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CLOSE THIS BOOKHealthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.)
Chapter Ten - LABOUR
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTPlanning for the Delivery
VIEW THE DOCUMENTHow Does Labour Start?
VIEW THE DOCUMENTThe Stages of Labour

Healthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.)

Chapter Ten - LABOUR

Labour is the process by which a woman delivers her baby into the world. Normally labour lasts about 5-18 hours, but this varies a lot. Labour requires great effort from the woman; it is often accompanied by pain, anxiety, and physical exhaustion. Despite the hard work of labour, however, most women also feel a deep sense of satisfaction in their accomplishment and love for their new child.

Planning for the Delivery

Plans for delivery should be made before labour begins. As described in Chapter 7, a decision should be made about where the baby will be delivered and who will help the mother during delivery. These decisions should be based on how healthy the woman is and whether there were any signs that she was likely to have a complicated delivery. Wherever the delivery takes place, essential supplies should be gathered, and transportation should be arranged in case a complication develops. The requirements for a safe delivery are listed in Box 10.1.

How Does Labour Start?

Nobody knows the full answer to this question. Labour appears to be caused by changes in the levels of hormones and other chemicals in the blood, but no one knows for sure. There are three signs that may indicate labour is starting: regular contractions of the womb, the "show", and a gush of water from the vagina. These three signs of labour do not necessarily occur in any particular order, and some women may never see any show or break their water. Usually, however, when these signs occur labour is beginning and preparations should be made for delivery.

Box 10.1: Basic Requirements for Proper Care During Delivery

Whether the delivery takes place at home, in a clinic, or at the hospital, certain basic requirements should be met. These include:

1. The delivery room should be clean, have fresh air, and offer some privacy.

2. Any instruments that will be used - razor blades, scissors, needles, thread, etc. - must be clean and sterile (scissors or a razor blade can be sterilised by leaving them in boiling water for 20 minutes). Unclean instruments can cause infection. Soap and water should be available for the birth attendant to wash her or his hands thoroughly, and if possible the attendant should wear surgical gloves. Clean towels, cloths, and cotton wool must also be available.

3. The birth attendant, whether a relative, neighbour, or midwife, should be experienced enough to recognise the warning signs of trouble which may arise suddenly. The attendant should also know what action to take (see Chapters 9 and 11).


4. If the delivery is taking place at home or in a local clinic, arrangements should be made to have transport available. That way, if a serious complication develops, valuable time is not wasted while the family searches for a vehicle and petrol, or for some other means to get to the hospital (see Chapter 11 for signs of serious complications during delivery).

Box 10.2: True vs. False Labour

TRUE LABOUR

· Contractions get stronger, longer, and closer together
· Contractions come in a regular pattern
· Walking or changing position makes them stronger
· The cervix gets thinner and opens (this can only be felt if a vaginal examination is done)

FALSE LABOUR

· Contractions remain the same strength, length, and time apart
· Contractions are usually irregular
· Walking or changing position does not affect the contractions

· The cervix does not change

CONTRACTIONS

During the last four weeks of pregnancy, a woman may notice occasional painful contractions of the womb. They may be regular, but do not last very long. These are called "false labour pains". True labour pains are caused by regular, rhythmic contractions of the womb. They are usually felt in the lower back first, then spread to the front. At the beginning, they occur every 10-15 minutes and last only a few seconds. As labour progresses, the contractions occur more and more frequently, last longer, and become stronger. These contractions are the most reliable sign that labour has actually started.

THE "SHOW"

During pregnancy, the neck of the womb or cervix is plugged by thick mucus. When labour starts, this mucus plug often comes out, together with a little bit of blood, as the cervix begins to open. This spotting of blood and mucus is called the show; it is not a flow like a heavy menstrual period. If there is a lot of blood or if the bleeding continues, the woman should go to a health facility immediately. This can be a sign of a serious complication.

GUSHING OF WATER

During labour, the bag of water surrounding the baby in the womb often tears, and the water escapes through the vagina in a "gush". Usually several cupfuls of fluid come out, although it may seem like more. This process is called rupture of membranes. It is usually caused by the contractions of the womb. It does not always happen, however, and some babies are born inside their unbroken bags of water.

The Stages of Labour

The process of labour has been divided into three stages.

THE FIRST STAGE

The first stage of labour is the period during which the cervix opens or dilates from a fraction of an inch (a few millimetres) to about four inches (ten centimetres). At the end of the first stage, the opening is large enough to allow the baby's head to pass through. This stage is marked by regular, painful contractions of the womb and can be the longest and most tiring of the three stages. Contractions gradually occur more often and last longer, until they come every 2-3 minutes and last about 40-50 seconds. This can be a very anxious as well as difficult time for the woman in labour because it requires great physical effort. In hospitals, some women may receive an injection to help reduce the pain. Usually this is not given if it is very early in labour or very near delivery (because it may make it harder for the baby to breathe after being born).

It is important for women to understand that with each set of contractions, the neck of the womb is gradually opening and the baby is being pushed towards the outside. At this early stage, while the neck of the womb is opening, the woman should be discouraged from pushing or "bearing down". Pushing too early can cause the neck of the womb to become swollen or damaged.

Probably the most trying period during the first stage is the period towards the end called "transition". By this time, the contractions seem to come very quickly without much rest in between. Often women begin to feel a strong urge to bear down or push as the baby's head descends into the birth canal.

For women having their first baby this stage of labour usually lasts between 8 and 18 hours. With later pregnancies this stage is usually shorter. A woman who is in hard labour (strong, regular contractions) for more than 12 hours should be taken to a hospital.

COMFORT AND SUPPORT IN LABOUR: Labour is a physically and emotionally demanding experience. A woman in labour must focus all of her attention and energy on completing the process of bringing new life into the world. For this reason it is important that she is given support during labour and birth, and made to feel as comfortable as possible.

When labour starts and the pain or discomfort is still mild, women usually appreciate doing something that distracts them: talking, walking around, eating a light meal, and drinking fluids. As labour progresses, the discomfort may prevent them from doing these things. Breathing deeply and relaxing between contractions can help relieve the intensity of labour. A massage, shower, or bath can be helpful. Women should also be encouraged to pass urine frequently, as a full bladder can contribute to problems during labour. Most women feel comforted by having someone with them, such as their mother, sister, friend, or husband. This can help them relax and may make the labour and delivery easier. A woman in labour should not be left alone.

If there are no complications and labour is progressing normally, women should be encouraged to be out of bed and walking around. Toward the end of labour, they should be allowed to find the position that is most comfortable for them. Figures 10.1-10.4 show some possible positions for delivery, both at home and in the hospital or health centre.

Positions for Delivery

A woman should be as comfortable as possible during delivery. The positions shown are good because they make it easier for the baby to pass through the birth canal. Whatever position makes it easiest for the woman to breathe and push is best.


Figure 10.1: Squatting

The woman should be supported from behind.


Figure 10.2: Lying on Side

This position may be more comfortable for some women.


Figure 10.3: On All Fours

This position is sometimes used in home deliveries. Care needs to be taken to make sure that the baby is fully supported as it comes out of the vagina.


Figure 10.4: Hospital Delivery (sitting semi-upright)

Most hospitals and health centres have delivery beds; the woman sits with her back supported and her knees apart.

USE OF THE PARTOGRAPH: In many hospitals and health centres, a partograph is used to measure the progress of labour during the first stage (see Figure 10.5). To use a partograph, a trained midwife measures the dilatation (opening) of the neck of the womb every four hours. These measurements are recorded on the partograph form, along with measurements of the woman's blood pressure, pulse, the frequency of the contractions, and the heart rate of the baby. If labour is not progressing rapidly enough, this can be seen easily by looking at the partograph, and appropriate action can be taken. Many midwives and doctors have been trained to use a partograph. Its use is a standard procedure in most hospitals and health centres today.

THE SECOND STAGE

This is the stage when the baby is actually delivered into the world. The neck of the womb is now fully open (about 4 inches or 10 centimetres) and the baby can be pushed out. Women often feel a strong urge to push or bear down with each contraction. They should be encouraged to push with each contraction and relax in between. This encouragement and reassurance is especially important if this is their first baby. Women generally feel better overall during the second stage: they know they are almost finished and they are actively pushing to bring their babies into the world. For a woman's first delivery, the second stage generally lasts around one hour. For women who have had babies before, this stage usually lasts around 15 minutes but may last as long as one hour. If a woman is in this stage for more than one hour, she needs to be taken to a hospital.


Figure 10.5: Using a Partograph to Measure the Progress of Labour

The partograph is a chart used to record information on the progress of labour (contractions, dilatation, blood pressure, pulse, and foetal heart rate). If labour is not progressing correctly, the partograph provides an early warning (the "alert line"), and shows when referral or other action may be necessary (the "action line").

THE THIRD STAGE

Labour is almost over after the baby comes out, but not quite. The placenta or afterbirth has yet to be delivered. The time between the birth of the baby and the delivery of the placenta is called the third stage (see Figure 10.6). It is usually a brief period lasting only 5-15 minutes, but it still carries some potential danger to the mother. Immediately after the birth of the baby, the contractions of the womb cause the placenta to separate from the wall of the womb. The next few contractions push the placenta into the vagina. It is then gently delivered by a birth assistant while the woman bears down just as she did with the birth of the baby. This stage is always accompanied by some bleeding. The birth attendant should not pull on the umbilical cord or push on the abdomen to make the placenta come out. This can cause severe bleeding, and can be very dangerous.

The baby may be put to the breast immediately while waiting for the placenta to come out (see Figure 10.7). Not only does this get the baby off to a good start, but it will also cause contractions which help the placenta separate and control bleeding. In most places, a procedure called "active management of the third stage" is used to ensure that the placenta comes out. In this procedure, as soon as the baby is delivered, the midwife or doctor first makes sure that it is not a twin delivery. Then the woman is given an injection with a drug called an oxytocin that helps promote contractions of the womb. This drug helps the womb push the placenta out quickly, and reduces the chances that there will be a lot of bleeding.

If the bleeding does not stop after the placenta is delivered, or if the bleeding is excessive, immediate assistance should be sought (see the next chapter on complications during labour).


Figure 10.6: Waiting for Delivery of the Placenta

After the baby has been delivered, the womb will continue to contract to push the placenta (afterbirth) out.


Figure 10.7: Delivery of the Placenta and Care of the Newborn

The baby should be put to the breast immediately following delivery. The baby's sucking causes the womb to contract, which helps push out the placenta and stop bleeding.

Summary: Labour

Labour is the process by which a baby is delivered into the world. It normally lasts 5-18 hours, but can be much shorter in a woman who has had a baby before.

THERE ARE THREE SIGNS THAT LABOUR IS BEGINNING:

Regular, painful contractions of the womb.
The "show": a small amount of blood mixed with mucus that comes out of the vagina.
A gush of water that comes out of the vagina when the bag or water around the baby breaks.

LABOUR IS DIVIDED INTO THREE STAGES:

FIRST STAGE: The neck of the womb begins to open and the contractions become more frequent. The baby begins to push down the birth canal. This stage generally lasts between 5 and 18 hours.

SECOND STAGE: The neck of the womb (cervix) has opened fully and the baby is born. This stage usually lasts about one hour.


THIRD STAGE: From the birth of the baby to the delivery of the placenta. This stage generally lasts 5-30 minutes.

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