Childbirth

Childbirth (also called labour, birth, partus or parturition) is the culmination of a human
pregnancy or gestation period with the delivery of one or more newborn infants from the
mother's uterus.
The process of human childbirth is categorized in 3 stages of labour. In the first stage, the
uterus begins rhythmic contractions which steadily increase in strength and frequency,
gradually widening and thinning the cervix. During the second stage, the infant passes
from the uterus, through the cervix and birth canal. In the third stage, the placenta pulls
from the uterine wall and is expelled through the birth canal.[1]

The natural birth

Mother and newborn with umbilical cord still attached after a water birth
First stage: contractions
A typical childbirth will begin with the onset of contractions of the uterus. The frequency
and duration of these contractions varies with the individual. The onset of labour may be
sudden or gradual, and is defined as regular uterine activity in the presence of cervical
dilatation.

During a contraction, long muscles of the uterus contract, starting at the top of the uterus
and working their way down to the bottom. At the end of the contraction, the muscles
relax to a state shorter than at the beginning of the contraction. This draws the cervix up
over the baby's head. Each contraction dilates the cervix until it becomes completely
dilated, often referred to as 10+ centimeters (cm) or 4+ inches (in) in diameter.
A gradual onset with slow cervical change towards 3 cm (just over 1 inch) dilation is
referred to as the "latent phase". A woman is said to be in "active labour" when
contractions have become regular in frequency (3 to 4 in 10 minutes) and about 60
seconds in duration. The cervix must shorten (efface) before it can dilate; for first time
mothers this can take a substantial period of time and can be a very tiring and
disheartening time. However, once the cervix is effaced dilatation can occur and the
downward journey of the fetus can commence. The now powerful contractions are
accompanied by cervical effacement and dilation greater than 3 cm (1¼ in) . The labour
may begin with a rupture of the amniotic sac, the paired amnion and chorion ("breaking
of the water"). The contractions will strengthen and accelerate in frequency. In the
"transition phase" from 8 cm–10 cm (3 or 4 in) of dilation, the contractions often come
every two minutes and typically last 70–90 seconds. Transition is often regarded as the
most challenging and intense for the mother. It is also the shortest phase.
During this stage, the expectant mother typically goes through several emotional phases.
At first, the mother may be excited and nervous. Then, as the contractions become
stronger, demanding more energy from the mother, she may become more serious and
focused. However, as the cervix finishes its dilation, some mothers experience confusion
or bouts of self-doubt or giving up. It is important during this time for the birth partners
to stay positive and supportive of the mother; to actively encourage if this is what she
wishes and to provide nutrition and hydration in order to keep her energy reserves up.
The duration of labour varies widely, but averages some 13 hours for women giving birth
to their first child ("primiparae") and 8 hours for women who have already given birth.
If there is a significant medical risk to continuing the pregnancy, induction may be
necessary. As this carries some risk, it is only done if the child or the mother are in danger
from prolonged pregnancy. Forty-two weeks' gestation without spontaneous labour is
often said to be an indication for induction although evidence does not show improved
outcomes when labour is induced for post-term pregnancies.[citation needed] Inducing
labour increases the risk of cesarean section uterine rupture in mothers that have had a
previous cesarean section.

Second stage: delivery

In the second stage of labour, the baby is pushed through the womb through the vagina by
both the uterine contractions and by the additional maternal efforts of "bearing down,"
which many women describe as similar in sensation to straining to expel a large bowel
movement. The imminence of this stage can be evaluated by the Malinas score.
This stage begins when the cervix is fully dilated. This can be determined by the woman's
onset of her desire to 'push' or it can be determined by performing a vaginal exam.
The baby is most commonly born head-first. In some cases the baby is "breech" meaning
either the feet or buttocks are descending first. Babies in the breech position can be
helped to be born vaginally by a midwife, although caesarean births are becoming more
common for breech presentation.
There are several types of breech presentations, but the most common is where the baby's
buttocks are born first and the legs are folded onto the baby's body with the knees bent
and feet near the buttocks (full or breech). Others include frank breech, much like full
breech but the baby's legs are extended toward his ears, and footling or incomplete
breech, in which one or both legs are extended and the foot or feet are the presenting part.
Another rare presentation is a transverse lie. This is where the baby is sideways in the
womb and a hand or elbow has entered the birth canal first. While babies who present
transverse will often move to a different position, this is not always the case and a
cesarean birth then becomes necessary.

A newborn baby with umbilical cord ready to be clamped

The length of the second stage varies and may be affected by whether a woman has given
birth before, the position she is in and mobility. The length of the second stage should be
guided by the condition of the fetus and health of the mother. Problems may be
encountered at this stage due to reasons such as maternal exhaustion, the front of the
baby's head facing forwards instead of backwards (posterior baby), or extremely rarely,
because the baby's head does not fit properly into the mother's pelvis (Cephalo-Pelvic
Disproportion (CPD)). True CPD is typically seen in women with rickets and bone
deforming illnesses or injuries, as well as arbitrary time limits placed on second stage by
caregivers or medical facilities.
Immediately after birth, the child undergoes extensive physiological modifications as it
acclimates to independent breathing. Several cardiovascular structures start regressing
soon after birth, such as the ductus arteriosus and the foramen ovale. In some cultures, the
father cuts the umbilical cord and the infant is given a lukewarm bath to remove blood
and some of the vernix on its skin before being handed back to its parents.
The practice of leaving the umbilical cord to detach naturally is known as a Lotus Birth.
The medical condition of the child is assessed with the Apgar score, based on five
parameters: heart rate, respiration, muscle tone, skin color, and response to stimuli. Apgar
scores are typically assessed at both 1 and 5 minutes after birth.
Third stage: placenta

Breastfeeding during and after the third stage

In this stage, the uterus expels the placenta (afterbirth). Breastfeeding the baby will help
to cause this. The mother normally loses less than 500 mL (2 cups, or 1 pint) of blood.
The placenta should never be pulled from the mother by an untrained person; this could
cause it to tear and not be expelled whole. It is essential that the placenta be examined to
ensure that it was expelled whole. Remaining parts can cause postpartum bleeding or
infection.
The alternative to natural delivery of the placenta is what is called Active Management:
this involves administration of a prophylactic oxytocic before delivery of the placenta,
and usually early cord clamping and cutting, and controlled cord traction of the umbilical
cord.
A Cochrane database study[2] suggests strongly that blood loss and the risk of
postpartum bleeding will be reduced in women offered active management of the third
stage of labour. However, the group treated with active third phase management, there
was an increased risk of unpleasant side effects (eg nausea and vomiting), and
hypertension. The authors suggest that this is due to the use of ergometrine as a
component of the oxytocic. No advantages or disadvantages were apparent for the baby.
Details of CCT are available. This procedure must not be attempted except by
appropriately trained providers.
After the birth

Medical professionals typically recommend breastfeeding of the first milk, colostrum, to

reduce postpartum bleeding/hemorrhage in the mother, and to pass immunities and other
benefits to the baby.
Parents usually bestow the infant its given names soon after birth.
Often people visit and bring a gift for the baby.
Many cultures feature initiation rites for newborns, such as naming ceremonies, baptism,
and others.
Mothers are often allowed a period where they are relieved of their normal duties to
recover from childbirth. The length of this period varies. In China it is 30 days and is
referred to as "doing the month" (see Postpartum period). In other countries taking time
off from work to care for a newborn is called "maternity leave" and varies from a few
days to several months.

Variations

When the amniotic sac has not ruptured during labour or pushing, the infant can be born
with the membranes intact. This is referred to as "being born in the caul." The caul is
harmless and its membranes are easily broken and wiped away. In medieval times, and in
some cultures still today, a caul was seen as a sign of good fortune for the baby, even
giving the child psychic gifts such as clairvoyance, and in some cultures was seen as
protection against drowning. The caul was often impressed onto paper and stored away as
an heirloom for the child. With the advent of modern interventive obstetrics, premature
artificial rupture of the membranes has become common, so babies are rarely born in the
caul.
Pain
The amounts of pain experienced by women during childbirth varies. For some women,
the pain is intense and agonizing; for other women there is little to no pain. Many factors
affect pain perception; fear, number of previous births, fetal presentation, cultural ideas of
childbirth, birthing position, support given during labor, beta-endorphin levels, and a
woman's natural pain threshold. Uterine contractions are always intense during childbirth.
Some women report these sensations as painful, though the degree of pain varies from
individual to individual.
The Huichol Indians have a tradition during childbirth where the husband's testicles are
tied to a rope, which is pulled by the labouring wife when she feels a painful contraction,
to share the pain of childbirth.

Non-medical pain control

Some women believe that reliance on analgesic medication is unnatural, or believe that it
may harm the child. They still can alleviate labour pain using psychological preparation,
education, massage, hypnosis, or water therapy in a tub or shower. Some women like to
have someone to support them during labour and birth, such as the woman's mother, a
sister, the father of the baby, a close friend, a partner or a trained professional doula.
Some women deliver in a squatting or crawling position in order to more effectively push
during the second stage and so that gravity can aid the descent of the baby through the
birth canal.
The human body also has its own method of pain control for labour and childbirth in the
form of beta-endorphins. As a naturally occurring opiate, beta-endorphin has properties
similar to pethidine, morphine, and heroin, and has been shown to work on the same
receptors of the brain.[4] Like oxytocin, beta-endorphin is secreted from the pituitary
gland, and high levels are present during sex, pregnancy, birth, and breastfeeding. This
hormone can induce feelings of pleasure and euphoria during childbirth.[5]
Water birth is an option chosen by some women for pain relief during labour and
childbirth, and some studies have shown waterbirth in an uncomplicated pregnancy to
reduce the need for analgesia, without evidence of increased risk to mother or
newborn.[6][7][8][9] The American Academy of Pediatrics still considers underwater
birthing "an experimental procedure that should not be performed except within the
context of an appropriately designed [randomized controlled trial] after informed parental
consent."[10] Many hospitals and birthing centres now offer women the option of
waterbirth, either via custom-made 'birthing pools' or large bath tubs, and have policies to
safeguard their use.

Meditation and mind medicine techniques for the use of pain control during labor and
delivery. These techniques are used in conjunction with progressive muscle relaxation
and many other forms of relaxation for the mind and body to aid in pain control for
mothers during childbirth. These techniques are a form of natural pain control. One such
technique is Calm Birth. This technique is a form of meditation that empowers and
liberates the mother by uplifting her body and its natural process to welcoming her new
child into the world.[citation needed]
Medical pain control
In Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control; in the
UK, midwives may use this gas without a doctor's prescription. Pethidine (with or
without promethazine) may be used early in labour, as well as other opioids, but if given
too close to birth there is a risk of respiratory depression in the infant.
Popular medical pain control in hospitals include the regional anesthetics epidural blocks,
and spinal anaesthesia. Doctors and many parents favor the epidural block because
medication does not enter the mother's circulatory system, thus it does not cross the
placenta and enter the bloodstream of the fetus. Some studies find that although epidural
use can lengthen the labour and increase the need for operative intervention, it has no
adverse effect on perinatal outcome, and is a safe and effective method of pain control

Different measures for pain control have varying degrees of success and side effects to
mother and baby. The risks of medical pain control should be balanced against the fact
that childbirth can be extremely painful, and anesthetics are an effective and generally
safe way to control pain.

Complications and risks of birth

Problems that occur during childbirth are called complications. They can affect the
mother or the baby. Sometimes they cause injury or even death. Doctors and midwives
are trained to deal with these problems if they should occur.
Infant deaths (neonatal deaths from birth to 28 days, or perinatal deaths if including fetal
deaths at 28 weeks gestation and later) are around 1% in modernized countries. The risk
of maternal death during childbirth in developed nations is comparatively low; only about
1 in 1800 mothers die in childbirth (only 1 in 3700 in North America). In the Third
World, it is a much riskier proposition: neonatal deaths rates in Sub-Saharan Africa and
South Asia are more than 3.7%,[13] and on average 1 in 48 women die during
childbirth.[14] The "natural" mortality rate of childbirth—where nothing is done to avert
maternal death—has been estimated as being between 1,000 and 1,500 deaths per
100,000 births.[15] (See main article: neonatal death, maternal death)

Emergency airlift of woman in labor by the US Coast Guard

The most important factors affecting mortality in childbirth are adequate nutrition and
access to quality medical care ("access" is affected both by the cost of available care, and
distance from health services). "Medical care" in this context does not refer specifically
to treatment in hospitals, but simply routine prenatal care and the presence, at the birth, of
an attendant with midwifery skills. A 1983-1989 study by the Texas Department of
Health revealed that the infant death rate was 0.57% for doctor-attended births, and
0.19% for births attended by non-nurse midwives. (The comparison may be misleading
because higher-risk births are less likely to be attended solely by a midwife.) Conversely,
some studies demonstrate a higher perinatal mortality rate with assisted home births.[16]
Around 80% of pregnancies are low-risk. Factors that may make a birth high risk include
prematurity, high blood pressure, gestational diabetes and a previous cesarean section.
One of the most dangerous risks to the fetus is that of premature birth, and its associated
low neonatal weight. The more premature (or underweight) a baby is, the greater the risks
for neonatal death and for pulmonary, respiratory, neurological or other sequelae. About
12% of all infants born in the United States are born prematurely. In the past 25 years,
medical technology has greatly improved the chances of survival of premature infants in
industrialized nations. In the 1950s and 1960s, approximately half of all low birth weight
babies in the US died. Today, more than 90% survive. The first hours of life for "premies"
are critical, especially the very first hour of life. Rapid access to a Neonatal Intensive
Care Unit is of paramount importance.
Some of the possible complications are:
• Heavy bleeding during or after childbirth, which is the most common cause of
mortality in new mothers, in both developed and undeveloped nations.[13] Heavy blood
loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not
rapidly treated by stemming the blood loss (medically with ergometrine and pitocin or
surgically) and blood transfusion. Hypopituitarism after obstetric hypovolemic shock is
termed Sheehan's syndrome.
• Non-progression of labour (longterm contractions without adequate cervical
dilation) is generally treated with intravenous synthetic oxytocin preparations. If this is
ineffective, Caesarean section may be necessary. Changes in maternal position is
effective in many cases.
• Fetal distress is the development of signs of distress by the child. These may
include rising or decreasing heartbeat (monitored on cardiotocography/CTG), shedding of
meconium in the amniotic fluid, and other signs.
• Non-progression of expulsion (the head or presenting parts are not delivered
despite adequate contractions): this can require interventions such as vacuum extraction,
forceps extraction or Caesarean section.
• In the past, a large proportion of women died from infection puerperal fever, but
since the introduction of basic hygiene during parturition by Ignaz Semmelweis, this
number has fallen precipitously.
• Lacerations can be painful. An episiotomy was once thought necessary to avoid
tears involving the anal sphincter, but its routine use—once normal—has now been
shown to increase the risk of deep lacerations especially involving and extending through
the anal sphincter.
Instrumental delivery (Forceps and Ventouse)
• The mother will have her legs apart supported in stirrups.
• If an anaesthetic is not already in place it will be given.
• For a forceps delivery an episiotomy will be done (a cut in the perineum or the
region between the vagina and anus), for ventouse extraction an episiotomy is not always
done.
• After the head is delivered the rest of the delivery is done in the manual method.
• After episiotomy or tears the mother is stitched up.
• In some cases a 'Trial of Forceps' will be tried out, this will be done in the
operating theatre, meaning they will try a forceps delivery and will switch to a caesarean
section if it fails.

Professions associated with childbirth

Midwives are experts in normal birth. Midwives believe that childbirth is a normal
process that is best accomplished with as little interference as possible. Midwives are
trained to assist at births, either through direct-entry or nurse-midwifery programs. Lay
midwives typically train in apprenticeship programs with experienced midwives.
Obstetricians are experts in dealing with abnormal births and pathological labour
conditions, though they sometimes attend normal births as a precautionary measure.
Obstetricians in most countries are trained as surgeons, so they can undertake surgical
procedures relating to childbirth. Such procedures include caesarean sections,
episiotomies, or emergency hysterectomies. Obstetricians' tendency to intervene
surgically to overcome complications has led to criticism that they perform surgery too
readily.[17] In the United States, obstetric malpractice settlements are typically very
large, so obstetricians argue that they are forced to intervene aggressively to limit their
liability.
Maternal-fetal medicine specialists are experts in managing and treating high-risk
pregnancy and delivery.
Obstetric nurses assist doctors, mothers, and babies prior to, during, and after the birth
process. Some midwives are also obstetric nurses. Obstetric nurses hold various
certifications and typically undergo additional obstetric training in addition to standard
nursing training

Doulas are trained assistants who support mothers during pregnancy, labour, birth, and
postpartum. They are not medical attendants; rather, they provide emotional support and
non-medical pain relief for mothers during labour.
Social aspects
In most cultures, childbirth is considered to be the beginning of a person's life, and their
age is defined relative to it.

Some families view the placenta as a special part of birth, since it has been the child's life
support for so many months. Some parents like to see and touch this organ. In some
cultures, parents plant a tree along with the placenta on the child's first birthday. The
placenta may be eaten by the newborn's family, ceremonially or otherwise.[citation
needed]

Psychological aspects
Childbirth can be a stressful event. As with any stressful event, strong emotions can be
brought to the surface.
Some women report symptoms compatible with post-traumatic stress disorder (PTSD)
after birth. Between 70 and 80% of mothers in the United States report some feelings of
sadness or "baby blues" after childbirth. Postpartum depression may develop in some
women; about 10% of mothers in the United States are diagnosed with this condition.
Abnormal and persistent fear of childbirth is known as tokophobia.
Preventative group therapy has proven effective as a prophylactic treatment for
postpartum depression.[18]
There are some who argue that childbirth is stressful for the infant. Stresses associated
with breech birth, such as asphyxiation, may affect the infant's brain.
Partner and other support
Main article: Men's role in childbirth

There is increasing evidence to show that the participation of the woman's partner in the
birth leads to better birth and also post-birth outcomes, providing the partner does not
exhibit excessive anxiety.[19] Research also shows that when a labouring woman was
supported by a female helper such as a family member or doula during labour, she had
less need for chemical pain relief, the likelihood of caesarean section was reduced, use of
forceps and other instrumental deliveries were reduced and there was a reduction in the
length of labour and the baby had a higher Apgar score (Dellman 2004, Vernon 2006).
It is the traditional history of home labour that makes The Netherlands an attractive site
for studies related to birth. One third of all baby deliveries there are still happening at
home in contrast with other western industrialized countries. Apparently, Dutch fathers
have been in the scene of labor for a long time as can be observed in paintings from the
17th and 18th centuries.

During this study, it was found that fathers can have different roles during birth and that
little is said about the conflicts between partners or partners and professionals. Among
other findings were also: the interpretation of the presence of fathers during birth as a
modern version of the anthropological couvade ritual to ease the mother’s pain; the
majority of fathers did not perceive any limitation to participate in their childbirth and
upper generations did not play an important rule in the transmission of knowledge about
birth to those fathers but the wives, feminine acquaintances and midwives.
The research was based, mainly, on in-depth interviews, where fathers described what
was happening from their partner’s first signals of birth labour until the placenta delivery.
Postnatal care
Main article: Postnatal

Well known authors on childbirth

• Janet Balaskas
• Jeannine Parvati Baker
• Robert A. Bradley
• Ina May Gaskin
• Sheila Kitzinger
• Frederick Leboyer
• Francesca Naish & Janette Roberts
• Michel Odent
• William Sears
• Miriam Stoppard
• David Vernon
• Erna Wright
• Robbie Davis-Floyd
• Penny Simkin

External links
• Discovery Health's Ultimate Guide to Pregnancy Tools, video, information for a

healthy pregnancy.
• 3D Medical Animation of Normal Child Birth at YouTube