.

Post-natal care

Breech babies may suffer bruising of their genitals, regardless of whether they are born vaginally or by Caesarean. This can be quite severe, and for boys may require an immediate ultrasound, but usually clears up within a few days. Otherwise a post-natal breech baby is the same as any other baby, except that she will automatically have a hip scan at 6 weeks, since breech babies are more likely to have "clicky hips".

Cranial osteopathy can also be very helpful for breech babies, since their bodies have not been subjected to the usual pressures of a head-down pregnancy and birth.

For more information:

Breech birth: What are my options? - Jane Evans, published by AIMS Breech birth - Benna Waites, available from Amazon and other booksellers The Breech Babies Club - www.breechbabiesclub.org

To find your nearest independent midwife - www.independentmidwives.org.uk

This article appears here, at www.birthlight.com<, and also in the Winter 2010/11 of the Voice, the Cambridge NCT newsletter.

The author, Amy Weatherup, is a Trustee of Birthlight, founder of the Breech Babies Club, & mother of 2 girls, 1 born head-first in hospital, & 1 born bottom-first at home. She is not a medical professional, just a well-read mother of a breech baby.

Some of the details in this article are specific to Addenbrookes Hospital, Cambridge, UK. The article text has been reviewed by one of the hospital's Consultant Obstetricians prior to publication.

If you are expecting a breech baby you should always consult your own midwife or doctor about the details of your care.

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Bottom first! What to expect if your baby is breech What is a breech baby? A breech baby is one that is born bottom first rather than the usual head first. Most breech babies will have straight legs going up past their ears (a "complete breech"), or bent legs in the usual foetal position (a "flexed ...

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Knowing what to expect and understanding why your doctor or midwife might recommend an assisted birth can help you feel more confident about the process. It's especially good to know about this just in case you have a long, challenging labour, or if concerns about the baby crop up. Read on to find out more.

What is an assisted birth?

An assisted or instrumental birth is when ventouse or forceps are used in the later stages of labour to help a baby to be born.

"About one in eight babies in the UK are born with the help of these instruments." (RCOG, 2012, 2016; NHS, 2017)

You're more likely to need an assisted birth if you're giving birth vaginally for the first time.

What are ventouse and forceps?

A ventouse is a cup-shaped suction device that can be attached to your baby's head to help them to be born. You might have heard it called a vacuum delivery (NHS, 2017).

Forceps are smooth, curved metal instruments that look like large tongs. They're placed around the baby's head to help pull the baby out.

Why might I need help with the birth of my baby?

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.

(RCOG, 2012; NICE, 2014; NHS, 2017)

What are my other options?

If your doctor thinks an assisted birth is possible but could be difficult, you would be moved to an operating theatre in case you need a caesarean section (NICE, 2014). Usually, you'd be offered an assisted birth first because if it works this can help your baby out quicker than a caesarean. This is important if the baby is in trouble.

As with any medical intervention being offered, you can say 'no' to an assisted birth. Your doctor or midwife should first discuss why you need an assisted birth and their choice of instrument and gain your consent (RCOG, 2012). A caesarean birth involves major surgery, which carries risks and takes longer.

If the ventouse or forceps do not help your baby out, you will need a caesarean.

What happens during a forceps or ventouse assisted birth?

The midwife or obstetrician will examine you. If there are concerns about you or your baby's health, you might need an emergency caesarean and be moved to an operating theatre. This way, if the forceps or ventouse is unsuccessful, a caesarean birth can happen soon after. For example, if the baby's head needs to be turned, forceps or ventouse might not help so easily.

If you haven't already had an epidural, you will be offered one, or a single spinal injection or local anaesthetic to numb the area around the vagina (RCOG, 2012). You'll lay on your back and have your feet in stirrups. Your bladder will be emptied using a catheter.

You might have a cut (episiotomy) made at this point to make your vaginal opening bigger (RCOG, 2012; NICE, 2014). This isn't routine but might be necessary (NHS, 2017). You're less likely to experience vaginal tearing with ventouse than with forceps (RCOG, 2012).

In a ventouse delivery, the obstetrician or specially-trained midwife will attach a suction cup to your baby's head. They'll then gently pull when you have a contraction, to help your baby out. They might need to pull more than once (RCOG, 2012).

A ventouse is not suitable if you are less than 34 weeks pregnant. This is because the baby's head is softer thus increasing the risk of your baby getting bruised, or having a brain haemorrhage or jaundice (RCOG, 2012).

If you have a forceps delivery, the doctor or midwife would gently place them around your baby's head. Then on the next contraction you will be asked to push as your baby is carefully pulled. You'd normally need an episiotomy first (RCOG, 2012).

Ventouse or forceps delivery?

Ventouse and forceps are both safe and effective. If you do need assistance, your doctor would choose the most suitable instrument for you, your baby and your situation. Forceps are more successful in assisting the birth than ventouse. Yet ventouse is less likely to cause vaginal tearing (NHS, 2017).

Can I avoid an assisted birth?

An assisted birth can't always be avoided but you can reduce the risk. Here's how:

If your pregnancy has been straightforward, try planning to give birth in a birth centre or at home. That means you are less likely to need forceps, ventouse or any other interventions.

Continuous support from a birth partner other than your midwife can make a positive difference.

Remain upright or on your sides and mobile to give you and your baby the best chance of a spontaneous birth.

Avoid an epidural if possible, or if you do have an epidural, wait for a while after your cervix is fully dilated before beginning to push.

(Hodnett et al, 2010; Hollowell et al, 2011; RCOG, 2012; Hodnett et al, 2013; NCCWCH, 2014)

What can birth partners do?

It might be helpful to think about the support you can give your partner if she need forceps or ventouse assistance. This could mean offering reassurance if this is a change to your birth plan, or simply holding her hand during the birth (RCM, 2012).

Some partners have said they found it difficult watching forceps or ventouse being used. So consider where you might want to stand during the birth.

It's also a good idea to discuss birth scenarios in advance so you're clear on whether your partner would prefer you to stay with her or go with the baby if needed. For example, you could provide skin-to-skin care for the baby if your partner isn't able to.

What are the effects of a forceps or ventouse delivery on babies?

Some parents-to-be worry their baby may be harmed during an assisted birth. But any effects are likely to be short term, resolving within 24 to 48 hours (RCOG, 2012).

Forceps can cause bruising, marks or cuts on a baby's head, while a ventouse may temporarily affect the shape of a baby's head (RCOG, 2012). The suction cup used for ventouse delivery might also mark a baby's head or cause a bruise that disappears in time (NHS, 2017). Small cuts on a baby's face and head may occur but generally fade quickly (RCOG, 2012).

If you are worried about any after-effects, talk to your health visitor or GP.

How will I be affected?

It's normal to feel bruised and sore after birth, particularly if you had an assisted birth.

Help and support is available, so do seek medical advice if you experience any difficulties or complications. Your midwife or GP can talk through your options with you.

As you're more likely to have an episiotomy during an assisted birth, stitches and swelling or tearing may make going to the toilet painful (RCOG, 2015). You'll probably need to up your intake of fibre (RCOG, 2015). You could also take a stool softener to make it easier to open your bowels. See our article about episiotomy care and recovery for more details.

Four in 100 women who have a ventouse birth will have a third or fourth degree tear (into the tissue surrounding the anus). That compares with eight to 12 women in 100 who have a forceps birth will have a third or fourth degree tear (RCOG, 2012).

Third or fourth degree tears would need to be repaired in an operating theatre and it is normal to feel pain for two or three weeks afterwards (RCOG, 2015). You'll be offered pain-relief and a course of antibiotics after the operation, and will need to keep the area clean (RCOG, 2015). See our article about perineal tears for more details.

Most women will recover from an assisted birth within a few weeks. But some might experience complications, such as severe vaginal tearing, blood clots and urinary or anal incontinence (RCOG, 2012). If you have any medical concerns talk to your midwife, health visitor or GP.

How will I feel?

Sometimes, an assisted birth can leave new parents feeling as if the situation was taken out of their hands. Difficult birth experiences like an assisted birth can affect women's psychological health with around one third of women in the western world evaluating their childbirth experience as traumatic (Ayers et al, 2006).

If this is how you feel, it can help to chat to the doctor or midwife before you leave hospital. You could ask about what happened and why it was necessary (RCOG, 2012).

Some women and their partners might also want to talk about the emotional impact after they have gone home (RCOG, 2012). If you did an NCT antenatal course, you could get in touch with your antenatal teacher to talk this through.

Most hospitals have a 'birth reflections' service. This service gives you the chance to discuss the events with a midwife and resolve unanswered questions (Ayers et al, 2006).

Will I need an assisted birth if I have another baby?

It's unlikely you will need an assisted birth with subsequent babies. Most women (80%) who have an assisted vaginal birth give birth spontaneously next time around (RCOG, 2012).

This page was last reviewed in September 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 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.

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Assisted birth: ventouse or forceps delivery | Labour & birth, Different types of birth articles & support | NCT

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Some births need a little help. Here we explain what an assisted birth is, why ventouse or forceps might be needed, what happens and how you might feel.

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General Anaesthetic for a Caesarean Section

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Most women can have a C-section with a spinal anaesthetic, which involves an injection in the back to numb the lower body while they remain awake. However, there are situations where you need to be put to sleep during the procedure in which case a general anaesthetic may be necessary.

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General Anaesthetia for Caesarean Birth

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GA For Caesarean CS - Information Card-FEB15

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How will my body feel after an assisted birth?

It's understandable if you feel physically vulnerable because your baby was born with the help of forceps or ventouse. Your body has been through a lot, so give yourself plenty of time to recover. It's normal to experience:

Soreness and bruising from a tear or an episiotomy (which may last for two weeks to three weeks) (NHS 2014).

Pain or numbness in the area between your vagina and anus (perineum) when you wee or poo (NHS 2014).

Problems with incontinence, sometimes leaking wee (Collins et al 2013, RCOG 2011), especially if you had a big baby (Hudelist et al 2005, Gupta et al 2003).

Problems with controlling wind, or when you poo, which is often a result of having a forceps birth (Collins et al 2013, RCOG 2012, RCOG 2011).

You may be in hospital for a couple of days after an assisted birth, depending on whether you had an episiotomy or a severe perineal tear (Collins et al 2013). Your doctor or midwife may give you medication to reduce your risk of developing a blood clot (RCOG 2011) and antibiotics to reduce your risk of infection (Collins et al 2013, RCOG 2007).
Your midwife will check that you're able to wee normally after the birth (RCOG 2011). This is particularly important if you've had an epidural (ACPWH 2011).

You probably had a catheter to drain your bladder during and after the procedure. It can be hard to wee normally again once the catheter is removed (Das 2013). As a guideline, you should be able to wee without problems every three hours to four hours during the day (ACPWH 2011).

If it's taking you a while to recover physically, your community midwife may keep you on her list for up to 28 days after your baby's birth.

How can I recover emotionally from an assisted birth?

If you're finding it hard to come to terms with your birth experience, you may have the following questions:

Why did it happen? Ideally, you should have the opportunity to talk it through with the doctor or midwife who assisted your birth (RCOG 2012).

How long will it take to recover? It depends on you and your body, but most women recover well from an assisted birth.

Will it affect future pregnancies? It may bring some comfort to know that eight out of 10 women who have an assisted birth have a straightforward birth next time around (RCOG 2012, RCOG 2011).

It's never too late to get help if you're struggling to come to terms with your birth experience. If, once you're home, you still have questions or worries about what happened, speak to your GP. She can refer you back to the obstetrician who cared for you in hospital (RCOG 2012). Your GP can also work with your health visitor to ensure you get the support you need.
How can I help myself to recover from an assisted birth?

Postnatal wards are busy places. Don't be afraid to press your alarm while you're on the ward if you're in pain. The midwives should give you regular pain relief to ease pain in your perineum and any soreness caused by your stitches (NICE 62014). Paracetamol or an anti-inflammatory drug (diclofenac) are the usual options (RCOG 2011).

Change your maternity pad often and wash your hands before and after you do this. Have a daily bath or shower to keep your stitches clean (NICE 2014). Let your midwife know at the first sign of infection, such as a bad smell from your wound or if you are having problems when you wee (NHS 2014, NICE 2014).

Once you're home, you may find it more comfortable to lie on your side or sit on a doughnut shaped cushion to relieve pain and pressure (NHS 2014). You could try using a Valley cushion, which is designed for use after childbirth. You can hire one from the National Childbirth Trust (NCT), or hire or buy one online.

When you wee, you may find that your cut stings (NHS 2014). Pour a jug of warm water over the area while you wee (Kettle and Tahill 2011). This will dilute your wee, reduce the sting, and keep your perineal area clean.

Squatting on the toilet, rather than sitting, may also help to reduce the stinging (NHS 2014). But if it's very uncomfortable, bathing or washing your wound afterwards in warm water may help to ease the discomfort (ACPWH 2011, NHS 2014).

It's natural to feel anxious about having a poo if you have stitches for an episiotomy or tear. If it was a severe tear, your midwife or doctor may prescribe a liquid laxative to help things along (Collins et al 2013, NHS 2014). The laxative will be very gentle, so there's no need to worry that you'll be caught out by the urge to go to the toilet.

To avoid constipation, drink between one litre and three litres of fluids a day and have a good level of fibre in your diet. Try to get up and about to help your bowels move. Go to the loo as soon as you feel the urge, and don't be rushed (ACPWH 2011).

If you are finding it hard to control your wee, practising your pelvic floor exercises will help (ACPWH 2011, NHS 2014).

If you are still having problems with incontinence several weeks after giving birth, talk to your doctor. She may refer you to a physiotherapist or continence expert (ACPWH 2011, Collins et al 2013, RCOG 2011).

How will my baby recover from an assisted birth?

Your baby may have some bruising or marks after an assisted birth, but he should recover well. Your baby is unlikely to have any long-term problems due to being born with forceps or ventouse (RCOG 2011).

After a ventouse birth, your baby may have:

A bruised swelling (a chignon or caput succedaneum) where the cup was applied (RCOG 2012).

Slight grazing to his scalp (RCOG 2012).

A blood blister (cephalhaematoma) within the first day or so (RCOG 2012).

Rarely, some bleeding in his eye (retinal haemorrhage) (Naderian et al 2013, Hughes et al 2006).

After a forceps birth, your baby may have:

Marks or bruising on his face, or on the side of his head (Hayman 2014, Collins et al 2013, RCOG 2012).

Damage to his facial nerve, causing one corner of his mouth to droop (palsy). This is usually only temporary and is not common (Hayman 2014, O'Mahony et al 2010).

These marks usually clear up on their own within a week or so of the birth, though a blood blister may take between six weeks and eight weeks to disappear (Hayman 2014).
The way your baby was born makes him more likely to develop jaundice, which may require ultraviolet light treatment (phototherapy) (RCOG 2012). Your midwife will keep an eye on your baby to check for signs of jaundice. She'll also explain to you what to look out for, as jaundice may take a few days to set in.

An assisted birth puts your baby at higher risk of vitamin K deficiency bleeding (VKDB) (PatientPlus 2014). VKDB is rare, but it can cause internal bleeding, so it can be very serious. Your midwife will have asked for your consent to give your baby vitamin K, either by injection or by drops in his mouth, to protect him from VKDB. If you decided you did not want your baby to have vitamin K, you should watch out for any spontaneous bruising or bleeding.

How can I help my baby to recover from an assisted birth?

If your baby is in any discomfort, do be gentle with him as he recovers. He may be irritable due to having a sore head, and this may cause him to have problems when feeding. Your doctor or midwife may give him pain relief (analgesic) to help with this.

If your baby has bruises and trauma after being born, be reassured that it will get better in time, even if it does look alarming to you (RCOG 2012).

References

ACPWH. 2011. Fit for the future: essential advice and exercises following childbirth. Association of Chartered Physiotherapists in Women's Health. www.pogp.csp.org.uk [Accessed July 2015]

Collins, S, Arulkumaran S, Hayes K, et al. 2013. Oxford Handbook of Obstetrics and Gynaecology. 3rd ed. Oxford: Oxford University Press, 2013: 232-304

Das M. 2013. Guideline for postpartum bladder care. Nottingham University Hospitals NHS Trust. www.nuh.nhs.uk [pdf file, accessed July 2015]

Gupta N, Kiran TU, Mulik V, et al. 2003. The incidence, risk factors and obstetric outcome in primigravid women sustaining anal sphincter tears. Acta Obstet Gynecol Scand 82(8):736-43

Hayman, R. 2014. Operative births. In: Marshall J, Raynor M, eds. Myles Textbook for midwives. 16th ed. Edinburgh: Churchill Livingstone Elsevier, 455-463

Hudelist G, Gelle'n J, Singer C, et al. 2005. Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy. Am J Obstet Gynecol 192(3):875-81

Hughes LA, May K, Talbot JF, et al. 2006. Incidence, distribution, and duration of birth-related retinal hemorrhages: a prospective study. J AAPOS 10(2):102-6

Kettle C and Tohill S. 2011. Perineal care. Clin Evid: 1401

Naderian G, Fesharaki H, Sajjadi V et al. 2013. Retinal hemorrhages in a neonate following vacuum extraction. J Ophthalmic Vis Res. Apr; 8(2): 179-181

NHS. 2014. Episiotomy. NHS Choices. Health A-Z, pregnancy and baby. www.nhs.uk [Accessed July 2015]

NICE. 2014. Postnatal care. National Institute for Health and Care Excellence, Clinical Guideline 37. London: NICE www.nice.org.uk [pdf file, accessed July 2015]

O'Mahony F, Hofmeyr GJ, Menon V. 2010. Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews (11): CD005455.

PatientPlus. 2014. Vitamin K deficiency bleeding. Professional reference. [Accessed July 2015]

RCOG. 2007. The management of third- and fourth-degree perineal tears. Royal College of Obstetricians and Gynaecologists, Green-top guideline, 29. London: RCOG press. www.rcog.org.uk [pdf file, accessed July 2015]

RCOG. 2011. Operative vaginal delivery. Royal College of Obstetricians and Gynaecologists, Green-top guideline, 26. London: RCOG press. www.rcog.org.uk [pdf file, accessed July 2015]

RCOG. 2012. An assisted vaginal birth (ventouse or forceps). Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [pdf file, accessed July 2015]

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It's understandable if you feel physically vulnerable because your baby was born with the help of forceps or ventouse. Your body has been through a lot, so give yourself plenty of time to recover. It's normal to experience: Soreness and bruising from a tear or an episiotomy (which may last for two weeks to three weeks) (NHS 2014).

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Microbiome seeding - what’s the evidence? - Dr Sara Wickham

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Dr Sara Wickham discusses microbiome seeding, also known as vaginal seeding, and why we need more evidence on this.

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You'll probably be in hospital for 3 or 4 days after a caesarean section, and may need to take things easy for several weeks.

Recovering in hospital

The average stay in hospital after a caesarean is around 3 or 4 days.

You may be able to go home sooner than this if both you and your baby are well.

While in hospital:

you'll be given painkillers to reduce any discomfort

you'll have regular close contact with your baby and can start breastfeeding

you'll be encouraged to get out of bed and move around as soon as possible

you can eat and drink as soon as you feel hungry or thirsty

a thin, flexible tube called a catheter will remain in your bladder for at least 12 hours

your wound will be covered with a dressing for at least 24 hours

When you're well enough to go home, you'll need to arrange for someone to give you a lift as you will not be able to drive for a few weeks.

Looking after your wound

Your midwife should also advise you on how to look after your wound.

You'll usually be advised to:

gently clean and dry the wound every day

wear loose, comfortable clothes and cotton underwear

take a painkiller if the wound is sore - for most women, it's better to take paracetamol or ibuprofen (but not aspirin) while you're breastfeeding

watch out for signs of infection

Non-dissolvable stitches or staples will usually be taken out by your midwife after 5 to 7 days.

Your scar

The wound in your tummy will eventually form a scar.

This will usually be a horizontal scar about 10 to 20cm long, just below your bikini line.

In rare cases, you may have a vertical scar just below your bellybutton.

The scar will probably be red and obvious at first, but should fade with time and will often be hidden by your pubic hair.

On darker skin, the scar tissue may fade to leave a brown or white mark.

Controlling pain and bleeding

Most women experience some discomfort for the first few days after a caesarean, and for some women the pain can last several weeks.

You should be given regular painkillers to take at home for as long as you need them, such as paracetamol or ibuprofen.

Aspirin and the stronger painkiller codeine present in co-codamol is not usually recommended if you're breastfeeding.

Your doctor will be able to advise you on the most suitable painkiller for you to take.

You may also have some vaginal bleeding.

Use sanitary pads rather than tampons to reduce the risk of spreading infection into the vagina, and get medical advice if the bleeding is heavy.

Returning to your normal activities

Try to stay mobile and do gentle activities, such as going for a daily walk, while you're recovering to reduce the risk of blood clots. Be careful not to overexert yourself.

You should be able to hold and carry your baby once you get home.

But you may not be able to do some activities straight away, such as:

driving

exercising

carrying anything heavier than your baby

having sex

Only start to do these things again when you feel able to do so and do not find them uncomfortable. This may not be for 6 weeks or so.

Ask your midwife for advice if you're unsure when it's safe to start returning to your normal activities.

You can also ask a GP at your 6-week postnatal check.

When to get medical advice

Contact your midwife or a GP straight away if you have any of the following symptoms after a caesarean:

severe pain

leaking urine

pain when peeing

heavy vaginal bleeding

your wound becomes more red, painful and swollen

a discharge of pus or foul-smelling fluid from your wound

a cough or shortness of breath

swelling or pain in your lower leg

These symptoms may be the sign of an infection or blood clot, which should be treated as soon as possible.

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You'll probably be in hospital for 3 or 4 days after a caesarean section, and may need to take things easy for several weeks. The average stay in hospital after a caesarean is around 3 or 4 days. You may be able to go home sooner than this if both you and your baby are well.

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Third Stage

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Third stage of labour: delivering placenta and cord clamping | Labour & birth articles & support | NCT

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You’ve met your baby but there’s still work to be done. Here’s what happens during the third – and, good news, the final – stage of labour…

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During labour, it is normal NHS policy to offer vaginal examinations, sometimes called a VE. It is important to know that they are entirely optional. This Birth Information Page explains some of the reasons why VEs are offered, and their benefits and risks, to help you to decide whether or not you would like to have them.

A VE involves a midwife or doctor inserting their fingers (after taking measures to reduce infection, including wearing gloves) into your vagina to feel the cervix and any changes that might be happening. This may be for a number of reasons; some of the most common reasons for offering VEs are:

To try to decide whether labour is 'established' or 'active'

To try to track the progress of labour by seeing how the cervix is dilating, thinning and changing over time

To help the midwife or doctor to judge the position of your baby and/or how they are moving through your birth canal

For any reason that VEs may be offered, the midwife or doctor is obliged to ensure that you completely understand these reasons before they perform a VE. If you decide to not have one, they have to support and respect that decision. Remember that you can also decline some and accept others. It's up to you.

It is important to know that although VEs are offered to almost every labouring woman or person, and they are often seen as an essential part of labour, they are not actually essential to the way labour is progressing and may not directly influence or dictate the outcomes for you or your baby. However, there is information that they can give, which may or may not be valuable to you and the caregivers looking after you. This article is intended to help you to decide what's right for you.

What do vaginal examinations feel like?

VEs are experienced very differently by everyone. Some people don't mind them. Others find them to be uncomfortable or painful. For others, having fingers inserted into their vagina can be a distressing experience; this is especially common for people who have experienced sexual abuse, although anyone can feel this way. While the midwife or doctor may have seen hundreds or thousands of vaginas, they may have never seen your vagina. How you feel each time an examination is carried out will also change, and so you cannot be expected to react to them the same way each time.

VEs are often done with the labouring woman or person lying on their back, because this is usually how midwives and doctors are taught to do them. This can be challenging for those who don't want to move out of a position they're in, and lying on our backs can make labour more painful than other positions. It is therefore useful to know that it is possible to do a VE in any position. Just ask!

Do you have to have vaginal examinations?

It is very important to know that no one can ever put their fingers into your vagina without your consent - ever.

Legally, VEs can only happen if you freely consent to them. Whether or not you choose to do so is up to you.

There are several reasons that vaginal examinations may be offered, some of which are listed above. It is important to note, however, that someone does not have to have a VE before they are provided with care of any kind (for example access to hospital, use of the pool, access to pain relief). Demanding this does not provide people with the genuine, free ability to say "no" and therefore is not informed consent.

Using vaginal examinations to decide whether labour is 'active'

The term 'active labour', or, sometimes, 'established labour', is intended to refer to the time when labour is progressing, rather than stop-starting, and the cervix has opened past a certain point. The way that labour happens can be very different for different people. A person can be 1cm dilated and be experiencing extremely painful contractions for which they need pain relief, and already be in 'active' labour. Another person may be 6cm dilated but still be having very slow, on-off labour which isn't yet ready to progress. Every labouring woman or person is different and relying only on vaginal examinations can lead to people being told that they're not in established labour and not being given access to hospital, even though they're ready for some additional support.

Labouring women and people might then additionally be denied adequate or appropriate pain relief because they are not considered to be at the right stage of labour. Some of these concerns have been increased during the Covid pandemic where women are, or were, sometimes denied the support of their partner until classed as being in the right stage of labour (i.e. 'active labour'). Such practices of relying on vaginal examinations to determine pain relief may invalidate a person's own need for the support of their partner and midwives. To stress this point, the fact that people are not as dilated as the hospital's guidelines state they should be when in 'active labour' does not change their needs.

While we acknowledge the sometimes confusing discussions about what is or isn't active labour, there is evidence to show that going into hospital too early in labour can lead to a higher number of interventions, which is something that you might want to consider. On the other hand, being turned away when you are seeking help can be very distressing. When deciding what is best for you, remember only you know how you feel and what you can cope with. We don't know for sure why women who are admitted to hospital earlier are more likely to have interventions. It might be that just being in hospital puts them on the track of the ' cascade of intervention '. However, it is also possible that some of those women who go to hospital earlier in labour do so because their instinct tells them that they need the additional help, and that they attend earlier because they need an intervention. The real answer is probably that both of these are what is happening.

The important thing to know is that you don't have to have a VE to access any service and services cannot be withheld from you if you decline a VE. Yet, VEs are often used to decide if someone is in active labour or not.

Using Vaginal examinations to estimate the progression of labour

It is very normal, when talking about birth, to hear the midwife or doctor mention the number of centimetres dilated. Your cervix needs to dilate from closed or nearly closed to around 10cm in order for your baby to be born. But it is important to know that this is not an exact measurement, and even two people can sometimes give you different results. However, all the cervix needs to be is fully open to allow the baby to pass through.

Not everyone dilates to exactly 10cm. What is really happening is that the cervix opens sufficiently to allow the baby to pass through. Again, this is not an exact measurement.

Because the cervix dilates from a small opening before labour to around 10cm as the baby is ready to be born, it might seem logical to assume that at 5cm labour is halfway through. This, however, is not true. The opening of the cervix is not linear. For example, it may take 10 hours of labour to reach 3cm, then jump to 10cm in an hour. Or it may go from closed to completely open in 2 hours. It may even be at 2cm for three weeks, before taking 8 hours to be ready for birth. Therefore, it is clear that what the cervix has done previously cannot tell us what it will do in the future. It may sometimes give us an idea of what to expect when someone is in labour, which is discussed below, but it does not tell us when the baby or babies will be born.

The idea that the opening of the cervix should follow a line on a graph was introduced by a man called Dr. Emanuel Friedman, in 1955. He tracked the length of labour of 500 women, all of White European backgrounds, and created a graph (The Friedman Curve) showing the 'average' length of labour, and how quickly the cervix supposedly opened. This data doesn't tell us whether there are differences in 'average labour' between people from different communities or ethnicities, as they were not included in the study. The graph plotted a line showing how much the cervix was expected to open each hour in order to be considered 'normal'.

An analogy might be to take all of the white children in a school. In each class, every child's height is measured, and then the average height of the children in class 1 is calculated, and the same for class 2, and class 3, and so on. It is then decided that the average height of the children in each class is the correct height, and all children who are smaller or taller than this average are wrong. Clearly, this makes no sense. Each child in the class is unique, and the right height for them.

Following the introduction of The Friedman Curve into obstetrics, it became expected that all women and birthing people's labours would follow this graph. If their cervix did not open sufficiently quickly, this was considered to be 'failure to progress' - a term that AIMS would like to see banned. Of course, not one of us is average, and our cervixes don't actually open according to Dr Friedman's graph. This means that using a vaginal examination to track the opening of the cervix in order to track labour progression, and to estimate how much longer labour may last, has little value. We simply cannot expect everyone to follow the "average".

There are exceptions to this. Sometimes, labour can stall for reasons such as the baby being in a position which makes it hard for them to press on the cervix (which helps it to open), or perhaps because the environment in the birth room means that the birthing woman or person doesn't feel safe, or cared for, which can trigger hormones which slow or stop labour. The cervix not dilating, or dilation slowing, might be an indication that changes in the room may need to happen, such as the people around, making the labouring woman or person feel more comfortable, or changes of position to help the baby to move. Other reasons may include dehydration, low blood sugar or exhaustion. See The AIMS Guide to Giving Birth to Your Baby for a more detailed look at labour and birth. Sometimes, even when all the environmental conditions are met, it may be appropriate to consider interventions such as a caesarean if the baby appears to be in a position that would make vaginal birth unlikely or may not be coping well with labour. In these cases, though, there are likely to be other indications of a problem, which your midwife or doctor must explain to you.

Other reasons why a vaginal examination may be offered

Sometimes, a VE is done to try to help to determine the position of the baby, by feeling the 'presenting part' of the baby, which means the part which is pressing on the cervix. Normally this will be the head, and by feeling the lines on the skull of the baby, the midwife or doctor may be able to work out whether or not the baby is coming down in a way that makes for an easier birth.

Sometimes, an examination of the vagina is offered as part of a check to see whether the waters have broken when it is not clear if this has happened. In this situation, this is likely to be done by using a speculum, which is a device to open the vagina and allow a midwife or doctor to more easily see inside and, if necessary and with your consent, to obtain a swab (a sample of fluid or discharge from within the vagina which is sent away to a lab to check against infection).

A VE is likely to also be offered before an induction, to see whether the cervix has already changed at all, and what would be the best option to try to encourage it to start to open.

Very rarely, a VE is offered during antenatal care although this is not normal practice in the UK.

What are the risks of vaginal examinations?

The most common risks of a vaginal examination are infection, pain and discomfort, so before you make a decision on whether or not to accept a VE, you may want to think about whether you want to know the information it may offer to you.

For some labouring women and people, the act of someone putting their fingers into their vagina can be hugely distressing. Any form of pain or distress can adversely affect labour, as this can release the hormone adrenaline, which inhibits a key labour hormone, oxytocin. This can slow labour down for some people, and sometimes stop it for a period of time. In addition, being told that you are 'not progressing', or not progressing as fast as expected, can lead to feeling disheartened and upset. As mentioned earlier, given that the dilation of the cervix at that moment gives no information as to the length that labour will ultimately be, this could be a pointless discouragement. The dilation measurement itself is not even necessarily accurate, and the estimate can differ from caregiver to caregiver.

Equally, for some labouring women and people, news that the cervix has dilated more can be reassuring and helpful, and give them the incentive to keep going!

Vaginal examinations can be a source of infection, and the more times they are done, the more chances there are of causing an infection. Unfortunately, anything that is put into the vagina - including a sterile speculum or gloved finger - will increase the risk of an infection whether or not the waters have broken, as doing so pushes germs up the vagina towards the uterus.

Additionally, a VE can cause the waters to be broken by mistake, which can then increase the risk of infection as well as sometimes causing contractions to become more difficult to cope with. In some cases, as we have heard many times on the AIMS helpline, midwives and doctors have accidentally or deliberately used a VE to break the waters despite the woman or person not having consented to having them broken.

It is very common towards the end of pregnancy for midwives or doctors to offer a 'stretch and sweep'. This is sometimes also offered in early labour. A stretch and sweep, commonly called a sweep, is a form of induction of labour that involves the midwife or doctor inserting their fingers into the vagina, and through the cervix. The procedure is explained in The AIMS Guide to Induction of Labour. Sometimes, a stretch and sweep might be performed after consent has been given for a VE, but explicit consent for the stretch and sweep has not been given. This is an assault because consent must be given for any intervention to be done. Just because a midwife or doctor has their fingers in someone's vagina does not mean that they can do another procedure at the same time.

What are the alternatives

While it may be arguable that knowing the dilation of the cervix by any method has limited value, due to the fact that it does not open at a linear rate, sometimes it may be useful to have an indication of progress. For labouring women and people who decide to decline the offer of a VE, some midwives and birth workers describe using other ways to estimate how labour is progressing, based on their own experience.

1) Watch and listen. While every woman and birthing person labours differently, it is generally possible to judge by a woman's behaviour how her labour is progressing. While this can be more difficult where a midwife might be caring for a number of labouring women and people, huge amounts of information can be gathered by just watching and listening.

2) The dilation line (sometimes called ' the purple line ') - In some women and birthing people (not all), a purple, silver, brown or red line can be seen, starting from the anus and developing up between the buttocks. This line tends to approximately reflect cervix dilation, with about 1cm of line equalling about 1cm of dilation of the cervix. This is not always the case - sometimes the line can be there but it does not relate to dilation - but it might be a useful indication in some cases.

3) Hot legs - as women and birthing people progress through labour, the extra blood needed by the uterus to do its hard work pulls blood away from their extremities. This can lead to the legs getting progressively colder, from the foot to the knee. When the colder part is at the mid calf, that equates roughly to 5cm dilated. This works less well for those who have had an epidural or some other pain relief. If they have been in a pool or warm bath, it will take around 20 minutes or so for the effect to be felt.

Summary

VEs might sometimes be useful for different reasons, but they do not provide benefits to all women and birthing people or their caregivers. It is always your choice whether or not you consent to having VEs, for any reason. If a healthcare provider coerces you into a VE, for instance by saying that you 'have to have one' before being given access to care, they leave themselves open to an accusation of criminal assault and battery, and other legal action (please see the AIMS information page on Obstetric Violence).

References:

[1] Miller et al, 2020, Variations in outcomes for women admitted to hospital in early versus active labour: an observational study: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03149-7

[2] Friedman, 1955, Primigravid labor; a graphicostatistical analysis: https://pubmed.ncbi.nlm.nih.gov/13272981

[3] Gluck et al, 2020, The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study: www.ncbi.nlm.nih.gov/pmc/articles/PMC7183634
Further reading about Vaginal Exams VEs - Essential Diagnostic Tool? Respectful Vaginal Examinations Project - Co-Production in Action The Assessment of Progress Vaginal examinations: a symptom of a cervical-centric birth culture Assessing Progress in Labour The purple line as a measure of labour progress: a longitudinal study
Written by: Emma Ashworth
Reviewed by: Megan Disley and Fanny Kernohan
Reviewed on: 21/04/2023
Next review needed: 21/04/2025

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 April 2023

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information for parents about vaginal examinations

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What is a stretch and sweep? - Dr Sara Wickham

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Many women are offered a 'stretch and sweep' in late pregnancy, sometimes on more than one occasion. But what is this, why and how is it done, does it work and can you say no?

What is a stretch and sweep?

It's a procedure in which a midwife or doctor will, while doing a vaginal examination, sweep a finger around and/or within the opening of your cervix (the lowest part of your womb).

Why is a stretch and sweep offered?

A stretch and sweep is offered in the hope that it will stimulate the uterus and bring labour on earlier than it might otherwise have begun. In other words, it is a way to try to induce labour.

Some hospitals have guidelines that tell the midwives that work for them to offer a stretch and sweep to all women. Stretch and sweeps are discussed in the NICE guidance in the UK. In other areas, midwives offer it because they know that women will be pressured to undergo hospital induction if they do not go into labour by a certain time. This is understandable, because midwives know that many women do not like induction and it can lead to unwanted consequences.

However, you do not have to accept any intervention, including a stretch and sweep.

Does it work?

We don't really know, to be honest. The results of studies that have looked at this have been very varied. Many were deemed to be of low quality and, where there is a difference between the women who had a sweep and the women who didn't, it was a small difference.

Here's what I wrote about the evidence in Inducing Labour: making informed decisions:

"The most recent Cochrane review of the research on this topic by Boulvain et al (2005) found that, while these may help bring on labour a bit sooner than otherwise would be the case, eight women need to have a stretch and sweep in order for one woman to go into labour without needing more induction interventions. However, this figure assumes that all women would decide to have induction, which is not the case." ( Wickham 2018).

The (lack of) evidence

The Cochrane review that I referred to in there has since been updated, but not much has changed. The most recent review shows that it's still very uncertain whether or not membrane sweeping makes a difference. Note that, in this quote, they can only say that it MAY help. They also note that the evidence isn't robust and that there are lots of areas that we need to know more about.

"Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour." (Finucane et al 2020). More on that review here.

Because there is so much uncertainty, it's really hard to know whether, if you go into labour after you've had a stretch and sweep, it was because of the stretch and sweep or whether your body was about to go into labour anyway.

Are there risks, and does it hurt?

Stretching and sweeping isn't benign, as some people like to suggest.

Here's another excerpt from my book on Inducing Labour:

"The risks and downsides of a stretch and sweep include discomfort, light bleeding and irregular contractions, which may interfere with a woman's ability to rest and sleep in the last few days of pregnancy. In some studies, the stretch and sweep intervention only brought the onset of labour forward by about 24 hours.

Vaginal examination always carries a risk of infection, and many women find such intimate examinations embarrassing and/or uncomfortable." (Wickham 2018).

The authors of the Cochrane review were concerned about the downsides of this procedure and concluded that, 'Current international guidelines state that induction of labour, as with any intervention, carries risks and advise it be performed only when there are clear indications that continuing with the pregnancy is of greater risk to the mother or fetus than the risk of induction of labour." (Finucane et al 2020).

Balancing risks and benefits

A previous review stated that:

"Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects' (Boulvain et al 2005: 2)." ( Wickham 2018)

How do women feel about it?

It is notable that few studies have asked women how they feel about membrane sweeping. Finucane et al (2020) say that:

"...limited data are insufficient to meaningfully discuss women's satisfaction with membrane sweeping for induction of labour".

However, we know from real-world stories and qualitative research that a stretch and sweep is not for everyone. Some women say they wish they had not had this method of induction performed on them, or that they had been given more information about it first. There's more on this in my book, In Your Own Time.

Wider concerns

I also hear from women whose midwife or doctor accidentally broke their waters while doing a stretch and sweep. I'm not aware of any data on how common this is. From experience it's not a very common problem, but it does happen occasionally. When it does happen, it means that, because there is now a risk of infection, hospital induction will be offered if you do not go into labour within a certain time. This news can come as a rather unpleasant surprise. Especially if you were not told that this was a risk before you agreed to a stretch and sweep.

It is because of this that it is always good to ask about the benefits and risks of any procedure. You may also wish to ask about alternatives and about what your options are if you decide to do nothing. ( We call this the BRAN analysis, and you can read about it here. I have also written a book designed to help you make decisions about things like this).

What do people say about a stretch and sweep after they have experienced it?

Like with anything else, if you go and read individual stories online, you will find a range of experiences. And you will find some extreme views. Some women love that they had a stretch and sweep. They swear that it works for them. Others hated it, or what happened as a result of it. Some wish they had said no. There are those who say they would never have one. And then some beg their midwife to do one as soon as possible and to repeat it as often as possible. There also lots of viewpoints in the middle, though these might not get shared as often, because we do tend to hear the ones on either end of the spectrum of experiences, especially online.

As with all stories, these are individual viewpoints. Unfortunately, we don't have any good research which has looked at this and which might be able to give us a more balanced perspective.

Why is it controversial?

The stretch and sweep is a controversial procedure for a number of reasons. As above, it isn't as effective as some people would like you to think. It will only work for a few people and, if it does work, it doesn't bring labour forward by much anyway.

It has potential downsides as well as potential benefits.

There's another reason it's controversial. Some women have found that this procedure is offered or suggested during an antenatal visit without much prior discussion. And, shockingly, sometimes it is suggested while a midwife or doctor is in the middle of a vaginal examination.

This is not OK.

Neither is it OK for someone to do this without your full consent.

A recent review of the literature on this has confirmed some of these things. Roberts et al (2020) found that, "There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour."

Can I say no?

Absolutely.

You can always say no to anything that you do not want, including a stretch and sweep or a vaginal examination for any reason.

If you are not sure about the implications of agreeing to an examination or procedure, then ask. And, if necessary, keep asking questions until you feel you have enough information to be able to make the decision that's right for you. If you feel you need to know more about that, please see this book.

It's also important to remember that you can also say no to induction of labour if this isn't what you want. Sometimes, people present the stretch and sweep intervention as an alternative to induction, and tell you that, if you have a stretch and sweep, you are less likely to 'have' to have induction.

But a stretch and sweep isn't a way of avoiding induction. As I said above, it is itself a form of induction.

You don't have to have induction at all, if it's not right for you.

Summing it up...

Although the stretch and sweep has side effects and doesn't always work, which means not everyone who has one will benefit from it, some people feel it is justified. That's because, overall, on a population basis, it may reduce the number of women who have a hospital induction. But, again, this is based on the assumption that everyone will agree to induction. Also, as the induction epidemic continues and membrane sweeping is offered earlier and in more situations, the effectiveness of the stretch and sweep as a means of reducing the hospital induction rate may decline.

Membrane sweeping is generally seen as less invasive than cervical ripening, artificial rupture of membranes and syntocinon. This does, however, ignore the fact that vaginal examination can be extremely traumatic for some. But a stretch and sweep is still interference. It's still a form of induction, and it is being offered more often and earlier, when a pregnancy has barely reached 'term', let alone 'post-term'. This results in an overall increase in intervention, and it may have emotional and social impacts that haven't been considered.

In Your Own Time...

And there are other ways of spending the last days of pregnancy. I met a lovely woman who, having heard the term 'stretch and sweep', not unreasonably thought that this related to her midwife's recommendation to relax, follow her nesting (and housework) urge and alternate movement and rest according to how she felt during the last few weeks of her pregnancy. The woman doesn't mind me sharing this story at all: she hopes it will encourage others to consider alternative forms of this practice. (I look forward to sharing the Cochrane review on housework and yoga to reduce the duration of pregnancy soon...)

But, as I discuss in In Your Own Time, unless you have a genuine medical condition which means that you or your baby needs birth to happen sooner rather than later, there are many advantages to allowing your baby to decide when to be born. And many other things you might like to be doing in the last days of pregnancy.

Where do we go from here?

I really do think we need to get a lot clearer on the question of intention. When I say 'stretching and sweeping isn't benign', I don't just mean that it can cause bleeding and discomfort. Or that it can be traumatic.

I mean that it is an intervention which is used in a deliberate way to attempt to induce labour, and it should be presented, discussed and evaluated it as such, rather than offering it as 'just what we do...'

We might also be wise to look at the stretch and sweep within the wider context of what happens around the end of pregnancy. One of the main reasons that the use of this intervention is increasing is because the goalposts around normality at the end of pregnancy are being progressively narrowed.

As a result, induction is offered more frequently, and stretch and sweep is seen in many areas as an attempt to avoid hospital induction of labour. Indeed, many of those who are offering membrane sweeping are doing so because they know it is preferable to hospital induction. But when the evidence for induction is not at all clear, the real question is whether someone wants their labour to be induced at all.

Because for those who do not feel that induction is something that they want, there's something else that can reduce their chance of having that: the word "no".

If you'd like more information, here are some books and pages which you might find useful. We also offer a monthly newsletter and online courses for midwives and birth folk who would like to stay on top of the evidence and improve their confidence at analysing and communicating the evidence in this and related areas.

Post-term pregnancy and induction of labour resources

References

Boulvain M, Stan CM, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2

Finucane EM, Murphy DJ, Biesty LM et al (2020). Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub3

Roberts J, Evans K, Spiby H et al (2020). Women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour. Midwifery, in press. https://doi.org/10.1016/j.midw.2019.102626

Wickham S (2018). Inducing Labour: making informed decisions. Avebury: Birthmoon Creations.

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What is a stretch and sweep? - Dr Sara Wickham

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Many women are offered a 'stretch and sweep' in late pregnancy, sometimes on more than one occasion. But what is this, why and how is it done, does it work and can you say no? What is a stretch and sweep?

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Authors: de Vaan MDT, ten Eikelder MLG, Jozwiak M, Palmer KR, Davies-Tuck M, Bloemenkamp KWM, Mol BJ, Boulvain M

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Mechanical methods for induction of labour

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We set out to determine from randomised controlled trials the effectiveness and safety of mechanical methods to bring on labour in the third trimester of pregnancy (> 24 weeks’ gestation). Use of a balloon to stretch the cervix (the lower end of the uterus) was compared with prostaglandin E2 (PGE2),…

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Artificial Rupture of Membranes - Breaking Waters 

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Artificial Rupture of Membranes - Breaking Waters 

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Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.

The aim of breaking the waters (also known as artificial rupture of the membranes (ARM), or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby's heart rate.

The review of studies assessed the use of amniotomy in all labours that started spontaneously. There were 15 studies identified, involving 5583 women, none of which assessed whether amniotomy increased women's pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended as part of standard labour management and care.

If you found this evidence helpful, please consider donating to Cochrane. We are a charity that produces accessible evidence to help people make health and care decisions.

On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care. We recommend that the evidence presented in this review should be made available to women offered an amniotomy and may be useful as a foundation for discussion and any resulting decisions made between women and their caregivers.

Read the full abstract...

Intentional artificial rupture of the amniotic membranes during labour, sometimes called amniotomy or 'breaking of the waters', is one of the most commonly performed procedures in modern obstetric and midwifery practice. The primary aim of amniotomy is to speed up contractions and, therefore, shorten the length of labour. However, there are concerns regarding unintended adverse effects on the woman and baby.

To determine the effectiveness and safety of amniotomy alone for routinely shortening all labours that start spontaneously.

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013).

Randomised controlled trials comparing amniotomy alone versus intention to preserve the membranes. We excluded quasi-randomised trials.

Data collection and analysis:

Two review authors assessed identified studies for inclusion, assessed risk of bias and extracted data. Primary analysis was by intention-to-treat.

We have included 15 studies in this updated review, involving 5583 women.

Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labour
There was no clear statistically significant difference between women in the amniotomy and control groups in length of the first stage of labour (mean difference (MD) -20.43 minutes, 95% confidence interval (CI) -95.93 to 55.06), caesarean section (risk ratio (RR) 1.27, 95% CI 0.99 to 1.63), maternal satisfaction with childbirth experience (MD -1.10, 95% CI -7.15 to 4.95) or Apgar score less than seven at five minutes (RR 0.53, 95% CI 0.28 to 1.00). There was no consistency between trials regarding the timing of amniotomy during labour in terms of cervical dilatation.

Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labours that have become prolonged
There was no clear statistically significant difference between women in the amniotomy and control group in caesarean section (RR 0.95, 95% CI 0.15 to 6.08), maternal satisfaction with childbirth experience (MD 22.00, 95% CI 2.74 to 41.26) or Apgar score less than seven at five minutes (RR 2.86, 95% CI 0.12 to 66.11).

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Amniotomy for shortening spontaneous labour

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Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. The aim of breaking the waters (also known as artificial rupture of the membranes (ARM), or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour.

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The microbiome seeding debate - let's frame it around women-centred care

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Induction of Labour - Worcester NHS Trust

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Induction of Labour - Worcester NHS Trust

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Worcestershire Acute Hospitals NHS Trust

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Having your baby - labour and Birth - Worcestershire Acute Hospitals NHS Trust

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If you are planning a home birth your community midwife will have explained to you how to contact a midwife when you go into labour.

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Induction Cwm Taf Morgannwg Health Board

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Induction Cwm Taf Morgannwg Health Board

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Cwm Taf Morgannwg University Health Board

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Induction of labour is where labour is started artificially. In Cwm Taf Morgannwg University Health Board over 30% of women are offered induction each year. There are many reasons why you may be recommended to have an induction of labour. Your midwife or doctor will discuss this with you if needed.

It is always your choice whether you are induced or not. Below is our Induction of labour leaflet which explains the process. If you have any concerns or questions please contact your midwife or doctor to discuss this further.
So you want to know more about induction of labour

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Induction of labour is where labour is started artificially. In Cwm Taf Morgannwg University Health Board over 30% of women are offered induction each year. There are many reasons why you may be recommended to have an induction of labour. Your midwife or doctor will discuss this with you if needed.

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Induction of Labour Oxfordshire Hospitals

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Induction of Labour Oxfordshire Hospitals