As we approach your due date I like to have a longer discussion with you and your partner, to discuss your birth plan. You do not need to have a written document, it is good to be informed, and to have an idea of how you would like the birth to go, but it is essential to be flexible, as babies do not always behave as you expect or want them to, both during the birth and afterwards.
My aim is to help you achieve the birth experience you would like. If you are wanting a natural birth then being in the best physical and mental shape you can be for labour is important. Courses like Calm Birth can be very helpful in reducing anxiety, reducing physical tension, and giving you the confidence to try and trust in yourself and to trust your body.
It is important to remember what the ultimate goal is i.e. healthy mother and healthy baby. If it takes an epidural or forceps or caesarean section to achieve that then you should not feel disappointed that your original birth plan did not come about. As much as I want you to stay confident and positive it is important to consider some of the variations that happen in labour, as they are common.
The first is epidural. Four out of five women who have private obstetric care choose to have an epidural. Your likelihood of asking for an epidural is reduced if you are highly motivated, or if you have a single support person with you throughout labour, and if you have attended a Calm Birth course or similar. It is increased if labour is induced
If you are keen to avoid an epidural, and you are coping well with labour then there is absolutely no reason to have one. You get a natural high from the adrenalin and endorphins after birth, you can quite rightly feel a strong sense of accomplishment after successful vaginal birth, particularly if you have done it drug free.
On the other hand there is no shame in having an epidural, many women know in advance that they want one. An epidural may well be of help if your labour is progressing slowly, and this commonly occurs if the baby is in a posterior position, i.e. head down but gazing up to the sky.
I will generally recommend an epidural if I need to do a forceps delivery, and sometimes if I need to do a vacuum or ventouse delivery.
Episiotomy:
Episiotomy is a cut with the scissors, usually from the lowest part, or “V” of the vagina, angled to the right. Many years ago an episiotomy used to be standard for all births. I do not perform episiotomy routinely, but sometimes they are necessary. I perform them always with forceps, sometimes with vacuum, and sometimes for other vaginal birth, especially when the perineum starts to tear early, or becomes very swollen, in which case it loses its natural stretch. If you do not have an epidural I will inject local anaesthetic into the perineum before doing an episiotomy where possible.
Ventouse:
A ventouse or vacuum delivery is required if we need to speed up delivery, either because you have been pushing for a long time, or baby is becoming distressed, or if baby is stuck in an awkward position. To do a vacuum delivery you need to have adequate pain relief, the cervix needs to be fully dilated, you need to be able to move the baby’s head and with pushing and there needs to be enough space in the pelvis, all of which I assess on vaginal examination, sometimes with the assistance of ultrasound.
It is important for you to know that successful delivery with a vacuum is not always guaranteed.
If I think there is a low likelihood of delivery then I might recommend forceps delivery, a caesarean section, or a trial of vacuum delivery in the Operating Theatres, with the option of proceeding to caesarean section if we are not successful. When the vacuum is applied there is a maximum amount of time when the vacuum can safely stay on for, and there needs to be some degree of success with each pull, whether it is rotation or decent of the head.
If the head does not move at all with the vacuum then I will generally need to do a caesarean section, if there is some descent with each pull then I will generally do up to three pulls, and a maximum of four, and then stop unless the head is by now partly out.
It is generally safer for your baby if I use just one instrument, so if I do not think that vacuum is likely to be successful I will recommend forceps. This is likely to be the case if the head is not very low in the pelvis, if there is a lot of swelling on the back of the baby’s head, so the suction cap is likely to fall off, or if the baby’s head does not move with pushing. If I do not think either can be tried safely I will recommend caesarean section.
Following ventouse delivery your baby will have a small round “bun” on the back of their head, in addition to the swelling that occurs naturally from being upside down in the pelvis. This usually settles within a few days. There is often a dark purple disc which can persist for around a week. Sometimes there is soft swelling under the scalp, which generally settles down after a few days. Occasionally this causes the baby some irritation, and your Paediatrician may prescribe baby Panadol.
Severe complications as a result of ventouse are rare, especially if we limit the number of pulls and the amount of pressure applied.
If your baby becomes stuck in labour or distressed before the cervix is fully dilated I will need to perform a caesarean section.
Forceps:
You require good pain relief for forceps delivery. Generally this means epidural. Sometimes I can perform what is known as a pudendal block, which is local anaesthetic injected inside the vagina. This is usually very effective.
I routinely perform episiotomy with forceps. This is to reduce the chance of a tear in the midline extending down into the sphincter muscle. The importance of such a tear, known as a third or fourth degree tear, is that if it occurs it can leave you with a greater chance of having little control over wind, liquids, and sometimes even solids from your bowel. Needless to say this is personally distressing and socially awkward, but fortunately it is rare. Even when it does occur it often improves and sometimes resolves completely with time.
Bladder function is often worse after birth. Many women report loss of bladder sensation, and loss of bladder control after birth, even after caesarean birth. The chance of reduced bladder control is greater if you have had long labour, big baby, ventouse delivery, and especially, forceps delivery.
Perineal Repair:
If you have a cut or a tear then I will suture or stitch the perineum with a dissolving stitch. This is usually a suture material known as Vicryl. In the deep layers the Vicryl is slowly dissolving, and takes two to three months to dissolve. In the skin layer the Vicryl dissolves after two or three weeks.
Because of the proximity of the perineum to the anus, and the multiple bacteria that live in the area it is very easy for the perineum to become infected. For that reason I wash the perineum extensively, before, after and during the repair, and I advise you to keep the perineum as clean and dry as you can after the birth
At the first sign of infection it is important to start antibiotics to prevent breakdown of the perineal repair. Early signs of infection are worsening pain, increasing tenderness, an unusual smell, and increasing redness of the perineum. Starting antibiotics promptly will generally prevent the perineum from becoming truly infected and the wound breaking down. If it does break down it will still heal, but healing will take longer.
The two issues I would like you to consider are issues after the baby is born. In a sense the birth is the easy bit if all goes well you push the baby out. If necessary I will do a vacuum or forceps delivery. If the baby gets distressed or baby gets stuck then I shall do a caesarean. Then the fun begins.
For most first time mums feeding and settling is a challenge. Most babies do not naturally attach to the breast. They often attach to the nipple and if that is not corrected then they will cause nipple damage which can be very painful, and take a while to heal. It is important, therefore, for both you and the baby to learn good technique from the outset.
Please take advantage of the expertise and support offered by the midwives on the ward. If necessary you can be referred to a Lactation Consultant. There are daily drop in classes, lactation consultant sessions and one on one sessions during the week, and sometimes even at weekends, depending which hospital you are booked at.
Your milk generally comes in on day three or day four. When it comes in you are often very tearful. Most babies lose between 5 and 10% of their birth weight in the first few days. If your baby loses much more than 10%, then you may need to supplement the breast milk with some formula, especially if your baby is jaundiced, or low birth weight to start with. This is something that you will be given advice on by your Paediatrician, in conjunction with the Midwife or Lactation Consultant.
Sleep:
By far the most difficult challenge facing new mums is coping with sleep deprivation. Before the birth please take some time to consider how you personally will cope with sleep deprivation. Most new mums are not prepared for just how difficult it can be to adjust to having a newborn, who, while delightful and engaging in every other way, wants to stay awake all night, and feed, cry, or play, or all of the above.
Most babies sleep in patches during the day so please take advantage of every opportunity during daylight hours when your baby goes down to have a rest as well. If partners or family are around then they can often take the baby for walks during the day while you rest.
I recommend you limit visitors to family and close friends. Visitors are well meaning, but often draining at a time when you need all your energy and resources. Take advantage of every offer of help from practical things such as shopping, cooking and cleaning, and offload peripheral responsibilities.
The good news is that there is light at the end of the tunnel. For a while you may feel like there is a heavy fog hanging over you preventing you from functioning normally and making rational decisions. Over time you become accustomed to broken sleep, and learn to take advantage of the sleep opportunities you have.
Above all else I think it is important not to torture yourself trying to do things perfectly. Most first time mums especially want to do everything perfectly, and if it works then that is fantastic, but please have a plan B. Sometimes you will need to give your baby formula top ups and that is no crime. Sometimes it is necessary to preserve your sanity, and your baby will still love you just the same.
I look forward to finishing this journey, and remember it will all be worthwhile when you are holding the little one in your arms.
Dr Rahul Sen, 2017