How to: labour with power

Knowledge is power, they say, but it can also bring peace of mind. Dr Nick Walker explains the birthing process and what you can do to get ready for delivery. 

Bing bing! My text message alert wakes me at 3.45am, informing me that one of my patients has gone into labour. Sarah* has been having contractions since her waters broke around 10pm. They’ve now become intense and she’s calling me to say she’s ready to head to the hospital. Her partner Stefan* is gathering bags and packing the car. They’re both feeling a bit edgy, as this is their first baby.

Preparing for labour is one of the most important aspects of any pregnancy. If my opening vignette fills you with nerves and trepidation, I’m guessing you’re near the end of your pregnancy and perhaps realising there is plenty yet for you to come to grips with before that big day. 

Covering the basics
Medically speaking, you’ll be well guided by your LMC and other health professionals as you prepare for labour. Patients with no medical problems should try to be as fit and active as possible towards the end of the pregnancy, as labour really is a major physical challenge for most people. A balanced and healthy diet will mean you have the energy to get through the day, and most LMCs will test for the need to supplement with iron tablets to avoid anaemia and reduce problems associated with the expected blood loss during birth. Avoiding constipation and haemorrhoids is important too as these can often make the birth more painful and unpleasant. Some medications should be stopped when going into labour, such as aspirin or other blood-thinners – you should inform your LMC if you’re taking these. 

It’s complicated
Many underlying medical issues, such as gestational diabetes and hypertension, will warrant induction of labour to optimise birth outcomes, but this only affects the timing of birth, not the labour itself so much. Generally speaking, induced labour will lead to a similar labour course to spontaneous (natural onset) labour. The difference is the process begins in hospital under supervised care and can thus be more reassuring (but usually seems to take longer!). Even patients expecting to deliver by Caesarean section may go into labour prior to their scheduled date, so they too need to prepare for this. Patients with complex medical problems will have a carefully drawn-up labour and delivery plan, formulated by multi-disciplinary health professional teams to address those issues specific to their condition.  

Early labour
Knowing the first signs of labour will allow you to stay calm and confident. The three most common signs are:

1. Passing the ‘show’ – a large amount of sticky and/or bloody mucus

2. Onset of contractions

3. The waters breaking

The mucous ‘show’ usually means that your cervix has started to open, releasing the mucous plug, which then passes out of the vagina. Contractions are rhythmic tightenings of the uterine muscle fibres. Over time these stretch the cervix over and around the head of the baby rather like when you pull on a turtleneck sweater over your own head. The active phase of labour is defined by LMCs as when this process causes the cervix to become dilated to at least three centimetres, as well as the contractions being regular (in terms of timing and intensity). The breaking of the waters (amniorrhexis) does not form part of the definition of labour, as it may occur well before or, rarely, right at the end of labour! Whether one, two, or all three of these events occur at once or in combination is highly variable from labour to labour, and from person to person.

While these things are happening, keep hydrated and eat if you feel hungry. Hot showers/baths and paracetamol are good for pain relief in the early stages. With luck you have a supportive partner who can rub your back, provide encouragement and make phone calls to your LMC and inquisitive relatives. Preparing for this early stage of labour is as simple as that. 

Place of birth
If you’re planning a homebirth, make sure your LMC is ready to look after you and that the birth environment is warm enough for the arrival of your baby. Ideally you’ll have had things physically prepared some time beforehand, and now it’s time to psychologically prepare for the labour and birth. You may have undertaken hypnobirthing classes and have extra support-people to consider calling. If homebirth is your goal, you’ll need to focus on that – your LMC will be responsible for contingency planning in the event that things turn out otherwise.
If you’re planning a hospital birth, you should prepare for this by knowing the route to drive and the location of the correct entries to the hospital – hospitals are usually large busy buildings and going to the wrong department or ward would be quite stressful for you and the staff! 

Pain management
One inflexible endpoint that many people reach during the early or the active phase of labour is the wish to access pain relief over and above what can be managed in the home. Considering pain relief options is a very important part of preparing for labour, and these options will themselves vary greatly according to your circumstances. In my experience most LMCs prepare a birth plan with their patient during the final month of pregnancy, and this ought to consider what forms of pain relief are expected to be available, and which ones of these the patient will select or omit. 

We can divide pain relief into two categories: one, non-pharmacological (no drugs); and two, pharmacological (drugs, funnily enough!). Examples of the first category include warm water, massage, aromatherapy, TENS devices, acupressure and hypnobirthing. Pharmacological options range from nitrous oxide gas at the entry level, through to an epidural at the most complex. The opiate medications morphine and pethidine are sometimes used during the early phases of labour to allow relaxation and even sleep during what can be a prolonged and tiring time.  Epidurals are not available in all hospitals, as they need to be placed by an anaesthetist skilled in the particular technique required to insert a hollow needle into the correct position near the spinal cord. A very fine flexible tube is threaded down the bore of this needle, which is then withdrawn leaving the tube in the epidural space. Varying types and dosages of medications are injected through the tube, aiming to give a good balance between achieving pain relief (blocking the nerves responsible for transmitting pain) and allowing some mobility and sensation to push during the last part of the labour (not blocking the nerves responsible for pressure and movement).

The decision for pain relief, I believe, lies with the labouring woman – simply because she is the one experiencing the process. The key role played by the LMC is to advise, using their experience to judge the likely length or difficulty of the birth, thus allowing the woman to make her choice accordingly. 

The home straight
Whatever pain relief is or is not chosen, the cervix continues to dilate, becoming ever more steadily stretched around the baby’s head. The first stage of labour is complete when the cervix is 10cm dilated (the head is actually right through the cervix at this point). From then on, the head moves through the vagina, parting the muscles of the pelvic floor, then neatly ducks under the pubic bone to be born. This describes the second stage of labour, and requires a good deal of pushing, AKA ‘expulsive effort’. The diaphragm and abdominal muscles play a large part in pushing the baby out, which is why it’s important to maintain good core strength during the pregnancy and good energy levels during the first stage of labour. After a successful birth you’ll feel as if you’ve done 200 sit-ups!

As the baby finally exits the vagina, the perineum (the area of skin between vagina and anus) will be stretched to its maximum and sometimes a small cut (episiotomy) is beneficial to release some pressure and avoid sudden tearing into the muscle surrounding the anus (3rd degree tear).Preparation with perineal massage and/or specially engineered medical aids for that purpose may reduce tearing or the need for an episiotomy.

With a well-prepared birth plan, Sarah arrived at the hospital and proceeded straight to the maternity ward. She was eight centimetres dilated (nearly into the second stage of labour), and having coped well to that point, she declined to use pain relief. She sipped ice water to stay cool, and with Stefan’s support, she progressed to a straightforward birth 90 minutes later. Obviously not all births are this simple, but any time spent planning, preparing and learning about the birthing process is certainly time well spent. 

*Names have been changed