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Childbirth

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This article is about birth in humans. For birth in other animals, see birth.
"Parturition" redirects here. For the Voyager episode, see Parturition (Star Trek: Voyager).

Childbirth (also called labour, birth, partus or parturition) is the culmination of a human pregnancy or gestation period with the expulsion of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labour: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta.[1] In many cases, with increasing frequency, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth.[2] In the U.S. and Canada it represents nearly 1 in 3 (31.8%) of all childbirths.[3] More than 22% of women undergo induction of labor and childbirth in the United States, doubling the rate in 2006 from 1990.[4] Medical professional policy makers find that induced births and elective cesarean can be harmful to the fetus and neonate without benefit to the mother, and have established strict guidelines for non-medically indicated induced births and elective cesarean before 39 weeks.[5]

Signs and symptoms

Natural childbirth at home.

Labour is accompanied by intense and prolonged pain. Pain levels reported by labouring women vary widely. Pain levels seem to be influenced by fear and anxiety levels, experience with prior childbirth, cultural ideas of childbirth and pain,[6][7] mobility during labour and the support given during labour. One study found that middle-eastern women, especially those with a low educational background, had more painful experiences during childbirth.[8]

Pain is only one factor of many influencing women's experience with the process of childbirth. A systematic review of 137 studies found that personal expectations, the amount of support from caregivers, quality of the caregiver-patient relationship, and involvement in decisionmaking are more important in women's overall satisfaction with the experience of childbirth than are other factors such as age, socioeconomic status, ethnicity, preparation, physical environment, pain, immobility, or medical interventions.[9]

Descriptions

Pain in contractions has been described as feeling like a very strong menstrual cramp. Midwives often encourage refraining from screaming but recommend moaning and grunting to relieve some pain. Crowning will feel like intense stretching and burning. Even women who show little reaction to labor pains often show a reaction to crowning.[citation needed]

Psychological

Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface.

Between 70% and 80% of mothers in the United States report some feelings of sadness or "baby blues" after childbirth.[citation needed] 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.

Preventive group therapy has proven effective as a prophylactic treatment for postpartum depression.[10]

Childbirth is stressful for the infant. In addition to the normal stress of leaving the protected uterine environment, additional stresses associated with breech birth, such as asphyxiation, may affect the infant's brain.[citation needed]

Normal human birth

Vaginal birth

Because humans are bipedal with an erect stance and have, in relation to the size of the pelvis, the biggest head of any mammalian species, human fetuses and human female pelvises are adapted to make birth possible.

The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the rectum. The head and shoulders require a specific sequence of maneuvers to occur for the bony head and shoulders to pass through the bony ring of the pelvis.

Six phases:

  1. Engagement of the fetal head in the transverse position. The baby's head is facing across the pelvis at one or other of the mother's hips.
  2. Descent and flexion of the fetal head.
  3. Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby's face is towards the mother's rectum.
  4. Delivery by extension. The fetal head passes out of the birth canal. Its head is tilted forwards so that the crown of its head leads the way through the vagina.
  5. Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.
  6. External rotation. The shoulders repeat the corkscrew movements of the head, which can be seen in the final movements of the fetal head.

The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.[11]

Latent phase

The latent phase of labor is also called prodromal labor or pre-labor. Sometimes, it is classified as preceding stage 1, and sometimes it is classified as being the "latent phase of stage 1", and in such classification the succeeding phase can be termed the "active phase of stage 1".[12]

In this phase, the contractions may be an intensification of the Braxton Hicks contractions that may start around 26 weeks gestation. Cervical effacement occurs during the closing weeks of pregnancy and is usually complete or near complete, by the end of the latent phase. Cervical effacement or cervical dilation is the thinning and stretching of the cervix. The degree of cervical effacement may be felt during a vaginal examination but is not necessary. A 'long' cervix implies that not much has been taken into the lower segment, and vice versa for a 'short' cervix. Latent phase ends with the onset of active first stage, and this transition is generally defined as a cervix dilation of either 3 cm[12] or 4 cm.

First stage: dilation

The first stage of labor (or "active phase of first stage" if previous phase is termed "latent phase of first stage")[12] is generally defined as starting when the effaced (thinned) cervix is 3 cm[12] or 4 cm dilated. Women may or may not have active contractions prior to reaching this point. Rupture of the membranes or a bloody show may or may not occur at or around this stage.

There are several factors that midwives and physicians use to assess the laboring mother's progress, and these are defined by the Bishop Score. The Bishop score is also used as a means to predict whether the mother is likely to spontaneously progress into second stage (delivery).

Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. The presenting fetal part then is permitted to descend. Full dilation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.

The duration of labour varies widely, but active phase averages some 8 hours[13] for women giving birth to their first child ("primiparae") and shorter[citation needed] for women who have already given birth ("multiparae"). Active phase arrest is defined as in a primigravid woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, which plots the typical rate of cervical dilation and fetal descent during active labor.[14] Some practitioners may diagnose "Failure to Progress", and consequently, perform a Cesarean.[15]

File:Cervix dilation sequence.svg
Sequence of cervix dilation during labor

Second stage: fetal expulsion

This stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead[citation needed]. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the pelvic inlet. The fetal head then continues descent into the pelvis, below the pubic arch and out through the vaginal introitus. This is assisted by the additional maternal efforts of "bearing down" or pushing. The fetal head is seen to 'crown' as the labia part. At this point, the woman may feel a burning or stinging sensation.

Complete expulsion of the baby signals the successful completion of the second stage of labor.

A newborn baby with umbilical cord ready to be clamped

The second stage of birth will vary by factors including parity, fetal size, anesthesia, the presence of infection. Longer labors are associated with declining rates of spontaneous vaginal delivery and increasing rates of infection, perineal laceration, obstetric hemorrhage, as well as need for intensive care of the neonate.[16]


SECOND STAGE OF LABOUR / PUSHING STAGE / PELVIC STAGE

DEFINITION: It begins with full cervical dilatation (10cm) till the birth of the baby.

DURATION: Primi gravida - 2 hours. Multi gravida - 30 minutes.

PHYSIOLOGY OF II STAGE OF LABOUR: I. Uterine action a. Expulsive uterine contraction b. Propulsive uterine contraction II. Soft tissue displacement


MECHANISM OF NORMAL LABOUR / CARDINAL MOVEMENTS OF LABOUR

DEFINITION: As the fetus descends, soft tissue and bony structures exert pressures which force fetus to negotiate the birth canal by a series of passive movements collectively known as Mechanism of labor.


PRINCIPLES: • Descent takes place throughout the labor. • Whichever part leads and first meets the resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis. • Whatever emerges from the pelvis will pivot around the pubic bone.

CHARECTERISTICS: • Lie is longitudinal • Attitude is one of the good flexion • Presentation is cephalic presentation • Position is right or left occipito anterior • Denominator is the occiput • Presenting part is the posterior part of the anterior parietal bone • Occiput points in left / right ileo pectinal eminence • Sagital sutures lies in right / left oblique diameter • Presenting diameter is suboccipito frontal diameter 10cm

CARDINAL MOVEMENTS:

1) Descend: • In primi gravida it occurs during latter weeks of pregnancy • It will be aided by  Forces of uterine contraction and retraction  Rupture of fore waters  Full cervical dilatation  Maternal efforts speeds progress  Slope of the pelvic floor muscle

2) Flexion:  This increases throughout the labor  Because of uterine contraction, fetal axis pressure will be exerted more on the occiput than the sinciput causing good flexion  Because of flexion the suboccipito frontal 10cm is reduced into suboccipito bregmatic 9.5cm  The occiput is the leading part

3) Internal rotation of the head:  Because of gutter – shaped and slope of pelvic floor gives resistance  The slope of the pelvic floor determines the direction of rotation  The second principle applied. The occiput is the leading part and meets the pelvic floor resistance and it will rotate 1/8 of the circle forward until it comes under the symphysis pubis.  Because of internal rotation there is a twist at the neck.  The sagital suture move from right or left oblique to Antero – posterior diameter 4) Crowning:  The occiput slips beneath the sub-pubic arch and crowning take place  The presenting part engages the vaginal outlet and it will not recede backward.  The sub-occipito bregmatic diameter 9.5cm distends the vaginal outlet.

5) Extension of the head:  Once crowning occur fetal head can extend  Third principle applied  The fetal head pivot around the the pubic bone  This releases sinciput, face and chin sweeps the perineum and born by a movement of extension.  The suboccipito frontal diameter 10cm distends the vaginal outlet


6) Restitution:  The occiput moves one-eighth of a circle towards the side from it started  Because of this the twist in the neck of the fetus which resulted from internal rotation is now corrected by a slight un twisted movement

7) Internal rotation of the shoulder:  Now the shoulder is the leading part which meets the pelvic floor resistance  Again second principle applied  So from oblique diameter it will turn to Antero – posterior diameter

8) External rotation of the head:  The head rotate in same direction as restitution and the occiput of the fetal head now lies laterally

9) Lateral flexion:  Anterior shoulder deliver by downwards and backward movement and posterior shoulder deliver by upward and forward movement  Body will be delivered by lateral flexion

Third stage: umbilical cord closure and placental expulsion

Further information: Umbilical cord and Placental expulsion
Breastfeeding during and after the third stage, the placenta is visible in the bowl to the right.

The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labor.

The umbilical cord is routinely clamped and cut in this stage, but it would normally close naturally even if not clamped. A 2008 Cochrane Review looked into the timing of clamping the umbilical cord. It found that the time of clamping made no difference to the mother, but did have effects for the baby. If the cord is clamped after 1–3 minutes, the infant receives increased amounts of haemoglobin in their first months of life, but may have an increased risk of needing phototherapy to treat jaundice. Sometimes a newborn’s liver is slow to break down all of the red cells they had in the womb, particularly if they are left with more fetal blood. Delayed cord clamping and phototherapy helps to speed the breakdown.[17]

Placental expulsion begins as a physiological separation from the wall of the uterus. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labor. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10–12 minutes dependent on whether active or expectant management is employed[18]

Placental expulsion can be managed actively, by giving a uterotonic such as oxytocin along with appropriate cord traction and fundal massage to assist in delivering the placenta by a skilled birth attendant. Alternatively, it can be managed expectantly, allowing the placenta to be expelled without medical assistance. In a joint statement, World Health Organization, the International Federation of Gynaecologists and Obstetricians and the International Confederations of Midwives recommend active management of the third stage in all vaginal deliveries.[19][20] This is a strong recommendation of the World Health Organization backed by moderate base evidence citing reduced risk of postpartum bleeding (i.e.: obstetric hemorrhage).

In as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta.[21]

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. With the advent of modern interventive obstetrics, artificial rupture of the membranes has become common, so babies are rarely born in the caul. III STAGE / PLACENTAL STAGE DEFINITION: It starts with separation of placenta till expulsion of placenta.

DURATION: Primi gravida : 15 minutes Multi gravida : 5 – 15 minutes

PHYSIOLOGY OF III STAGE OF LABOR:

I) MECHANICAL FACTORS: Separation of placenta by Schultz method and Mathews Duncan method. Central separation is known as Schultze method. Lateral separation of placenta is known as Mathews Duncan method which has More blood loss No retro placental clot formation Maternal surface comes first

II) Haemostasis: Normal volume of blood flow through the placental site is 500 – 800ml / mt 1) Retraction ring / Living ligature 2) Presence of Vigorous uterine contraction 3) Achievement of haemostasis

Fourth stage

The "fourth stage of labor" is a term used in two different senses:

  • It can refer to the immediate puerperium,[22] or the hours immediately after delivery of the placenta.[23]
  • It can be used in a more metaphorical sense to describe the weeks following delivery.[24]

Afterwards

Further information: Postnatal

Many cultures feature initiation rites for newborns, such as circumcision, 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 many countries, taking time off from work to care for a newborn is called "maternity leave" or "parental leave" and can vary from a few days to several months.

Station

Refers to the relationship of the fetal presenting part to the level of the ischial spines. When the presenting part is at the ichial spines the station is 0 (synonymous with engagement). If the presenting fetal part is above the spines, the distance is measured and described as minus stations, which range from -1 to -4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations ( +1 to +4 cm). At +3 and +4 the presenting part is at the perineum and can be seen.[25]

Management

Eating or drinking during labor is an area of ongoing debate. While some have argued that eating in labor has no harmful effects on outcomes,[26] others continue to have concern regarding the increased possibility of an aspiration event (choking on recently eaten foods) in the event of an emergency delivery due to the increased relaxation of the esophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anesthetic in the event of an emergency cesarean.[27]

Labor Inductions and elective cesarean

More than 22% of women undergo labor induction the United States, and more than doubled the rate from 1990 to 2006.[4][28] Induced labor is indicated when either the fetus or woman will benefit compared to continuation of pregnancy, but procedures are often elective. Childbirth by C-Sections increased 50% in the U.S. from 1996 to 2006, and comprise nearly 32% of births in the U.S. and Canada.[29][4] Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective induction and C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%.[5] The researchers found many benefits but “no adverse effects” in the health of the mothers and babies at those hospitals.[30][5]

Oxytocin is the most commonly agent for induction in the United States, and is used to induce uterine contractions. Other methods of inducing labor include stripping of the amniotic membrane, artificial rupturing of the amniotic sac (called amniotomy), or stimulation of the nipples or one breast. Ripening of the cervix can be accomplished with the placement of a Foley catheter or the use of synthetic prostoglandins such as misoprostol.[4]

The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks (full term) of gestation for reduced mortality and optimal health of the newborn when considering induction of labor. Per these guidelines, the following conditions may be an indication for induction, including:

Induction is also considered for logistical reasons, such as the distance from hospital or psychosocial conditions, but in these instances gestational age confirmation must be done, and the maturity of the fetal lung must be confirmed by testing.

The ACOG also note that contraindications for induced labor are the same as for spontaneous vaginal delivery, including vasa previa, complete placenta praevia, umbilical cord prolapse or active genital herpes simplex infection.[31]

Pain control

Non pharmaceutical

Some women prefer to avoid analgesic medication during childbirth. They can still try to alleviate labor pain using psychological preparation, education, massage, acupuncture, TENS unit use, hypnosis, or water therapy in a tub or shower. Some women like to have someone to support them during labor and birth, such as the father of the baby, a family member, a close friend, a partner, or a doula. The human body also has a chemical response to pain, by releasing endorphins. Endorphins are present before, during, and immediately after childbirth.[32] Some homebirth advocates believe that this hormone can induce feelings of pleasure and euphoria during childbirth,[33] reducing the risk of maternal depression some weeks later.[32]

Water birth is an option chosen by some women for pain relief during labor 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.[34] Hot water tubs are available in many hospitals and birthing centres.

Meditation and mind medicine techniques are also used for pain control during labour 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 women during childbirth. One such technique is the use of hypnosis in childbirth. There are a number of organizations that teach women and their partners to use a variety of techniques to assist with labor comfort, without the use of pharmaceuticals.

A new mode of analgesia is sterile water injection placed just underneath the skin in the most painful spots during labor. A control trial in Iran of 0.5mL injections was conducted with normal saline which revealed a statistical superiority with water over saline.[35]

Pharmaceutical

Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 50% nitrous oxide, 50% oxygen, known as Entonox; 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 such as fentanyl, 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. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost.[36] Generally, pain and cortisol increased throughout labor in women without EDA. Pain and stress hormones rise throughout labor for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but may rise again later.[37] Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus.[38] Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.[39]

Augmentation

Augmentation is the process of facilitating further labour. Oxytocin has been used to increase the rate of vaginal delivery in those with a slow progress of labor.[40]

Instrumental delivery

Obstetric forceps or ventouse may be used to facilitate childbirth.

Multiple births

In cases of a cephalic presenting twin (first baby head down), twins can often be delivered vaginally. In some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e.g.

  • Both twins born vaginally - this can occur both presented head first or where one comes head first and the other is breech and/or helped by a forceps/ventouse delivery
  • One twin born vaginally and the other by caesarean section.
  • If the twins are joined at any part of the body - called conjoined twins, delivery is mostly by caesarean section.

Support

See also: Men's role in childbirth
Baby on warming tray attended to by her father.

There is increasing evidence to show that the participation of the child's father in the birth leads to better birth and also post-birth outcomes, providing the father does not exhibit excessive anxiety.[41] Research also shows that when a laboring woman was supported by a female helper such as a family member or doula during labor, she had less need for chemical pain relief, the likelihood of caesarean section was reduced, use of forceps and other instrumental deliveries were reduced, there was a reduction in the length of labor, and the baby had a higher Apgar score (Dellman 2004, Vernon 2006). However, little research has been conducted to date about the conflicts between partners, professionals, and the mother.

Monitoring

For the Fetus

External Monitoring

For monitoring of the fetus during childbirth, a simple fetoscope[disambiguation needed] (pinard stethoscope) or doppler fetal monitor ("doptone") can be used. A method of external foetal monitoring (EFM) during childbirth is cardiotocography, using a cardiotocograph that consists of two sensors: The heart (cardio) sensor is a ultrasonic sensor, similar to a Doppler fetal monitor, that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound. The pressure-sensitive contraction transducer, called a tocodynamometer (toco) has a flat area that is fixated to the skin by a band around the belly. The pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction.[42] Monitoring with a cardiotocograph can either be intermittent or continuous.

Invasive Monitoring

A mother's waters have to break before invasive monitoring can be used. More invasive monitoring can involve a foetal scalp electrode to give an additional measure of fetal heart activity, and/or intrauterine pressure catheter (IUPC). It can also involve foetal scalp pH testing.

For the Mother

Sometimes a mother may need monitoring during childbirth, parameters such as pulse, blood pressure, reflexes and the percentage of oxygen in the blood (pulse oximetry) can be measured. [citation needed]

Collecting stem cells

It is possible to collect two types of stem cells during childbirth: amniotic stem cells or umbilical cord blood stem cells. To collect amniotic stem cells, it is necessary to do amniocentesis before or during the birth. Amniotic stem cells are multipotent and very active, useful for both autologous or donor use. There are private banks in US; the first is Biocell Center in Boston.[43][44][45]

Umbilical cord blood stem cells are also active, but less multipotent than amniotic stem cells. There are a lot of banks of cord blood, both private and public and for autologous or eterologous use.

Complications

See also: Birth trauma (disambiguation)
Disability-adjusted life year for maternal conditions per 100,000 inhabitants in 2002.[46]
  no data
  less than 100
  100-400
  400-800
  800-1200
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  1600-2000
  2000-2400
  2400-2800
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  3200-3600
  3600-4000
  more than 4000
Disability-adjusted life year for perinatal conditions per 100,000 inhabitants in 2002.[46]
  no data
  less than 100
  100-400
  400-800
  800-1200
  1200-1600
  1600-2000
  2000-2400
  2400-2800
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  3200-3600
  3600-4000
  more than 4000

Childbirth is an inherently dangerous and risky activity, subject to many complications. The "natural" mortality rate of childbirth—where nothing is done to avert maternal death—has been estimated at 1500 deaths per 100,000 births.[47] (See main article: neonatal death, maternal death). Modern medicine has greatly alleviated the risk of childbirth. In modern Western countries, such as the United States and Sweden, the current maternal mortality rate is around 10 deaths per 100,000 births.[47]: p.10  As of June 2011, about one third of American births have some complications, "many of which are directly related to the mother's health."[48]

Birthing complications may be maternal or fetal, and long term or short term.

Pre-term

Newborn mortality at 37 weeks may be 2.5 times the number at 40 weeks, and was elevated compared to 38 weeks of gestation. These “early term” births were also associated with increased death during infancy, compared to those occurring at 39 to 41 weeks ("full term").[5] Researchers found benefits to going full term and “no adverse effects” in the health of the mothers or babies.[5]

Medical researchers find that neonates born before 39 weeks experienced significantly more complications (2.5 times more in one study) compared with those delivered at 39 to 40 weeks. Health problems among babies delivered "pre-term" included respiratory distress, jaundice and low blood sugar.[5][49] The American College of Obstetricians and Gynecologists and medical policy makers review research studies and find increased incidence of suspected or proven sepsis, RDS, Hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4 - 5 days. In the case of cesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor cesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery prior to 39 weeks.[5]

Labor complications

The second stage of labor may be delayed or lengthy due to:

Secondary changes may be observed: swelling of the tissues, maternal exhaustion, fetal heart rate abnormalities. Left untreated, severe complications include death of mother and/or baby, and genitovaginal fistula.

Dystocia (obstructed labour)

Main article: Dystocia

Obstructed labour
Other namesLabour dystocia
Illustration of deformed pelvises. A deformed pelvis is a risk factor for obstructed labour
SpecialtyObstetrics
ComplicationsPerinatal asphyxia, uterine rupture, post-partum bleeding, postpartum infection[50]
CausesLarge or abnormally positioned baby, small pelvis, problems with the birth canal[51]
Risk factorsShoulder dystocia, malnutrition, vitamin D deficiency[52][51]
Diagnostic methodActive phase of labour > 12 hours[51]
TreatmentCesarean section, vacuum extraction with possible surgical opening of the symphysis pubis[53]
Frequency6.5 million (2015)[54]
Deaths23,100 (2015)[55]

Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally.[51] Complications for the baby include not getting enough oxygen which may result in death.[50] It increases the risk of the mother getting an infection, having uterine rupture, or having post-partum bleeding.[50] Long-term complications for the mother include obstetrical fistula.[51] Obstructed labour is said to result in prolonged labour, when the active phase of labour is longer than 12 hours.[51]

The main causes of obstructed labour include a large or abnormally positioned baby, a small pelvis, and problems with the birth canal.[51] Abnormal positioning includes shoulder dystocia where the anterior shoulder does not pass easily below the pubic bone.[51] Risk factors for a small pelvis include malnutrition and a lack of exposure to sunlight causing vitamin D deficiency.[52] It is also more common in adolescence as the pelvis may not have finished growing by the time they give birth.[50] Problems with the birth canal include a narrow vagina and perineum which may be due to female genital mutilation or tumors.[51] A partograph is often used to track labour progression and diagnose problems.[50] This combined with physical examination may identify obstructed labour.[56]

The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis.[53] Other measures include: keeping the women hydrated and antibiotics if the membranes have been ruptured for more than 18 hours.[53] In Africa and Asia obstructed labor affects between two and five percent of deliveries.[57] In 2015 about 6.5 million cases of obstructed labour or uterine rupture occurred.[54] This resulted in 23,000 maternal deaths down from 29,000 deaths in 1990 (about 8% of all deaths related to pregnancy).[51][55][58] It is also one of the leading causes of stillbirth.[59] Most deaths due to this condition occur in the developing world.[50]

Cause

The main causes of obstructed labour include a large or abnormally positioned baby, a small pelvis, and problems with the birth canal.[51] Both the size and the position of the fetus can lead to obstructed labor. Abnormal positioning includes shoulder dystocia where the anterior shoulder does not pass easily below the pubic bone.[51] A small pelvis of the mother can be a result of many factors. Risk factors for a small pelvis include malnutrition and a lack of exposure to sunlight causing vitamin D deficiency.[52] A deficiency in calcium can also result in a small pelvis as the structures of the pelvic bones will be weak due to the lack of calcium.[60] A relationship between maternal height and pelvis size is present and can be used to predict the possibility of obstructed labor. This relationship is a result of the mother's nutritional health throughout her life leading up to childbirth.[50] Younger mothers are also at more risk for obstructed labor due to growth of the pelvis not being completed.[60] Problems with the birth canal include a narrow vagina and perineum which may be due to female genital mutilation or tumors.[51] All of these factors lead to a failure in the progress of labor.

Evolution

Obstructed labor is more common in humans than any other species and continues to be a main cause of birth complications today.[61] Modern humans have morphologically evolved to survive as bipeds, however, bipedalism has resulted in skeletal changes that have consequently narrowed the pelvis and the birth canal.[62] The combination of increased brain size and changes in pelvic structure are the major contributors of obstructed labor in modern humans. It is also common for obstructed labor in humans to be caused by the fetus' broad shoulders. However, morphological shifts in pelvic structure still account for the inability of a fetus to effectively pass through the birth canal without major complications [63]

Other primates have a wider and straighter birth canal that allows a fetus to pass through more effectively.[64] Mismatch between birth canal size and infant cranial width and length due to bipedal locomotion requirements have often been referred to as the obstetric dilemma, since compared to other great apes, modern humans have the greatest disproportion between infant cranial size and birth canal size.[65] Shrinking of upper extremities and curvature of the spine have also affected the way modern humans give birth. Quadruped apes have longer upper limbs that allow them to reach down and pull their fetus out of the birth canal unassisted.[63] Other primates also have a wider and straighter birth canal that allows a fetus to pass through more effectively.[64] Modern human's shorter upper extremities and evolution of bipedal locomotion may have placed a premium on assistance during labor. For this reason, researchers argue that assisted labor may have evolved with bipedalism.[63] Obstructed labor has been documented as a complication of childbirth since the field of obstetrics originated. For over 1,000 years obstetricians have had to forcibly remove obstructed labor fetuses to prevent the death of the mother.[66]

Prior to the existence of the cesarean section, fetuses that were obstructed had a low survival rate.[66] Even in the 21st century, if obstructed labor is left untreated, it could result in mother and infant death.[65] Although surgical removal of the fetus is the preferred method of managing obstructed labor, manual removal using medical tools is also common.[64]

Diagnosis

Obstructed labour is usually diagnosed based on physical examination.[56] Ultrasound can be used to predict malpresentation of the fetus.[60] In examination of the cervix once labor has begun, all examinations are compared to regular cervical assessments. The comparison between the average cervical assessment and the current state of the mother allows for a diagnosis of obstructed labor.[50] An increasingly long time in labor also indicates a mechanical issue that is preventing the fetus from exiting the womb.[50]

Prevention

Access to proper health services can reduce the prevalence of obstructed labor.[60] Less developed areas have inadequate health services to attend to obstructed labor, resulting in a higher prevalence among less developed areas. Improving nutrition of female, both before and during pregnancy, is important for reducing the risk of obstructive labor.[60] Creating education programs about reproduction and increasing access to reproductive services such as contraception and family planning in developing areas can also reduce the prevalence of obstructed labor.[67]

Treatment

Before considering surgical options, changing the posture of the mother during labor can help to progress labor.[67] The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis.[53] Caesarean section is an invasive method but is often the only method that will save the lives of both the mother and the infant.[67] Symphysiotomy is the surgical opening of the symphysis pubis. This procedure can be completed more rapidly than Caesarean sections and does not require anesthesia, making it a more accessible option in places with less advanced medical technology.[67] This procedure also leaves no scars on the uterus which makes further pregnancies and births safer for the mother.[50] Another important factor in treating obstructed labor is monitoring the energy and hydration of the mother.[60] Contractions of the uterus require energy, so the longer the mother is in labor the more energy she expends. When the mother is depleted of energy, the contractions become weaker and labor will become increasingly longer.[50] Antibiotics are also an important treatment as infection is a possible result of obstructed labor.[60]

Prognosis

If cesarean section is obtained in a timely manner, prognosis is good.[50] Prolonged obstructed labour can lead to stillbirth, obstetric fistula, and maternal death.[68] Fetal death can be caused by asphyxia.[50] Obstructed labor is the leading cause of uterine rupture worldwide.[50] Maternal death can result from uterine rupture, complications during caesarean section, or sepsis.[67]

Epidemiology

In 2013 it resulted in 19,000 maternal deaths down from 29,000 deaths in 1990.[58] Globally, obstructed labor accounts for 8% of maternal deaths.[69]

Etymology

The word dystocia means 'difficult labour'.[50] Its antonym is eutocia (Ancient Greek: εὖ, romanized: eu, lit. 'good' + Ancient Greek: τόκος, romanized: tókos, lit. 'childbirth') 'easy labour'.

Other terms for obstructed labour include difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, and dysfunctional labour.[citation needed]

Other animals

The term can also be used in the context of various animals. Dystocia pertaining to birds and reptiles is also called egg binding.[citation needed]

In part due to extensive selective breeding, miniature horse mares experience dystocias more frequently than other breeds.[citation needed]

Most brachycephalic dogs require caesarean sections to decrease risk of mortality for both the bitch and puppies.[70] In the Boston Terrier, French Bulldog, and the Bulldog more than 80% of births require caesarean sections.[71]

  • Assisted delivery: miniature horse dystocia. Note the position of the head.
    Assisted delivery: miniature horse dystocia. Note the position of the head.
  • Miniature horse dystocia. Note the position of the head.
    Miniature horse dystocia. Note the position of the head.

References

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Further reading

Maternal complications

Vaginal birth injury with visible tears or episiotomies are common. Internal tissue tearing as well as nerve damage to the pelvic structures lead in a proportion of women to problems with prolapse, incontinence of stool or urine and sexual dysfunction. Fifteen percent of women become incontinent, to some degree, of stool or urine after normal delivery, this number rising considerably after these women reach menopause. Vaginal birth injury is a necessary, but not sufficient, cause of all non hysterectomy related prolapse in later life. Risk factors for significant vaginal birth injury include:

  • A baby weighing more than 9 pounds.
  • The use of forceps or vacuum for delivery. These markers are more likely to be signals for other abnormalities as forceps or vacuum are not used in normal deliveries.
  • The need to repair large tears after delivery.

Pelvic girdle pain. Hormones and enzymes work together to produce ligamentous relaxation and widening of the symphysis pubis during the last trimester of pregnancy. Most girdle pain occurs before birthing, and is known as diastasis of the pubic symphysis. Predisposing factors for girdle pain include maternal obesity.

Infection remains a major cause of maternal mortality and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of puerperal fever and saved many lives.

Hemorrhage, or heavy blood loss, is still the leading cause of death of birthing mothers in the world today, especially in the developing world. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated. Blood transfusion may be life saving. Rare sequelae include Hypopituitarism Sheehan's syndrome.

The maternal mortality rate (MMR) varies from 9 per 100,000 live births in the US and Europe to 900 per 100,000 live births in Sub-Saharan Africa.[1] Every year, more than half a million women die in pregnancy or childbirth.[2]

Fetal complications

Mechanical fetal injury

Risk factors for fetal birth injury include fetal macrosomia (big baby), maternal obesity, the need for instrumental delivery, and an inexperienced attendant. Specific situations that can contribute to birth injury include breech presentation and shoulder dystocia. Most fetal birth injuries resolve without long term harm, but brachial plexus injury may lead to Erb's palsy or Klumpke's paralysis.[3]

Neonatal infection

Disability-adjusted life year for neonatal infections and other (perinatal) conditions per 100,000 inhabitants in 2004. Excludes prematurity and low birth weight, birth asphyxia and birth trauma which have their own maps/data.[4]
  no data
  less than 150
  150-300
  300-450
  450-600
  600-750
  750-900
  900-1050
  1050-1200
  1200-1350
  1350-1500
  1500-1850
  more than 1850

Neonates are prone to infection in the first month of life. Some organisms such as S. agalactiae (Group B Streptococcus) or (GBS) are more prone to cause these occasionally fatal infections. Risk factors for GBS infection include:

  • prematurity (birth prior to 37 weeks gestation)
  • a sibling who has had a GBS infection
  • prolonged labour or rupture of membranes

Untreated sexually transmitted infections are associated with congenital and perinatal infections in neonates, particularly in the areas where rates of infection remain high. The overall perinatal mortality rate associated with untreated syphilis, for example, approached 40%.[5]

Neonatal death

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 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).[citation needed]

A 1983-1989 study by the Texas Department of State Health Services highlighted the differences in neonatal mortality (NMR) between high risk and low risk pregnancies. NMR was 0.57% for doctor-attended high risk births, and 0.19% for low risk births attended by non-nurse midwives. Conversely, some studies demonstrate a higher perinatal mortality rate with assisted home births.[6] 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.

Intrapartum asphyxia

Intrapartum asphyxia is the impairment of the delivery of oxygen to the brain and vital tissues during the progress of labour. This may exist in a pregnancy already impaired by maternal or fetal disease, or may rarely arise de novo in labour. This can be termed fetal distress, but this term may be emotive and misleading. True intrapartum asphyxia is not as common as previously believed, and is usually accompanied by multiple other symptoms during the immediate period after delivery. Monitoring might show up problems during birthing, but the interpretation and use of monitoring devices is complex and prone to misinterpretation. Intrapartum asphyxia can cause long-term impairment, particularly when this results in tissue damage through encephalopathy.[7]

Professions associated with childbirth

Model of pelvis used in the beginning of the 19th century to teach technical procedures for a successful childbirth. Museum of the History of Medicine, Porto Alegre, Brazil

Different categories of birth attendants may provide support and care during pregnancy and childbirth, although there are important differences across categories based on professional training and skills, practice regulations, as well as nature of care delivered.

“Childbirth educators” are instructors who aim to educate pregnant women and their partners about the nature of pregnancy, labour signs and stages, techniques for giving birth, breastfeeding and newborn baby care. In the United States and elsewhere, classes for training as a childbirth educator can be found in hospital settings or through many independent certifying organizations such as Birthing From Within, BirthWorks, The Bradley Method, Birth Arts International, CAPPA, HypBirth, HypnoBabies, HypnoBirthing, ICTC, ICEA, Lamaze, etc. Each organization teaches its own curriculum and each emphasizes different techniques. Information about each can be obtained through their individual websites.

Doulas are 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 women during labour. Like childbirth educators and other assistive personnel, certification to become a doula is not compulsory, thus, anyone can call themself a doula or a childbirth educator.

Midwives are autonomous practitioners who provide basic and emergency health care before, during and after pregnancy and childbirth, generally to women with low-risk pregnancies. Midwives are trained to assist during labour and birth, either through direct-entry or nurse-midwifery education programs. Jurisdictions where midwifery is a regulated profession will typically have a registering and disciplinary body for quality control, such as the College of Midwives of British Columbia (CMBC) in Canada[8] or the Nursing and Midwifery Council (NMC) in the United Kingdom.[9]

In jurisdictions where midwifery is not a regulated profession, traditional or lay midwives may assist women during childbirth, although they do not typically receive formal health care education and training.

Medical doctors who practice obstetrics include categorically specialized obstetricians; family practitioners and general practitioners whose training, skills and practices include obstetrics; and in some contexts general surgeons. These physicians and surgeons variously provide care across the whole spectrum of normal and abnormal births and pathological labour conditions. Categorically specialized obstetricians are qualified surgeons, so they can undertake surgical procedures relating to childbirth. Some family practitioners or general practitioners also perform obstetrical surgery. Obstetrical procedures include cesarean sections, episiotomies, and assisted delivery. Categorical specialists in obstetrics are commonly dually trained in obstetrics and gynecology (OB/GYN), and may provide other medical and surgical gynecological care, and may incorporate more general, well-woman, primary care elements in their practices. Maternal-fetal medicine specialists are obstetrician/gynecologists subspecialized in managing and treating high-risk pregnancy and delivery.

Anaesthetists or anesthesiologists are medical doctors who specialise in pain relief and the use of drugs to facilitate surgery and other painful procedures. They may contribute to the care of a woman in labour by performing epidurals or by providing anaesthesia (often spinal anaesthesia) for Cesarean section or forceps delivery.

Obstetric nurses assist midwives, doctors, women, and babies prior to, during, and after the birth process, in the hospital system. Some midwives are also obstetric nurses. Obstetric nurses hold various certifications and typically undergo additional obstetric training in addition to standard nursing training.

Facilities

Following are facilities that are particularly intended to house women during childbirth:

  • A labor ward, also called a delivery ward or delivery unit, is generally a department of a hospital that focuses on providing health care to women and their children during childbirth. It is generally closely linked to the hospital's neonatal intensive care unit and/or obstetric surgery unit if present. A maternity ward or maternity unit may include facilities both for childbirth and for postpartum rest and observation of mothers in normal as well as complicated cases.
  • A birthing center generally presents a more home-like environment than a hospital labor ward.

In addition, it is possible to have a home birth.

Society and culture

Further information: Ageing

Childbirth routinely occurs in hospitals in much of Western society. Before the 20th century and in some countries to the present day it has more typically occurred at home.[10]

In Western and other cultures, age is reckoned from the date of birth, and sometimes the birthday is celebrated annually. East Asian age reckoning starts newborns at "1", incrementing each Lunar New Year.

Some families view the placenta as a special part of birth, since it has been the child's life support for so many months.The placenta may be eaten by the newborn's family, ceremonially or otherwise (for nutrition; the great majority of animals in fact do this naturally).[11] Most recently there is a category of birth professionals available who will encapsulate placenta for use as placenta medicine by postpartum mothers.

The exact location in which childbirth takes place is an important factor in determining nationality, in particular for birth aboard aircraft and ships.

See also

Wikinews has related news:
Wikimedia Commons has media related to Childbirth.

References

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  1. ^ Maternal mortality in 2005. World Health Organization (2008).
  2. ^ "Maternal mortality ratio falling too slowly to meet goal". WHO. October 12, 2007.
  3. ^ Warwick, R., & Williams, P.L, ed. (1973). Gray’s Anatomy (35th ed.). London: Longman. p. 1046.{{cite book}}: CS1 maint: multiple names: editors list (link)
  4. ^ "WHO Disease and injury country estimates". World Health Organization. 2009. Retrieved Nov. 11, 2009. {{cite web}}: Check date values in: |accessdate= (help)
  5. ^ "Sexually transmitted infections: Infections and Transmission". World Health Organization.
  6. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 9694754, please use {{cite journal}} with |pmid=9694754 instead.
  7. ^ Handel, Mariëlle; Swaab, Hanna; Vries, Linda S.; Jongmans, Marian J. (2007). "Long-term cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: A review". European Journal of Pediatrics. 166 (7): 645–54. doi:10.1007/s00431-007-0437-8. PMC 1914268. PMID 17426984.
  8. ^ College of Midwives of British Columbia. Accessed 14 March 2011
  9. ^ UK Nursing and Midwifery Council. Accessed 14 March 2011
  10. ^ Stearns, Peter N. (1994). Encyclopedia of Social History. ISBN 0-8153-0342-4.
  11. ^ Having a Great Birth in Australia, David Vernon, Australian College of Midwives, 2005 p56

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