IN THIS CHAPTER
Pushing to the finish in a vaginal delivery
Helping things along with forceps or vacuum extractors
Preparing for a cesarean delivery
Looking at the first few moments after delivery
When you’re nearing the end of the second stage of labor, you’re very close to the point of delivery. Now is the time you’ve been waiting and preparing yourself for. Keep in mind that you don’t have to worry too much ahead of time. You can prepare yourself — by taking childbirth classes and by reading this book, for example. And remember that your practitioner and her assistants in the delivery room will guide you through the process. Accept and rely on their help. Trust in yourself, too, and let this natural process move along one step at a time.
Basically, babies are delivered in one of three ways: through the birth canal by your pushing, through the birth canal with a little assistance (that is, using forceps or a vacuum extractor), or by cesarean delivery. The method that’s right for you depends on many factors, including your medical history, the baby’s condition, and your pelvis’s size relative to your baby’s size. Don’t feel overwhelmed. This chapter gives you the lowdown on all three.
Having a Vaginal Delivery
Most expectant mothers spend a great deal of time during the 40 weeks of pregnancy thinking ahead to the actual delivery. If you’re having a baby for the first time, it may seem pretty scary. Even if you’ve had a child before, worrying a bit until you see your beautiful baby is normal. A little knowledge goes a long way, though, and being informed and prepared for all possibilities is always helpful.
The most common method of delivery is, of course, a vaginal delivery. (Figure 5-1 gives you an overview of the process.) Most likely, you’ll experience what doctors call a spontaneous vaginal delivery, which means that it occurs as a result of your pushing efforts and proceeds without a great deal of intervention. If you do need a little help, it may come in the form of forceps or a vacuum extractor. A delivery requiring the use of one of these tools to help pull the baby out is called an operative vaginal delivery. We cover both courses of events in this chapter.
Illustration by Kathryn Born, MA
FIGURE 5-1: An overview of the delivery process.
During the first stage of labor, your cervix dilates and your membranes rupture. When your cervix is fully dilated (open to 10 centimeters), you reach the end of the first stage of labor and are ready to enter the second stage, in which you push your baby through the birth canal (vagina) and actually deliver the baby. At the end of the first stage, you may feel an overwhelming sensation of pressure on your rectum. You may feel as if you need to have a bowel movement. This sensation is likely to be greatest during contractions. Your baby’s head descending in the birth canal and putting pressure on neighboring internal organs is causing this sensation.
If you have an epidural (a type of regional anesthesia used to take away the pain of labor — see Book 2, Chapter 4), you may not feel this pressure, or the feeling may be less intense. If you do feel it, let your nurse or practitioner know because it’s probably a sign that your cervix is getting close to being fully dilated and that it may be time for you to push. Your nurse or doctor performs an internal exam to confirm that your cervix is fully dilated. If it is, she tells you to start pushing.
Whether your nurse, doctor, or midwife is actually coaching you during pushing varies from hospital to hospital and from practitioner to practitioner. The important factor is that someone is with you to help you through this stage of labor.
Occasionally, you may be fully dilated when the fetal head is still relatively high up in the pelvis. In this case, your practitioner may want you to wait until the contractions cause the head to descend more before you start to push.
Pushing the baby out
Pushing generally takes 30 to 90 minutes (though sometimes it takes as long as three hours), depending on the baby’s position and size, whether you have an epidural, and whether you’ve had children before. (If this isn’t your first delivery, your cervix may begin to dilate weeks before your due date, and after you’re fully dilated, you may push only once or twice to deliver!) Your nurse or practitioner gives you specific instructions on how to push.
While you’re pushing, your baby moves farther along his downward course. Women often begin pushing as soon as the baby’s head has descended into the pelvis. How long you push depends on how far down the head is when you start pushing and how efficient you are at it. Sometimes it takes a while to get the hang of it. After you deliver the head, your doctor may tell you to stop pushing so that she can suction some fluid out of the baby’s mouth and also feel to see if the umbilical cord is around the baby’s neck. After that, you’ll push one or two more times to deliver the rest of the baby.
You have several possible positions in which to push (Figure 5-2 shows three that can help):
· Lithotomy position: In this position, which is the most common, you lean back and pull your flexed knees to your chest. At the same time, you bend your neck and try to touch your chin to your chest. The idea is to get your body to form a C. The position isn’t the most flattering, but it does help to align the uterus and pelvis in a position that makes delivery relatively easy.
· Squatting position: An advantage of squatting is that you have gravity working with you. A disadvantage is that you may be too tired to hold the position for very long, and any monitoring equipment or an intravenous line you may have can be cumbersome.
· Knee-chest position: The knee-chest position is one in which you push while on all fours. This position is sometimes helpful if the baby’s head is rotated in the birth canal in such a way that makes pushing the baby out in the lithotomy or squatting position difficult. The knee-chest position may be awkward for some women and difficult to stay in for very long.
Illustration by Kathryn Born, MA
FIGURE 5-2: Positions you can assume in childbirth.
Finding the one position that feels and works best for you may take a bit of experimentation. If you find that you’re not making progress, try changing positions.
When you start to feel a contraction, your nurse or doctor usually tells you to take a deep, cleansing breath. After that, you inhale deeply again, hold in the air, and push like crazy. Focus the push toward your rectum and perineum (the area between the vagina and the rectum), trying not to tense up the muscles of your vagina or rectum. Push like you’re having a bowel movement. Don’t worry or be embarrassed if you pass stool while you’re pushing. (If it happens, a nurse quickly cleans the perineum.) It’s the rule rather than the exception, and all the people helping to take care of you have seen it many times before. In fact, passing stool is a sign that you’re pushing correctly, so congratulate yourself. Trying to hold it in only impedes your efforts to push the baby out.
Hold each push for about ten seconds. Many nurses count to ten or ask your coach to count to ten to help you judge the time. After the count of ten, quickly release the breath you have been holding, take in another deep breath, and push again for another ten seconds, exactly as before. You usually push about three times with each contraction, depending on the length of the contraction.
Between contractions, try your best to relax and rest so that you can get ready for the next one. If it’s okay with your practitioner, your coach may give you some ice chips or pat your forehead with a damp, cool cloth.
After your baby gets far enough down the birth canal, the top of the head becomes visible during your pushing efforts. This first glimpse is called crowning because your practitioner can see the crown of the baby’s head. Some labor rooms have mirrors so that you, too, can see the head crowning, but many women have no desire to look. (Don’t feel bad or somehow inadequate if you don’t want to — you’re busy enough.) After the contraction, the baby’s head may again disappear back up into the birth canal. This retraction is normal. With each push, the baby comes down a little farther and recedes a little less afterward.
TO WATCH OR NOT TO WATCH
Some partners want to see everything that’s happening during childbirth; others feel uncomfortable even being in the delivery room. Likewise, some women want their partners to witness everything, and others prefer that their partners not see them in this situation.
However you feel about it, communicate your feelings to your partner so that you can make each other feel as comfortable as possible. The last thing you need is for you or your partner to be embarrassed during a time that should be one of joy and happiness.
Getting an episiotomy
Just before birth, the baby’s head distends the perineum and stretches the skin around the vagina. As the baby’s head comes through the vagina’s opening, it may tear the tissues in the back, or posterior, part of the vaginal opening, sometimes even to the point that the tear extends into the rectum. To minimize tearing of the surrounding skin and perineal muscles, your practitioner may make an episiotomy — a cut in the posterior part of the vaginal opening large enough to allow the baby’s head to come through with minimal tearing or to provide extra room for delivery. Although an episiotomy may decrease the likelihood of a severe tear, it doesn’t guarantee that you won’t get one (that is, the cut made for the episiotomy may tear open even further as the baby’s head or shoulders are delivered).
Your practitioner doesn’t know whether you need an episiotomy until the head is almost out. Some doctors routinely make an episiotomy, and others wait to see whether it’s necessary. Episiotomies are more common in women having their first baby than in those who have delivered before because the perineum stretches more easily after a previous birth. Tell your practitioner if you have strong wishes regarding receiving an episiotomy. Keep in mind, though, that some natural tears can be worse than an episiotomy.
The type of episiotomy made depends on your body, on the position of the baby’s head, and on your practitioner’s judgment. Practitioners can choose from two main types of episiotomies:
· Median: Straight down from the vagina toward the anus
· Mediolateral: Angled away from the anus
A local anesthetic can numb the area if you haven’t had an epidural.
A median episiotomy may be less uncomfortable later on, and it may heal more easily. (See Book 2, Chapter 7 for coverage of the care and healing of an episiotomy.) However, a median episiotomy has a slightly greater chance of extending to the rectum. A mediolateral episiotomy, on the other hand, may be more uncomfortable later on and take longer to heal, but it has less chance of extending to the rectum when the baby’s head passes through.
Most tears or lacerations that occur during delivery are in the perineum or are extensions of an episiotomy, which is also in that area. Occasionally, especially when the baby is exceptionally large or you have an operative vaginal delivery, lacerations can occur in other areas, such as the cervix, on the vagina’s walls, the labia, or the tissue around the urethra. Your practitioner examines the birth canal carefully after delivery and sews up any lacerations that need to be repaired. These lacerations usually heal very quickly and almost never cause long-term problems. Don’t worry about having the stitches removed — most doctors use the type of sutures that dissolve on their own.
“DO I REALLY NEED AN EPISIOTOMY?”
The answer to this question depends on many factors, including the point of view of your practitioner. It’s an issue of frequent debate among people who deliver babies. And as you may already know, it’s also a big topic of discussion among pregnant women. Many practitioners believe that repairing a controlled cut in the perineum is easier than repairing any uncontrolled tear through the skin and perineal muscles that may occur without an episiotomy. The same people usually contend that episiotomies heal better, too. Although a doctor may see the layers of tissue in a cut better than in a tear, medical professionals aren’t sure that makes any major difference. Compounding the issue is the fact that it’s difficult to tell before labor whether the patient will need an episiotomy.
During delivery, the baby’s head stretches the vagina’s opening when the mother pushes. Sometimes the birth canal stretches enough that the baby’s head doesn’t need the extra room that an episiotomy provides. Then again, sometimes the birth canal doesn’t. If you can “hold” the head at the perineum to let additional stretching occur, you may help matters. But holding the head there is easier said than done because of the incredible pressure that the baby’s head exerts. One potential advantage of epidurals is that they allow for a slower delivery of the head and therefore reduce the chances that you’ll need an episiotomy.
Handling prolonged second-stage labor
If you’re having your first child and you remain in the second stage of labor for more than two hours (or three hours if you have an epidural), the labor is considered prolonged. If you’re having your second or subsequent child, a second stage nearing one hour (or two hours if you have an epidural) is also considered prolonged.
A prolonged second stage may be due to inadequate contractions or to cephalopelvic disproportion, which is a poor fit between the baby’s head and the mother’s birth canal (see Book 2, Chapter 4). Sometimes, the baby’s head is in a position that blocks further descent. Oxytocin (Pitocin) may help, or your practitioner may try to rotate the baby’s head. You may also try changing your position to push more effectively. Sometimes forceps do the trick if the baby’s head is low enough in the birth canal (see the later section “Assisting Nature: Operative Vaginal Delivery”). If all else fails, your doctor may recommend a cesarean delivery.
The big moment: Delivering your baby
When the baby’s head remains visible between contractions, your nurse helps get you into position to deliver. If you’re laboring in a birthing room, all she needs to do is to remove the platform at the foot of your bed and set up padded leg supports. If you need to be moved to a delivery room (more like an operating room), your nurse moves you and all your monitors to a stretcher. Whether you deliver in a birthing room or a delivery room depends both on the facility where you have your baby and on any risk factors you may have.
When you’re in position to deliver, you still have to keep pushing with each of your contractions. Your doctor or nurse cleans your perineum, usually with an iodine solution, and places drapes over your legs to keep the area as clean as possible for the newborn. As you’re pushing, your perineum is getting more and more stretched out. Whether you need an episiotomy is usually determined in these final moments.
With each push, the baby’s head descends farther and farther until finally it comes out of the birth canal. After the baby’s head delivers, your practitioner tells you to stop pushing so that she can suction secretions from the baby’s mouth and nose before the rest of the body comes out.
To stop pushing at this point can be difficult because of the intense pressure in your perineal area; panting (breathe as if you’re blowing out tiny candles!) may make it a little easier not to push. If you have an epidural, you may not feel this intense pressure.
Your practitioner also checks at this point to see whether the umbilical cord is wrapped around the baby’s neck. A nuchal cord, as it’s called, is actually quite common and very rarely a cause for worry. Your practitioner simply removes the loop from around the baby’s neck before delivering the rest of the baby.
Finally, your practitioner instructs you to push again to deliver the baby’s body. Because the head is typically the widest part, delivery of the body is usually easier. After your baby has made it fully into the world, her mouth and nose are suctioned again.
Normally, after the baby’s head delivers, the shoulders and body follow easily. Occasionally, though, the baby’s shoulders may be stuck behind the mother’s pubic bone, which makes delivery of the rest of the baby more difficult. This situation is known as shoulder dystocia. If you have this problem, your practitioner can perform various maneuvers designed to dislodge the shoulders and deliver the baby. These methods include the following:
· Applying pressure directly above your pubic bone to push away the entrapped shoulder
· Flexing your knees back to allow more room for delivery
· Rotating the baby’s shoulders manually
· Delivering the posterior arm of the baby first
Although shoulder dystocia can occur in women with no risk factors, certain characteristics make this condition more likely:
· Very large babies
· Gestational diabetes
· Prolonged labor
· A history of large babies or babies with shoulder dystocia
Delivering the placenta
After the baby is born, the third stage of delivery begins — the delivery of the placenta, also known as the afterbirth (refer to Figure 5-1). This stage lasts only about 5 to 15 minutes. You still have contractions, but they’re much less intense. These contractions help separate the placenta from the uterus’s wall. After this separation occurs and the placenta reaches the vagina’s opening, your practitioner may ask you to give one more gentle push. Many women, exhilarated by and exhausted from the delivery, pay little attention to this part of the process and later on don’t even remember it.
Repairing your perineum
After the placenta is out, your practitioner inspects your cervix, vagina, and perineum for tears or damage and then repairs (with stitches) the episiotomy or any tears. (If you didn’t have an epidural and you have sensation in your perineum, your practitioner may use a local anesthetic to numb the area before repairing it.)
After the practitioner finishes with the repairs, a nurse cleans your perineal area, removes your legs from the leg supports, and gives you warm blankets. You may also continue to feel mild contractions; these contractions are normal and actually help to minimize bleeding.
Assisting Nature: Operative Vaginal Delivery
If the baby’s head is low enough in the birth canal and your practitioner feels that the baby needs to be delivered immediately or that you can’t deliver the baby vaginally without some added help, she may recommend the use of forceps or a vacuum extractor to assist. Using either of these instruments is called an operative vaginal delivery. Such a delivery may be appropriate to use when
· You’ve pushed for a long time, and you’re too tired to continue pushing hard enough to deliver.
· You’ve pushed for some time, and your practitioner thinks you won’t deliver vaginally unless you have this type of help.
· The baby’s heart rate pattern indicates a need to deliver the baby quickly.
· The baby’s position is making it very difficult for you to push it out on your own.
(Figure 5-3 shows forceps, two smooth, curved, spatula-like instruments that are placed on the sides of the baby’s head to help guide it through the outer part of the birth canal. The vacuum extractor is a suction cup that is placed on the top of the baby’s head, to which suction is applied to allow your practitioner to gently pull the baby through the birth canal.
Illustration by Kathryn Born, MA
FIGURE 5-3: Two ways to help the process of a vaginal delivery along: (a) using forceps or (b) using a vacuum extractor to help guide the baby through the birth canal.
Both techniques are safe for you and the baby if the baby is far enough down in the birth canal and the instruments are used appropriately. In fact, these techniques can often help women avoid cesarean delivery (but not always — see the next section). The decision to use forceps or a vacuum extractor often depends on your practitioner’s judgment and experience and the baby’s position and station.
If you haven’t had an epidural, you may need extra local anesthesia for a forceps or vacuum delivery, and most practitioners perform an episiotomy to make extra room. After the forceps or vacuum is applied, the practitioner asks you to continue to push until the head emerges. The forceps or vacuum extractor is then removed, and the rest of the baby is delivered with your pushing.
If forceps are used, very often the baby is born with marks on her head where the forceps were applied. If this happens to your baby, remember that it’s typical and that the marks disappear within a few days. A vacuum extractor may cause the baby to be born with a round, raised area on the top of the head where the extractor was applied. This mark, too, goes away in a few days.
Having a Cesarean Delivery
Many patients wonder whether they’ll need a cesarean. Sometimes your doctor knows the answer before labor even begins — if you have placenta previa (see Book 2, Chapter 2), for example, or if the baby is in a breech or transverse lie (that is, the baby is lying sideways within the uterus rather than head-down). But most of the time, neither you nor your doctor can know whether you’ll need a cesarean until you see how your labor progresses and how your baby tolerates labor.
Because a cesarean is a surgical procedure, a doctor performs a cesarean delivery in an operating room under sterile conditions. A nurse inserts an intravenous line in the patient’s arm and a catheter in the bladder. After a nurse or nurse’s assistant scrubs the patient’s abdomen with antiseptic solution, a nurse places sterile sheets over the patient’s belly. One of the sheets is elevated to create a screen so that the expectant parents don’t have to watch the procedure. (Although childbirth is usually an experience shared by both parents, a cesarean delivery is still a surgical operation. Most doctors feel that the procedure isn’t something that expectant parents should watch because it involves scalpels, bleeding, and exposure of internal body tissue that’s normally not seen, which is disturbing to many people.)
Many hospitals allow the coach or partner to be in the operating room during a cesarean delivery, but this decision depends on the nature of the delivery and on hospital policy. If the cesarean is an emergency, the doctors and nurses are moving quickly to ensure the safety of both the mother and the baby, which may make it necessary for the partner or coach to wait elsewhere.
The exact place on the woman’s abdomen where the incision is made depends on the reason she’s having the cesarean. Most often, it is low, just above the pubic bone, in a transverse direction (perpendicular to the torso). This cut is known as a Pfannensteil incision or, more commonly, a bikini cut. Less often, the incision is vertical, along the midline of the abdomen.
After the doctor makes the skin incision, she separates the abdominal muscles and opens the inner lining of the abdominal cavity, also called the peritoneal cavity, to expose the uterus. She then makes an incision in the uterus itself, through which the infant and placenta are delivered. The incision in the uterus can also be either transverse (most common) or vertical (sometimes called a classical incision), depending again on the reason for the cesarean and previous abdominal surgery. After delivery, the uterus and abdominal wall are closed with sutures, layer by layer. A cesarean delivery takes 30 to 90 minutes to perform.
Understanding anesthesia
The most common forms of anesthesia used for cesarean deliveries are epidural and spinal (see Book 2, Chapter 4 for more information on anesthesia). Both kinds of anesthesia numb you from mid-chest to toes but also allow you to remain awake so that you can experience your child’s birth. You may feel some tugging and pulling during the operation, but you don’t feel pain. Sometimes the anesthesiologist injects a slow-release pain medication into the epidural or spinal catheter before removing it in order to prevent or greatly minimize pain after the operation.
If the baby has to be delivered in an emergency and there’s no time to place an epidural or spinal, general anesthesia may be needed. In that case, you’re asleep during the cesarean and totally unaware of the procedure. Also, general anesthesia may be needed in some cases because of complications in pregnancy that make it unwise to place epidurals or spinals.
UNCOVERING CESAREAN’S ROOTS
Cesarean delivery, in which the baby is born through an incision in the mother’s abdomen, is hardly a new medical innovation. Cases have been documented since the beginning of recorded history. In fact, many famous works of medieval and Renaissance art depict abdominal deliveries.
The origin of the term cesarean section is a subject of some controversy. Julius Caesar, it turns out, probably wasn’t delivered this way, according to Cesarean Delivery, a history written by physicians Steve Clark and Jeffrey Phelan (published by Chapman & Hall). In those days, it was rare for the mother to survive the procedure. Yet Caesar’s mother survived her delivery and was depicted in Renaissance art that recounted the life of Caesar as an adult.
One theory is that the name comes from the Lex Cesare, the laws of the ancient Roman emperors. One of those laws mandated that any woman who died while she was pregnant be delivered by an abdominal incision so that the infant could be baptized. This rule later became canon law of the Catholic Church. A third possible explanation for the term cesarean is its relationship to the Latin term cadere, which means to cut. The term section also implies surgical cutting, so if cadere is indeed the origin of cesarean, then cesarean section is redundant. In modern obstetrics, the phrase is cesarean delivery or cesarean birth. Still, many people continue to call the operation a cesarean section or c-section.
Looking at reasons for cesarean delivery
Your doctor may perform a cesarean delivery for many reasons, but all are about delivering the infant in the safest, healthiest way possible while also maintaining the mother’s well-being. A cesarean delivery can be either planned ahead of labor (elective), unplanned during labor (when the doctor determines that delivering the baby vaginally isn’t safe), or done as an emergency (if the mother’s or the baby’s health is in immediate jeopardy).
If your practitioner feels that you need a cesarean delivery, she’ll discuss with you why it is needed. If your cesarean is elective or proposed because your labor isn’t progressing normally, you and your partner have time to ask questions. In cases in which the baby is in a breech position, you and your practitioner may consider together the pros and cons of having either an elective cesarean delivery or a vaginal breech delivery (refer to Book 6, Chapter 2). Both carry some risks, and often your practitioner asks you which risks are most acceptable to you. If the decision to perform a cesarean is due to a last-minute emergency, the discussion between you and your doctor may happen quickly, while you’re being wheeled to the operating room.
If things seem hurried or rushed when you’re on your way to the operating room for an emergency cesarean, don’t panic. Doctors and nurses are trained to handle these kinds of emergencies.
Your practitioner may suggest that you have a cesarean delivery for one of many reasons. The following lists describe the most common ones.
Reasons for elective, or planned, cesarean delivery:
· The baby is in an abnormal position (breech or transverse).
· You have placenta previa (see Book 6, Chapter 2).
· You’ve had extensive prior surgery on the uterus, including previous cesarean deliveries or removal of uterine fibroids. (See Book 6, Chapter 1 for information on vaginal births after cesarean delivery.)
· You’re delivering triplets or more.
Reasons for unplanned but nonemergency cesarean delivery:
· The baby is too large in relation to your pelvis to be delivered safely through the vagina — a condition known as cephalopelvic disproportion (CPD) — or the position of the baby’s head makes vaginal delivery unlikely.
· Signs indicate that the baby isn’t tolerating labor.
· Maternal medical conditions, such as severe cardiac disease, preclude safe vaginal delivery.
· Normal labor comes to a standstill.
Reasons for emergency cesarean delivery:
· Bleeding is excessive.
· The baby’s umbilical cord pushes through the cervix when the membranes rupture.
· There’s prolonged slowing of the baby’s heart rate.
Other than the fact that the baby and placenta are delivered through an incision in the uterus rather than through the vagina, for the baby, there’s not much difference between cesarean and vaginal delivery. Babies delivered by a cesarean before labor usually don’t have cone-shaped heads, but they may if you’re in labor for a long time before having a cesarean. As the baby is trying to make its way through the vaginal canal, the head often molds, forming a cone-shape as it squeezes through. Sometimes, the early formation of swelling, leading to a cone-head shape and occurring way before the pushing stage, may be a sign that the baby isn’t fitting through. (For more on cone-shaped heads, see Book 2, Chapter 6.)
Women who have labored for a long time only to find they need a cesarean delivery are sometimes understandably disappointed. This reaction is natural. If it happens to you, keep in mind that what is ultimately most important is your safety and your baby’s safety. Having a cesarean delivery doesn’t mean that you are a failure in any way or that you didn’t try hard enough. Roughly 20 to 30 percent of women need a cesarean delivery for a variety of reasons. Practitioners stick to basic guidelines when monitoring progress through labor, and those guidelines are all about giving you and your baby the best chance for a normal, healthy outcome.
All surgical procedures involve risks, and cesarean delivery is no exception. Fortunately, these problems aren’t common. The main risks of cesarean delivery are
· Excessive bleeding, rarely to the point of needing a blood transfusion
· Development of an infection in the uterus, bladder, or skin incision
· Injury to the bladder, bowel, or adjacent organs
· Development of blood clots in the legs or pelvis after the operation
Recovering from a cesarean delivery
After the surgery is finished, you’re taken to a recovery area, where you stay for a few hours until the hospital staff can make sure that your condition is stable. Often, you can see and hold your baby during this time.
The recovery time from a cesarean delivery is usually longer than from a vaginal delivery because the procedure is a surgical one. Typically, you stay in the hospital for two to four days — sometimes longer, if complications arise. Check out See Book 2, Chapter 7 for details on recovering from a cesarean delivery.
DEBUNKING MYTHS OF CESAREAN RATES
Some women choose their practitioner or the hospital where they’re going to deliver based on the number of cesarean deliveries (as a percentage of total deliveries) that the practitioner, group, or hospital has done. However, that number is meaningless, unless you also know the demographics of the practice or hospital. For example, a maternal–fetal medicine specialist who predominantly cares for older women, women with many medical problems, or women carrying twins or more is expected to have a higher cesarean rate than a doctor or midwife who takes care of young, healthy women. The important issue isn’t the cesarean delivery rate but whether the cesareans were done for appropriate reasons.
Congratulations! You Did It!
Women may experience any and every kind of emotion after their babies are born. The spectrum of feelings is truly infinite. Most of the time, you’re completely overcome with joy when your long-awaited baby finally is born. You may be incredibly relieved to see that your baby appears healthy and obviously okay. If your baby requires extra medical attention for some reason and you can’t hold her right away, you may be upset or, at the very least, disappointed. Just remember that very soon you’ll have her to hold and enjoy for the rest of your life. Some women feel too scared or overwhelmed to care for their baby right away. Don’t feel guilty about any such feelings — they, and most others, are completely normal. Just take one moment at a time. You’ve come through a phenomenal event.
Shaking after delivery
Almost immediately after delivery, most women start to shake uncontrollably. Your partner may think that you’re cold and offer you a blanket. Blankets do help some women, but you aren’t shivering because you’re cold. The cause of this phenomenon is unclear, but it’s nearly universal — even among women who’ve had cesarean deliveries. Some women feel nervous about holding their babies because they’re shaking so much. If you feel this way, let your partner or your nurse hold your baby until you feel up to it.
Don’t be concerned at all about this shaking. It usually goes away within a few hours after delivery.
Understanding postpartum bleeding
After delivery — either vaginal or cesarean — your uterus begins to contract in order to squeeze the blood vessels closed and thus slow down bleeding. If the uterus doesn’t contract normally, excessive bleeding may occur. This condition is known as uterine atony. It can happen when you have multiple babies (twins or more), if you have some infection in the uterus, or if some placental tissue remains inside the uterus after the placenta is delivered. Then again, in some cases, excessive bleeding happens for no apparent cause. If it happens to you, your doctor or nurse may first massage your uterus to get it to contract. If massage doesn’t solve the problem, you may be given one of several medications that promote contracting, like oxytocin, methergine, or hemabate.
If you have some placental material remaining in your uterus, it may need to be removed by reaching inside the uterus or by a D&C (dilation and curettage), which involves scraping the uterus’s lining with an instrument. The vast majority of the time, the bleeding stops without a problem. However, if it doesn’t stop with these medications and procedures, your doctor will discuss other forms of treatment with you.
Hearing your baby’s first cry
Shortly after delivery, your baby takes her first breath and begins to cry. This crying is what expands your baby’s lungs and helps clear deeper secretions. In contrast to the stereotype, most practitioners don’t spank a baby after she’s born but instead use some other method to stimulate crying and breathing — rubbing the baby’s back vigorously, for example, or tapping the bottom of the feet. Don’t be surprised if your baby doesn’t cry the very second she’s born. Often, several seconds, if not minutes, pass before the baby starts making that lovely sound!
Checking your baby’s condition
All babies are evaluated by the Apgar score, named for Dr. Virginia Apgar, who devised it in 1952. This score is a useful way of quickly assessing the baby’s initial condition to see whether she needs special medical attention. Five factors are measured:
· Heart rate
· Respiratory effort
· Muscle tone
· Presence of reflexes
· Color
Each parameter is given a score of 0, 1, or 2, with 2 being the highest.
The Apgar score is calculated twice, at both one and five minutes following birth. The parameters are added up. The lowest score is a 0 (very rare), and the highest, a 10. An Apgar score of 6 or above is perfectly fine. Because some of the characteristics are partially dependent on the infant’s gestational age, premature babies frequently get lower scores. Factors such as maternal sedation also can affect a baby’s score.
Many new parents anxiously await the results of their child’s Apgar score. In fact, an Apgar score taken one minute after the baby is born indicates whether the baby needs some resuscitative measures but is not useful in predicting long-term health. An Apgar score taken five minutes later can indicate whether resuscitative measures have been effective. Occasionally, a very low five-minute Apgar score may reflect decreased oxygenation to the baby, but it correlates poorly with future health. The purpose of the Apgar score is merely to help your doctor or pediatrician identify babies who may need a little extra attention in the very early newborn period. It certainly is no indication of whether your baby will get into Harvard or Yale.
Cutting the cord
After the baby is actually delivered, the next step is to clamp and cut the umbilical cord. Some practitioners may offer your labor coach the opportunity to cut the cord — but your partner is under no obligation to do so. If having the opportunity to cut the cord is something you feel strongly about, let your practitioner know ahead of time.
At the time of this writing, there has been a lot of discussion about the risks and benefits of delayed cord clamping. The idea is that by delaying the clamping of the cord by two or three minutes, you can give your baby more blood that is stored within the cord and placenta. Recent data based on an analysis of about 15 different studies showed a significant benefit in premature infants. For these preemies, delayed cord clamping showed lower rates of transfusion for anemia, lower rates of a complication called necrotizing enterocolitis, and lower rates of intraventricular hemorrhage (known as IVH, a potentially serious complication in very preterm babies). Although the levels of bilirubin (a breakdown product of hemoglobin, which in high levels can cause problems) were higher, there was no greater need to treat these babies with phototherapy (a way of breaking down bilirubin).
In contrast, in full-term babies, the studies did show that although hemoglobin levels were higher in the immediate newborn period and there was less iron deficiency at 3 and 6 months, there was a 40 percent increase in the need for phototherapy for high bilirubin levels and jaundice. Therefore, the decision to perform delayed cord clamping should be individualized. There doesn’t seem to be large proven benefits in term infants, and there are some significant risks, so at this time it isn’t routinely performed. However, in premature infants, the decrease in the risk of IVH is compelling and should be considered.
After cutting the cord, your practitioner either lays your baby on your abdomen or gives the baby to your labor nurse to put under an infant warmer. The choice depends on your baby’s condition, your doctor’s or nurse’s standard practice, and the institutional policy where you’re delivering. (See more on newborn care in Book 2, Chapter 6)
Banking cord blood and tissue
Cord blood is blood that is left in the umbilical cord and placenta after birth. Recently, couples have had the option of collecting this blood through a private or public bank. The rationale for collecting the cord blood is that it contains blood-forming stem cells, which may be used to treat some disorders of the blood or immune system and even for complications associated with certain cancer treatments. Very recently, some facilities started storing umbilical cord tissue, which contains stem cells that may be used for the treatment of other conditions.
You may store cord blood for public or private use:
· Public cord banks store umbilical cord blood that is available for anyone who needs it. There is no charge for collection and storage. You don’t, however, have control over your child’s own cord blood. Public cord banking is not available in all, or even many, institutions.
· Private cord banks store your blood specifically for your own use. The blood may be used to treat your child or other relatives. There’s an annual fee for storage of the blood and often a charge for collecting the blood.
There are some important things to know about cord blood cells. If a baby is born with a genetic disorder, the practitioner can’t use the baby’s own stem cells for treatment because they have the same genes that caused the disorder in the first place. Also, if a child gets leukemia, you can’t use that child’s own stem cells for treatment. However, stem cells from a healthy child can be used to treat another child’s leukemia.
Many couples ask whether it’s worth paying the money to bank their child’s cord blood. The chance that the cord blood will actually be needed to treat your child or a relative is low, about 1 in 2,700. However, that number may change as research on treating various conditions advances. The cord stem cells are not miracle cells, and they can’t treat all conditions. It also isn’t known how long the cells will last. If you do decide to store the umbilical cord blood privately, you should find out the specific fees and ask what would happen if the company were to go out of business.
Finding out about new uses for your placenta
The placenta is an amazing organ that provides nutrients and oxygen to your baby and provides for elimination of waste from your fetus. It’s rich in hormones and protein. Some couples ask if they can take their placenta home — you’d need to discuss this with your doctor or find out from the hospital.
Some potential uses of the placenta (not necessarily scientifically proven) are as follows:
· Cultural norms: Some cultures advocate eating the placenta for nutritional as well as cultural significance. Others believe that eating the placenta can ward off postpartum depression.
· For use in beauty products: Many companies sell skin treatments containing extracts of animal placenta. Don’t be surprised at ads claiming anti-aging properties and the elimination of dark spots! Placentas have also been found in hair products that claim to strengthen hair. Many of these products use cow or sheep placentas. Believe it or not, horse placenta is thought to heal sports injuries.
Of course, if you’ve had any complications, such as preeclampsia or a baby measuring small, or you delivered prematurely, your placenta should be sent to pathology for scientific evaluation.