Labour and Birth

The main signs of labour starting are strong, long, regular contractions and a ‘show’. A show is when the plug of mucus from your cervix comes away. However, it is not unusual to ‘have a show’ several days or weeks before your labour begins and unless it is heavily blood stained, this is nothing to worry about.

Other signs that labour is beginning include your waters breaking (rupture of the membranes), or strong intermittent backache and contractions that become more regular.

You’re likely to recognise the signs of labour when the time comes, but if you’re in any doubt, don’t hesitate to contact your midwife for advice.

Backache

Lower backache is very common in labour and is part of the normal processes. You may get backache or the aching, heavy feeling that some women experience with their monthly period.

A ‘Show’

While you are pregnant, a plug of mucus is present in your cervix. Just before labour starts, or in early labour, the plug comes away and you may pass this into your underwear. This small amount of sticky, jelly-like pink mucus is called a show.

It may come away all at once or gradually. It is pink in colour because it’s blood-stained, and it’s normal to lose a small amount of blood mixed with mucus. If you’re losing more blood, it may be a sign that something is wrong, so telephone Triage straight away.

The numbers for maternity triage are below:

Maternity Triage Oxford Road Campus: 0161 276 6567

Maternity Triage Wythenshawe: 0161 291 2724

A show may indicate that the cervix is starting to open and labour may follow quickly, or it may take several days or even weeks. Some women do not have a show.

Waters Breaking

Most women’s waters break during labour, but it can also happen before labour starts. Your unborn baby develops and grows inside a bag of fluid called the amniotic sac. When it’s time for your baby to be born, the sac breaks and the amniotic fluid drains out. This is your waters breaking.

You may feel a slow trickle, or a sudden gush of water that you cannot control. To prepare for this, you could keep a sanitary towel (but not a tampon) handy if you are going out and put a protective sheet on your bed.

Amniotic fluid is clear and a pale straw colour. Sometimes it’s difficult to tell amniotic fluid from urine. When your waters break, the water may be a little blood-stained to begin with. Tell your midwife immediately if the waters are smelly or coloured, or if you are losing blood, as this could mean that you and your baby require urgent attention.

As soon as your waters break, you need to contact maternity triage, see the numbers below:

Maternity Triage Oxford Road Campus: 0161 276 6567

Maternity Triage Wythenshawe: 0161 291 2724

Without amniotic fluid your baby is no longer protected and there is a small risk of infection. Your midwife and doctors will discuss what this means, and your options, if you do not go into labour on your own.

At the beginning of labour

• Walking and moving can help the labour to progress.
• Drink plenty of clear fluids and you may find isotonic drinks (sports drinks) help to keep your energy levels up.
• Have regular snacks, although many women don’t feel very hungry and some feel sick.
• As the contractions get stronger and more painful, you can try relaxation and breathing exercises – your birth partner can help by doing these with you.
• Your birth partner can rub your back as it can help relieve pain.
• You can take paracetamol 1g (2 tablets) every 4-6 hours, up to a maximum of 8 tablets in 24 hours.
• A warm bath or shower may also help.

Before the neck of your womb or ‘cervix’ can start to open, it needs to soften. Contractions in early labour help to soften the cervix so that it can gradually open. The process of your cervix softening can take several hours before you’re in what midwives call ‘established’ or ‘active’ labour.

For the majority of women with an uncomplicated pregnancy, studies have shown that the labour will progress better in your own environment at home, therefore your midwife will probably advise you to stay at home until your contractions become and remain frequent.

When your contractions last 30-60 seconds and occur every five minutes, call your midwife for further guidance.

Remember, if your waters break before labour starts, contact Saint Mary’s hospital on the number you have been given by your midwife. Tell your midwife immediately if the waters are smelly or coloured, or if you are losing blood, as this could mean that you and your baby require urgent attention.

If your midwife has advised you to come into the hospital, please remember to bring your hand-held notes.

The process of your cervix softening can take several hours before you’re in what midwives call ‘established’ or ‘active’ labour. Established labour is when you are having regular contractions and your cervix has dilated to 4cm or more. If you are seen by the midwife in The Manchester Birth Centre or one of our Triage Departments before labour is established, you may be advised to go home for a while to wait for your labour to establish.

When at home, you should make sure that you eat and drink. Many women don’t feel hungry or feel sick, but it is important to keep your energy up. Overnight, if you can, try and rest whilst labour establishes. A warm bath or shower might help you to relax. During the day, keep upright and active. Moving around and keeping upright means that gravity will help your baby to move down the pelvis and encourage the neck of your womb to open.

When your contractions last 30-60 seconds and occur every five minutes, call your midwife for further guidance.

When you are having regular contractions and your cervix has opened, the midwife will want to closely monitor the wellbeing of yourself and your baby. This involves monitoring the baby’s heart rate either intermittently or continuously. The next section will discuss this in more depth, but as a minimum, we recommend that we listen to your baby’s heartbeat every 15 minutes in active labour.

Midwives and obstetricians also like to monitor the progress of your labour. This is done via regular vaginal examinations, usually ever 4 hours, to see how dilated or ‘open’ your cervix is. Once you are in active labour, we expect your cervix to open by 2cm every 4 hours.

The neck of the womb, or cervix, needs to open fully to about 10cm for a baby to pass through.  This is what’s called being ‘fully dilated’.

If the midwife is worried that your contractions slow down or become less strong, the midwife may suggest several things that can help to accelerate (speed up) labour. These include:

• Getting up and moving around, drinking more water or isotonic drinks, small snacks and/or making sure that you have emptied your bladder recently.
• Breaking your waters for you. This procedure is called an ‘artificial rupture of membranes’ or ‘ARM’. During a vaginal examination, the midwife or doctor makes a small hole in the membranes around your baby- much like bursting a water-balloon. The idea is that the cushion that your waters provide is burst, meaning that your baby’s head will put more pressure on the neck of the womb and encourage it to open.

These actions do not change where you can birth or how the midwife would like to monitor your baby. If these actions do not increase the number of contractions you are having, or how strong they feel, the midwife or doctor will suggest what is commonly known as the ‘hormone drip’. The hormone drip, known to midwives and doctors as ‘oxytocin’ or ‘syntocinon’ will be prescribed by a doctor and can only be given on the consultant-led delivery suite. The drip is given into a vein in your hand. After the drip is attached, the midwife will monitor your baby’s heartbeat continuously using something called a CTG. More information about this is provided in the next section.

This includes the ‘pushing’ stage.  It begins when the cervix is 10cm or fully dilated and lasts until the birth of your baby.  Your midwife will help you find a comfortable position and guide you when the time comes to push.

Finding a Position to Give Birth

Find the position you prefer and that will make labour easier.  You can stand, sit, kneel or squat and an upright position is recommended as this is the easiest and most effective position to birth a baby.  Some positions are more appropriate depending on the position of your baby and your midwife can guide you to choose the best position for both of you.

Here’s a useful link about positions in labour.

Pushing the Baby Out

When your cervix is fully dilated and your baby moves downwards, you may feel a very strong urge to push. This is often described as needing to open your bowels. The midwife will support you with this. At Saint Mary’s Hospital we recommend using a hands-on technique to support your perineum – the skin and muscles between your vagina and your anus. The midwife or doctor may ask you if they can use a warm compress to support your perineum as the baby is about to be born. If you are in the pool, the water provides this support. As the baby’s head is about to be born what midwives and doctors call ‘crowning’, the midwife or doctor will encourage you to pant. This is to help the baby’s head be born slowly and in a controlled way.

This is the name given to the delivery of the placenta. The midwife will discuss options about the delivery of the placenta with you: these are called either a physiological or active third stage. In an active 3^rd stage, the midwife will offer you an injection to help to deliver your placenta. This is given into your thigh just as the baby is born. The injection is useful in preventing heavy bleeding after birth for some women. Not all women choose to have the injection and may choose to have a physiological third stage. This involves pushing the placenta out yourself, without medication, after the birth of your baby. Please discuss with your midwife if the injection is recommended for you after the birth of your baby.

Soon after your placenta is delivered, your midwife will ask to examine your vagina and perineum for any tears. If needed, your midwife or a doctor will repair these  to help the healing process.

Encourage your baby to lie skin to skin on your chest after birth – this could also be done by your partner.  Skin to skin has been shown to encourage parent-baby bonding, regulate baby’s temperature and breathing and will encourage you both to recover after birth.  It also prepares your baby for their first feed, regardless of feeding method.

Intermittent monitoring, ‘listening in’, or intermittent auscultation is the process of listening to the baby’s heart rate intermittently during the active stage of labour. This means that the midwife will use a handheld doppler (sonicaid) or pinard stethoscope to listen to your baby’s heartbeat at least every 15 minutes in the first stage of labour and at least every 5 minutes in the second stage of labour. Your midwife should count this for one full minute, straight after a contraction and feel your pulse at the same time. The midwife will plot your baby’s heart rate on something called a partogram. This is used to check that your baby’s heart rate remains within a normal range (a baby’s heart rate is much quicker than an adults) and that the baseline or ‘average’ heart rate remains consistent throughout your labour.

Intermittent auscultation has many benefits including allowing you to be more mobile than continuous monitoring. We recommend intermittent auscultation for uncomplicated pregnancies as it has been shown to reduce the need for unnecessary interventions. If you choose to birth at home or in The Manchester Birth Centre, your baby’s heart rate will be monitored using this method.

Another method of monitoring your baby’s heartbeat during your labour would be to use continuous electronic monitoring using a monitor called a Cardio-Toco-Graph (CTG), which records your baby’s heartbeat continuously throughout your labour. The monitor also records the frequency of your contractions. A CTG works by attaching two plastic pads to your tummy with elastic belts – one which records your baby’s heartbeat, and the other which records the contractions’ It is your choice whether you have electronic fetal monitoring (EFM) or not. If you are advised to have this form of monitoring your midwife will explain the reasons for the recommendation.

Common things that may lead your midwife or doctor to recommend continuous monitoring include:

• Induction of labour using oxytocin
• Your baby has been found to be small from a scan
• Your baby has opened its bowels and your waters are a green colour- meconium.
• You start bleeding in labour
• There has been a concern with your baby’s heart rate at any time in labour
• You have certain underlying medical conditions such as diabetes
• You have raised Blood Pressure, a high heart rate or a high temperature
• You would like an epidural
• There is a delay in your labour
• Your baby was not moving as normal before the onset of your labour

CTG

There are several ways that the midwife may continuously monitor your baby’s heart rate. The most common is using a CTG (cardiotocograph). Two pads will be held onto your abdomen (tummy) using soft belts. You can still get up and move around with a CTG, but how far you can move will depend on the type of machine.  We use some CTG machines that are wireless and waterproof and are called ‘telemetry’. Telemetry CTG machines enable you to move further or use the birthing pool on the consultant led delivery suite as there are no wires connecting you to the monitoring machine.

The purpose of this monitoring is so that midwives and doctors can interpret a trend of your baby’s heart rate and there are several things that they will look for in this trend to assess your baby’s wellbeing. It is important for midwives and doctors to be able to interpret this trend. This recording is printed out on paper and also stored electronically. You will be kept fully informed throughout your labour of any concerns regarding your baby’s heart rate.

Fetal Scalp Electrode (FSE)

In certain circumstances, the midwife may not be able facilitate a good heart rate trace using the external montiring. The midwife or doctor may recommend using a fetal scalp electrode, sometimes called an FSE or a ‘clip’ to improve the monitoring of your baby’s heart rate. The clip is put onto your baby’s head during a vaginal examination and your waters will be broken if they have not already done so.

Fetal Blood Sample (FBS)

Sometimes if there are concerns with the baby’s heart rate it is necessary to find out whether a baby is coping with the contractions and maintaining their oxygen levels.  If this happens, the doctor will talk to you about an extra test on your baby called a fetal blood sample (FBS).  This involves a vaginal examination, using a speculum. The doctor will make a small scratch on the baby’s head and collect a small blood sample, which will be analysed immediately. The scratch is superficial and will heal quickly after birth. This is a safe procedure. You will be informed of the result from this test in a couple of minutes and your midwife and doctor will discuss your options with you, depending on the result of the test. Your midwife and Doctor will advise you of the safest option. At this point the options would include:

• continuing with labour
• taking a second fetal blood sample
• having an assisted birth or a caesarean section as soon as possible.

Sometimes it is not always possible to get a good fetal blood sample, if this is the case then the midwife and doctor will likely advise you to have a caesarean section or assisted vaginal birth if you have reached fully dilated.