Birth And The Post-Natal Period

22.3.06

"Childbirth itself is a natural phenomenon, and the large majority of women need no interference whatsoever - only close observation, moral support and protection."
-Klooserman, 1972.

Antenatal
• Scans.
• Clinics.
• Groups.
• Birth plan.
• Waiting.

Onset of labour
• Spontaneous rupture of membranes.
• Cervical changes.
• Change in contractions.

Spontaneous rupture of membranes
• "Waters break."
• Regular observations of mother and foetus.
• If >24 hours to deliver - paediatric care for infant.
• If >72 hours to delivery - induce.

Cervical changes
• Hormonal effects thin cervix (effacing).
• The show.
• Mechanical effects cause cervix to dilate.
• Dilates up to 4cm in early (latent) phase of labour).
• Dilation of >2cm considered "in labour."

Changes in contractions
• Natural rhythmic smooth muscle contractions through late pregnancy.
• Hormonal and mechanical changes cause alteration to contractions.

Remember!
• Pregnancy, labour and birth are normal.
• Physiology, not pathology.

Where to now?
• Home versus hospital.
• Individual decision.
• Majority of babies delivered in hospital.
• ≈30 home births per year in Liverpool region.
• Philosophical, resource, midwifery and legal issues.

Home births
• Ante-natal preparation and perinatal monitoring.
• Uncomplicated pregnancies with expected normal labour and delivery.
• Primiparous women accepted.
• Patients given information on safety of home births.
• Initial home visit in second trimester to check environment.
• Second visit at 35+ weeks to ensure equipment delivered and confirm birth plane.
• Patient contacts delivery suite as normal at onset of labour.
• Two midwives at birth.
• Problems lead to 999 transfer to hospital.

Pain relief in labour - non-pharmacological methods
• Support.
• Position.
• Mobilisation.
• Complementary therapies - massage, acupressure, aromatherapy, music etc.
• Water.
• TENS.

Pharmacological methods
• Paracetemol.
• "Gas and air" (nitrous oxide and oxygen in 1:1 ratio).
• Opiates - pethidine (less crosses into foetal circulation).
• Epidural (not home births).

Progression of labour
Stage 1
• Latent phase - up to 8 hours, gradual increase in strength of contraction.
• Active phase - up to 6 hours, contractions become more painful.
• Transitional phase - ≈1 hour, painful contractions.
• Progression from latent to active phase heralds time to call delivery suite.
• Progression variable, but overall labour 12-14 hours for primiparous women (6-7 hours for multiparous women).

Stage 2 - delivery
• Vaginal canal fully relaxed, cervix fully dilated.
• Frequent and strong prolonged contractions.
• Irresistible urge to push.

Stage 2 - birth
• Perineal bulging - emptying of residual bowel/bladder contents.
• Crowning of baby's head.
• Check cord position.
• Two midwives attend birth.
• Head delivered, followed by shoulders.
• Baby delivered in ≈1 hour from start of second stage.

In-patient care and support - paediatricians
• APGAR scores at 1 and 5 minutes (and 10 minutes if problems).
-Pulse.
-Breathing.
-Movements.
-etc.
-7-10 normal, 4-7 resuscitative support, 0-3 emergency resuscitation.

Episiotomy
• Some controversy, less common now.
• Performed to prevent uncontrolled tearing/need for caesarean section.
• Indication - large head, need for forceps.

Stage 3 - placenta
• 20-25cm, 500g.
• Smooth with central cord on uterine cavity (baby) side.
• Uterus relaxes after stage 2 for 10-15 minutes.
• As contraction restart, placenta shears away from uterine wall.
• Delivered via gentle consistent pressure on cord with above pressure to control descent.
• Must examine placenta to ensure intact.
• Post-partum haemorrhage - >500ml blood loss.
• Medical emergency usually due to failure of uterus to contract or placenta remnants.
• Risks reduced by routine syntocinon.
• Vaginal tears/episiotomy should be repaired immediately after delivery.

Caesarean section
• Non-cephalic presentations.
• Multiple pregnancies.
• >1 previous caesarean section.
• Suspected/previous problems in delivery.
• Foetal distress.
• Failure to progress.

Midwives
• Baby care information.
• Feeding support - breast versus bottle.
• Maternal rest and support.
• Advice wrt wound care, cord care, lochia etc.
• Early signs of problems.
• Labour "debriefing."
• Administration advice.

Paediatrics
• Second check within 24 hours,
• Weight, height, head circumference.
• Face.
• Back.
• Digits.
• Genitals.
• General appearance and behaviour.

Going home
• Discharge.
• Midwife visits on first day at home.
• Further visits as needed, up to 28 days post-delivery.
• Eighth day visit for heel prick test.

Health visitor
• Statutory visit 10-14 days post-delivery.
• Establish relationship.
• Support feeding.
• Baby routine and ailments.
• Weight/growth monitoring.
• Depression monitoring - Edinburgh Post-Natal Depression Score (EPNDS).
• Subsequent visits as indicated.
• Open access clinics every 2 weeks.
• Post-natal groups.
• Positive parenting groups.
• Ongoing growth/development monitoring.
• Ongoing maternal support and monitoring.
• Open dialogue.

Post-natal depression
• 10% of women.
• Weeks or months post-delivery.
• Symptoms of depression.
• Poor bonding with baby.
• Feelings of failure and guilt.
• Lasts for months.

"Baby blues"
• 50% of women, 4-10 days post delivery.
• Tearful and irritable.
• Rapidly resolves.

Puerperal psychosis
• 1 in 500 women within 2 months of delivery.
• Personality change, agitation, depression.
• Threaten suicide or harm to baby.
• Requires prolonged in-patient treatment.

GP's role
• Massively reduced - post-natal role only.
• Contact parents after delivery.
• Support/advice as needed.
• Part of health care team.
• 6 week check.

6 week check
• Parental concerns and questions.
• Weight and head circumference.
• General behaviour and appearance.
• Palate and fontanelles.
• Motor tone, reflexes.
• Eyes, hearing and vocalisation.
• Cardiovascular system.
• Spine, hips, feet.
• Hernias, testes, genitalia.
• Health education and advice.
• Contraception.
• Parental/family support.