Birthing & Delivery

I consider many factors before inducing labour, including how the pregnancy is progressing, your age, medical history, and your own wishes for birth.  Our understanding of when to recommend induction has changed  in recent years, due to a number of major scientific studies that were published, including the ‘ARRIVE’ trial which recommends delivery at 39 weeks to reduce maternal and foetal complications (including the reduction of emergency caesarean sections).

Labour induction is the use of medications or other methods to start labour. The most common type of induction is a hormone gel induction. Another method of inducing labour is to insert a soft balloon catheter just inside cervix. I determine which method is the safest and best for you.

Prostin gel is synthetic hormone similar to the one your body procedures naturally. This hormone softens and opens the cervix ready for labour. It is used when the cervix hasn’t ripened by itself. Natural ripening usually happens over a few days before labour commences. When the gel is used to the cervix usually ripens overnight, it gradually opens and thins the cervix overnight with the aim of being able to rupture your membranes (break your waters) the following morning. Sometimes women go into labour with the gel, and spontaneously rupture their membranes overnight.

You will come to Wollongong Private Hospital the afternoon before your induction, at 3pm (Maternity ward, level 2). Bring your packed hospital bag. Partners are welcome to stay overnight with you.

On arrival, you will be given a room in the Maternity Ward. A midwife will be assigned to your care and will ask you some questions about your pregnancy and feel your abdomen to find out the position of your baby. A CTG (fetal heart tracing) monitor applied. A CTG involves placing 2 straps around your abdomen with a monitor attached, which records your baby’s heart beat (trace) for about 30mins.  If your induction is with a hormone gel (prostin), it will be inserted by your midwife into your vagina and the CTG will be put back on for another 20mins. Lying down for that time will also assist in absorption of the gel. As the gel is absorbed, most women start to contract.  For some women this will be mild period-pain type cramps and for others it will be strong labour-like contractions.  This may all settle down after a few hours or it may progress into labour.

You will be further reviewed about 6 hours labour to determine if you need a second dose of Prostin. If your cervix is already thinning and about 2cm dilated, you will not need a second dose. The second examination can sometimes be more uncomfortable as your cervix is starting to change and you will start to pre labour. Please let your midwife know if you are in any pain, we can offer you pain relief and a sleeping tablet if you need.  If you are in early labour and in discomfort,  you will be transferred to the Birthing Unit. Some women will go into labour during the night.

Things you should be aware of :

Prostaglandin sometimes causes vaginal soreness and irritation.
A small number of women experience some reactions such as nausea, vomiting or diarrhoea. Very occasionally, prostaglandin can cause the uterus (womb) to contract too much. If this happens, you will be given medication to relax the uterus.

The next morning

Your induction will commence around 8 am the following day. Your will be transferred to the Birthing Unit  (on the same floor) where you will meet your midwife who will look after your during your labour.  You will have a small drip inserted into your hand or arm, so we can give you fluids and your oxytocin drip. I will see you in the morning, I will examine you, and with permission, I will perform a vaginal exam and break your waters. I use a small clip that fits over my finger, rarely do I need to use the long hook that you may have seen in antenatal classes.

Your oxytocin drip is started and I encourage you to be as mobile as possible, as once your waters have been broken, gravity helps the baby’s head put pressure onto the cervix and helps dilate the cervix.

A small number of women (approximately 2 out of 1000) will not go into labour despite breaking the waters and starting an IV drip. These women will need to have a caesarean section.

Risks of induction of labour

Induction of labour has the following possible complications:

• The Prostin may over stimulate the uterus causing contractions to be too rapid. This is why it is important to monitor your baby after the Prostin gel. If this occurs we give you medication through a drip to help relax the uterus. Overstimulation may cause distress to the baby and there is a very small chance you may need an emergency caesarean section.
• You may not go into labour despite treatment.

The baby’s cord may prolapse (the cord come out of the cervix before the baby is born) after your membranes are ruptured (very rare) If this occurs you will need an emergency caesarean section.

A Caesarean section is an operation in which a cut is made in your abdomen and in the wall of your uterus so that your baby can be delivered without passing down through your vagina. The cut is made low at the level of your bikini line.

It is a very safe and common operation, but with any surgery, complications can occur. Not all of these risks are unique for caesarean section but are increased compared to having a vaginal birth.
These consequences include:

• Blood loss (slightly more than a vaginal delivery)
• Wound infection (<5%)
• Blood clots in your legs (known as a deep vein thrombosis, or DVT)
• A blood clot that moves from your leg to your lungs (known as a pulmonary embolus). You will be given once-daily injections (clexane) while in hospital to minimise the risk of developing clots in your legs and lungs. This is a rare, but serious, complication of caesarean section.
• Potential damage to organs near the operation site, including your bladder. This might require further surgery.
• Anaesthetic risks such as low blood pressure, nausea and vomiting and post-dural puncture headache. This occurs when the epidural or spinal needle punctures the dura (tissue which surrounds the spinal cord). When a puncture occurs, it causes the spinal fluid to leak out of the hole and it is this which causes a headache. Most headaches will settle within a few days but some may last longer. Information about the risks of anaesthesia during a caesarean section and for pain relief can be found at anzca.edu.au/Patients
• Slower recovery
• Post operation neuropathic pain, a nerve pain around the wound that continues after 6 weeks. This is rare and usually settles with time.

Risks for the baby

The most common problem affecting babies born by caesarean section is temporary breathing difficulty. It is important to note that some babies are still difficult to deliver during a caesarean and forceps or vacuum may be used. They therefore may still have bruising around their head or body.

Benefits of a Caesarean Section

• An elective caesarean is associated with small but reduced perinatal mortality (death of a baby) compared to a planned vaginal birth. This is because elective caesarean result in earlier delivery and we think because babies are not as big. Every day spent in the uterus carries a risk of unexplained stillbirth.
• Elective caesarean prevents anal sphincter tears, which are much more common than previously assumed at 10–20 per cent of women who delivery vaginally, and the main factor for faecal incontinence in women
• Elective caesarean prevents levator (pelvic floor muscles) and irreversible hiatus (muscle)l over-distension, which affect 12–35 per cent of women after a first vaginal birth and which are the main causes of female pelvic organ prolapse.

Operating theatre

The procedures for a caesarean section are very similar whether the operation is elective or an emergency.

When you arrive in the operating theatre, there will be a number of people present. All of them have an important role to play to ensure the safety of you and your baby.

• Anaesthetist – will provide your anaesthetic and pain relief
• Obstetrician – will perform the operation and deliver your baby (me)
• Surgical assistant – assists the Obstetrician
• Scrub nurse –coordinates the theatre and passes the instruments to the doctor
• Scout nurse – assists the scrub nurse and gathers additional equipment that is required
• Anaesthetic nurse – assists the Anaesthetist
  Midwife –receives the baby and cares for it until you return to the postnatal ward
• Theatre technician – helps move you on and off the operating table, positions lights and equipment.
• Support person-you are allowed one person with you

There will be a buzz of activity happening at this time, before the operation starts. A plastic cannula (thin tube) will be put into the vein in the back of your hand or arm so that fluids and medication can be given to you. A urinary catheter (a soft, plastic tube) will be inserted into your bladder to keep your bladder empty during the operation.  Your partner can stay with you during this time.

During the Caesarean, you will not feel any pain, but you will feel a lot of pressure and pulling.

A Caesarean Section usually takes about 40 minutes.

You will be wearing special stockings known as ‘TED’ stockings during the surgery until you are moving around after the operation. The purpose of these stockings is to reduce the risk of blood clotting during inactivity.

Baby friendly Caesarean Section

When your baby is born, we offer the drape to be dropped so you can see your baby being born (not everyone wants to). Your baby is lifted up so you can see your baby immediately, I then pass your baby directly to the midwife and if your baby is well, the baby will go directly into your arms for skin to skin. We aim for minimal separation of you and your baby and offer breast feeding in recovery with the support of our midwife. If you have an emergency Caesarean Section, sometimes this is not always possible, but we try our best to provide this to you.

Recovery after a Caesarean Section

Pain relief
You will get regular pain relief medication (paracetamol, an anti-inflammatory and a slow release stronger pain relief) You will also be charted for extra strong pain relief (endone or buprenorphine), as every woman has different pain relief requirements, you will need to ask for these. Please make sure you do, especially for the first 48 hours. Your pain will rapidly improve each day, you are walking the day after your Caesarean Section and are usually you will only require paracetamol and an anti-inflammatory when discharged home. I recommend taking this regular pain relief for at lease 3-4 days once you get home.

Bladder protection

• Before the operation a catheter (tube) is placed into the bladder to allow urine to drain. This keeps the bladder empty and out of the way during the operation. The catheter is inserted in theatre after the anaesthetic has taken effect, usually within the first 12-24 hours depending on your mobility.
• Following catheter removal the amount of urine will be measured. The bladder is generally back to normal when you have a normal urge to urinate, you pass 150 to 600mls of urine on more than two separate occasions.
  .
• Empty your bladder every two to three hours. Following the birth you will be losing body fluid that you gained during your pregnancy. This creates a lot of urine in the first few days. Keeping it empty will prevent over stretching of the bladder, help control wound pain and reduce the amount of bleeding from your uterus.
• You should be aiming to drink 2-3L of fluid per day, especially when breast feeding.
• After having a baby some women may experience discomfort or difficulty when passing urine, incontinence (leaking) of urine or a lack of sensation of a full bladder. Please let your midwife and Obstetrician know, these symptoms are usually short lived.

You may notice increased swelling in your hands and feet at this time which is normal. Continue to drink fluids, walk and go to the toilet regularly and the swelling will go away. When resting, lie on your bed and elevate your legs above the level of your heart.

Wound care

I use an absorbable suture for your wound, they are absorbed by the body and do not need to be removed. You will have a clear dressing on your wound which will be removed the day you leave hospital. Keep your wound clean and dry. Wear loose clothing and look for signs of infection (such as redness, pain, swelling of the wound or bad-smelling discharge). The incision will heal over the next few weeks. During this time, there may be mild cramping, light bleeding or vaginal discharge, as well as pain and numbness in the skin around the incision site.

Most women will feel well by six weeks postpartum, but numbness around the incision and occasional aches and pains can last for several months.

Try not lift any weight that is heavier than your baby. Be careful of your back when you lift and don’t lift anything that causes you pain. You should not drive a car until you have fully recovered and your wound has healed. This may take up to 6 weeks. I will see you at 6 weeks post delivery, but if you want to be cleared to drive earlier, see your GP. Avoid sex until you feel comfortable. After birth of any kind it is quite normal to take weeks, even months, before you are ready to have sex. If you are breast feeding, your vagina often feels sore and dry (this is because of decreased oestrogen as you generally do not ovulate).

Future births

As the number of previous Caesarean Sections increase, so does the risk of rare but serious complications. You should consider the size of the family you want. If you have four or more caesarean births, some complications become more common.

These include:

• Problems with your placenta implanting low in the uterus, near your scar, in future pregnancies. This condition is referred to as placenta praevia.
• Problems when your placenta does not come away as it should when your baby is delivered. This condition is known as placenta accreta and increases with each caesarean section
• Extra procedures that may become necessary during the caesarean section such as a blood transfusion or emergency hysterectomy, particularly if there is heavy bleeding at the time of your caesarean section. A hysterectomy would mean you are unable to have any further children. The risk of needing to undergo a hysterectomy at the end of a subsequent pregnancy increases with each caesarean section, but overall is still very low.

Delayed cord clamping occurs when the umbilical cord is NOT immediately clamped after the baby is born.  The interval can be anywhere from 60 seconds to a number of minutes – some people refer to this as the ‘golden minute’.  Delayed cord clamping is recommended as standard practice by the Australian College of Obstetricians and Gynaecologists.

The baby will receive 50-100mls of blood, depending on the baby’s birth weight and most of this occurs in the first minute after birth.

The main benefits are increased iron stores in the first 6 months after birth.  Better circulation in the newborn infant. Less likelihood of anaemia, cerebral haemorrhage and necrotising enterocolitis. These benefits are more significant in premature or growth restricted infants.

The disadvantage of delayed cord clamping is an increased risk of jaundice with the baby more likely to require phototherapy with UV lights.

If you want to bank your baby’s cord blood then less will be available for storage with delayed cord clamping.

If the baby has the umbilical cord tight around the neck, it will require clamping and cutting before the shoulders are delivered.  If the baby requires resuscitation then it is more appropriate to clamp and cut the cord immediately to facilitate treatment.  In these situations delayed cord clamping will not be possible.

Group B Streptococcus is a bacteria that is present in the vaginal or bowel flora in approximately 20% of women. Most women will not have any symptoms, however GBS can be significant for women in labour. We test for GBS (a vaginal swab) at 36 weeks gestation.

What happens if you are GBS positive in pregnancy? 

• If a woman carries GBS and it is untreated there is a 1-2% chance the baby will get a significant lung (pneumonia) or blood (septicaemia) infection with serious consequences to the baby’s health.
• Most babies who come into contact with GBS will not suffer any ill health, but unfortunately, we cannot tell which babies will get sick and which will not.

Women who are attempting a vaginal birth will normally be screened for GBS by having a low vaginal swab at around 36 weeks gestation.  The result only takes 2 days to return.If the result is positive, then the mother will be given intravenous penicillin in labour or when the waters break. Another antibiotic (Clindamycin) will be used if the mother is allergic to penicillin.

What happens if labour or the waters break prior to 36 weeks?

• In these circumstances, a swab will be taken and antibiotics administered, as preterm labour has a higher association with GBS.

What happens if my labour is so quick that antibiotics are not given at least an hour before delivery?

• The baby will have swabs from the groin and umbilicus taken and its temperature/observations monitored for 48 hours.

What about women who are having an elective Caesarean section?

• Usually GBS swabbing is not necessary, as the baby does not come into contact with GBS during an elective Caesarean section.
• On the rare chance of the waters breaking prior to the planned Caesarean section date then antibiotics may be given prior to the Caesarean section being performed.

• Long charger cord
• Healthy snacks
• Hair brush
• Hair dryer
• Makeup bag
• Bio oil
• Dry shampoo/nice smelling shampoo/haircare
• Face wash
• Contacts/glasses
• Loose clothing
• Bras
• Loose undies
• Computer & charger
• Maternity nighty
• Hair tie, bobby pins and clip
• Essential oils
•  headphones
• Nursing tops
• Thank you card (for staff)
• Body wash
• Pawpaw cream
• Slippers
• Dressing gown
• Wipes
• Adult Nappies and maternity pads
• Hydrogel nipple pads
• Nipple balm
• Nipple shields

Bub:

• Wipes
• Going home outfit/nice wrap for photo
• Bottles and steriliser if wanting to formula feed
• Dummy (if needed)
• Sudo cream
• Sleep suit
• Wraps x 3
• Socks x 4
• Nappies
• Onsies x 3
• Singlets x 4