When the time for the delivery gets closer, the future mother begins to notice some changes in her body. She has to visit her doctor more often, using these visits to ask her questions and share her fears that increase as the time of delivery gets closer.

It is very important that the mother learns to recognize and distinguish some symptoms that can come up so that she can accurately determine if it's the prepartum or if its time to go to the hospital because she is about to give birth.

1.1 THE PREPARTUM 1.2 TELLING SYMPTOMS OF LABOR 1.3 PROVOKING THE DELIVERY 1.4 UPON ARRIVAL AT THE HOSPITAL 1.5 THE POSITIONING OF THE BABY DURING THE DELIVERY 1.6 THE BIRTH 1.7 DIFFICULTIES DURING THE DELIVERY

The physical changes of this period can appear at the end of the eighth month of pregnancy or just a few hours before the delivery but they always include, besides the dilatation of the neck of the uterus, other signs, such as:

-The Braxton Hicks contractions, the professionals also call them “prodromes”. They can appear anytime after the fifth month. With these contractions, uncomfortable but not very painful, the uterus contracts as a practice for the real contractions of the delivery. They are irregular and can last about 30 seconds but they can be as long as two minutes.

The mother observes how the uterus gradually hardens from the top down and then how her muscles relax.

These contractions are more frequent and intense, even painful, as the delivery gets closer and this is why they can be confused with the true contractions that bring about the delivery.

The Braxton Hicks contractions do not entail a real dilatation and are not strong enough to expel the baby but they may provoke the beginning the first stage of the delivery. This is why the mother must clearly describe the contractions to her doctor so that he can assess the risks of a premature delivery.

These contractions appear earlier and more often among women who have had babies already.

-The positioning takes place when the baby moves to the lower part of the abdomen to place his head in the mother's pelvis.

In the woman who is expecting her first son this can happen between 15 and 30 days before the birth and when there have been previous deliveries, the positioning takes place when the woman goes into labor.

When the baby goes down to position himself some mothers actually feel some relief because there is less pressure on the diaphragm and they can breather better. However, the baby may now press on the bladder and the woman may urinate more often.

-Increased pressure on the pelvis and rectum, and in some cases, pain on the lower back. The women that have given birth before may feel cramps and some discomfort in the groin.

-Slight weight increase during the last month, but some women may actually lose one or two kilos.

-During the prepartum, some mothers may actually feel fatigue, as if they were running out of energy, others feel an increase of their vitality, wanting to constantly clean up the house and get the things for the baby ready.

-It is possible that there may be some vaginal losses, thicker than before, and there could even be a pink mucous because when the neck of the uterus dilates, some capillary veins may break. This can occur 24 hours before the delivery, or even a few days before.

-When the neck of the uterus begins to dilate, the mucous gel block that has been closing it, the show, can be released and go down through the vagina to be expelled. This plug has fulfilled its mission of isolating the uterus from the exterior during the pregnancy and protecting the baby of possible infections.

This happens when the neck of the uterus begins to dilate or even 10 to 15 days before the beginning of the real contractions of labor. In many instances, the mother is not aware that she is expelling the plug because it can be released with thicker fluids, but if she notices it, she should contact her doctor so that he can assess the condition of the neck of the uterus.

IT IS NOT YET TIME IF:

• The contractions disappear when the mother changes position or walks.
• The contractions are not regular, and do not increase in frequency or intensity.
• The contractions are accompanied by movements of the baby.
• The vaginal losses are grayish, without any traces of blood in them.

1.2 TELLING SYMPTOMS OF LABOR

The more revealing signs are the intense and regular contractions and the breaking of waters or the two symptoms at the same time.

The breaking of the membranes or “the sac of water”.

As we saw in previous sections, during the pregnancy, the baby floats in the amniotic fluid that is held by some fine membranes that form a bag that is called the sac of water. When the time comes for delivery, the membranes break, without pain, to release the fluid and the baby can then be born.

At times, the mother may confuse this with a urinary incontinence or vaginal losses because the membranes may leak instead of breaking completely.

When there is a clear break, the mother expels abundant, lukewarm and transparent liquid, with a sweet smell. She will continue to lose fluid little by little until the delivery, when all the liquid will go out along with the baby.

If the membranes have leaks, the mother will expel the amniotic fluid little by little until the moment when she goes into labor.

The membranes can break at any time, sometimes this happens after a painful or particularly long contraction but they can remain intact until the time of delivery. In this case, the doctor will use a special needle to puncture the sac.

If the mother breaks the sac, she must go to the hospital at once because the membranes no longer protect the baby from infections by germs from the vagina and there is also the possibility that the fluid may shift the umbilical cord, placing it under the head of the baby who can compress it. These risks are minor if the mother lays down on her way to the hospital.

There are some very few cases (premature delivery or positioning when the baby does not place his head in the pelvis) in which the umbilical cord is shifted and can reach the neck of the uterus or, even, the vagina, this is why the mother should go at once to the hospital if she notices anything wrong.

Normally, the delivery takes place within 12 hours after breaking waters, but in some cases, it may go on for as long as 24 hours or even more. When this occurs, the doctors may induce the delivery with oxitocyn, to avoid any risks of infection.

The coloring of the amniotic fluid by meconium

The meconium is a substance that comes from the digestive system of the baby, it is brownish and has a foul smell and the baby usually spells it with his first faeces after birth. When the waters break and the amniotic fluid contain this substance, it may be an indicator that the baby is stressed, has some ailment or is post mature.

The coloring by meconium does not mean that there will be complications but the doctor should rule out this possibility at once.

The contractions

It is normal that the mother may have felt slight contractions during the pregnancy, especially during the 8th and 9th month (Braxton Hicks contractions). However, the contractions that provoke the dilatation of the neck of the uterus have specific characteristics.

The contractions in preparation for the delivery at first occur every 15 or 30 minutes, do not last longer than 20 minutes and the mother feels something similar to the “pulls” and pains of her period.

The intensity increases and the time lapses between contractions diminish. If she places her hand over her belly, the woman can feel how her uterus hardens during the contraction and how it softens. These contractions do not go away when she changes postures or relaxes, they are spontaneous and automatic. The duration is measured by checking the time the uterus remains hard; it is a mistake to measure the time the pain lasts because each woman perceives pain differently.

When the contractions become regular, indicating that the delivery is close, the mother should avoid eating or drinking anything to prevent her from vomiting during the labor, and so that she can be in optimal conditions in case she may require general anesthesia.

1.3.- PROVOKING THE DELIVERY

When the pregnancy has gone beyond term and there are no signs of labor.

42 weeks after her last period, the woman has to give birth. If at that time, she has not done so, the doctor makes some tests to verify that the evolution of the pregnancy is correct.

If the doctor suspects that there is a problem, he would conduct an amnioscopy introducing a very fine tube through the neck of the uterus to check the color of the amniotic fluid that darkens when the placenta has degenerated. He also checks the heart beat of the baby and if he detects any anomaly, he would induce the labor.

Induced delivery.

When the doctor has reasons to suppose that there are risks for the health of the mother or the baby, he induces the delivery artificially, so that it starts. The most frequent cases in which this is done are:

In some cases, to provoke the dilatation it is enough for the doctor to puncture the membranes, but in most cases, oxitocyn is used to activate the uterus. These substance are applied with a medicine dropper and the dosage can be increased to obtain the contractions, just as oxitocyn would naturally do.

Other substances can be used such as prostaglandins, in vaginal ovules to dilate the neck of the uterus and provoke the contractions.

If at some point, these medicines over stimulate the uterus provoking contractions that are too lengthy and intense, the medicine drop is reduced and the doctor may opt for stopping it all together and practice an urgent cesarean.

When the pregnant woman has one or several signs that she is going into labor, she should go to the hospital or clinic she has selected to give birth to her baby. Upon arrival at the hospital, the midwife or doctor will ask her for the date of her expected delivery, the frequency of the contractions and if this is her first time or not. They will perform a medical check up to confirm the positioning of the baby and if the delivery has really begun or not.

 

After the check up, she will have to go through the admission procedure and provide her medical background. If the labor has begun, she will be placed in an individual or group dilation room, depending on the medical center. In most cases, she will be given an enema and she will be monitored.

Monitoring

Thanks to modern technology, the doctor can survey the condition of the baby and the mother during the delivery.

Monitoring is done through a cardio meter that records the values on a screen, prints them on paper and rings an alarm when there are anomalies.

Monitoring can be internal or external but in both cases, the same measurements are taken and the same records are kept.

•  External monitoring: by placing two sensors on a strap around the belly of the mother, the connection to the cardio meter records the heartbeats of the baby and measures the contractions of the uterus. This technique, although very reliable is slightly less so than the internal monitoring because even the slightest movement of the mother can affect the results.

•  Internal monitoring: it is done by placing an electrode on the head of the baby and a catherer inside the uterus. The data is more reliable because the movements of the mother do not affect the readings and the heart beat of the baby is recorded directly. The only inconvenience is that this technique can only be used after the membranes have broken.

The baby usually between 120 and 160 heartbeats per minute, that vary, slowing down during the contractions and returning to normal after them. If this does not occur, it may be an indication that the fetus is suffering and it may be necessary to use a forceps or to practice a Cesarean. Currently, most deliveries are monitored because this technique allows the doctor or midwife to act rapidly if there are any difficulties or anomalies.

Monitoring is absolutely essential in the case of high risk pregnancies, babies with very low weight or induced deliveries.

Fetal stress

This occurs when there is hypoxia, that is when there is little or low oxygen in the blood of the baby, if this situation goes on for too long, it may cause brain damage and, in extreme cases, the death of the baby.

This is caused by previous illnesses or hypertension of the mother, malformations of the baby or problems with the placenta. When labor has begun, fetal stress can be due to problems of the umbilical cord or of the contractions, or a decrease in the flow of blood into the uterus.

To prevent complications, the doctor should make all the necessary tests during the pregnancy and, by means of ecographies, he can compare the situation and growth of the baby. At the end of the pregnancy and at the beginning of labor, the monitoring of the mother allows to measure the contractions of the uterus and the heart beat of the baby to verify that there is no fetal stress. Another way of ruling out this possibility is to verify that there is no meconium in the amniotic fluid.

When the doctor detects that there is an alteration, he obtains a blood sample from the baby to measure the level of oxygen in it and, if its necessary to use a forceps of practice a cesarean. In this last case he can use epidural anesthesia so that the mother is conscious and can collaborate and see the birth of her baby.

1.5 THE POSITIONING OF THE BABY DURING THE DELIVERY

The baby moves freely within the uterus during the first six months but, as he grows in size, his mobility diminishes considerably. During the 7th month of the pregnancy, 96% of the babies usually have their head placed in the back of the uterus and between week 32 and 36, they rotate until their head is downwards and they maintain this position until the time of the delivery.

However, some babies do not rotate until a few days before their birth and some do not manage to turn, taking different positions that will influence on the delivery.

Doctors take into account three aspects to define the position of the baby at the time of birth:

The position , relating the axis of the spines of the mother and the baby. The situation can be:

•  Lengthwise, when the axis are parallel, either with the baby's head upwards or downwards. This is the most common situation.

•  Crosswise, when the baby is in a horizontal position, across the uterus. The head can be either on the left or the right side. This situation is less habitual and may require a cesarean.

•  Oblique , when the baby is in a diagonal position. This situation is even less common than the previous one.

The presentation is evaluated according to the part of the body of the baby placed in the mother's pelvis.

Cephalic , when the head of the baby is placed in the pelvis. It can be as follows:

•  Vertex . This is the ideal presentation and the most common. The baby places the tip of his head in the pelvis, and this way, helps the dilatation of the neck of the uterus.

•  Forehead . The baby places his neck backwards and places his forehead in the pelvis.

•  Face forward . The neck of the baby is flexed backwards and he places his chin or his face in the pelvis.

Buttocks , This position only occurs in about 3% of the births. It is more frequent when the mother has had other babies or if the baby is smaller than normal, when there is an excess of amniotic fluid or in the case of uterine malformations or when there are twin babies. This presentation can be complete or incomplete.

•  Complete, when the baby is placed as if he was seating on the belly of the mother, with flexed knees and hips and the buttocks and feet on the pelvis.

•  Incomplete, when the baby is seating with his legs extended upwards and his feet in front of his face.

Feet forward. In this presentation, the baby is placed with one or both feet on the neck of the uterus and in some cases, they are visible.

The position is defined by the orientation of the baby's back in relation to the body of the mother. In any presentation the face of the baby can be looking forward, backward or to either side.

Forward , when the spine of the baby is on the belly of the mother. This is the most adequate and common position
Backward , when the baby's spine is on the mother's. Although this position is not the most adequate, there are usually less complications during the delivery.

Turning the baby around.

Some doctors may try to rotate the baby when his buttocks are forward at the end of the 8th month. After giving the mother a relaxant, so that the uterus is distended, the doctor presses on the mother's belly with his hands trying to move the baby through the abdominal wall while monitoring the procedure with an ecography.

This maneuver is not done very frequently because the baby may rotate again and in some cases it can not be done (when the baby is too big, or placed in a lower area, if there are malformations of the uterus or there is little amniotic fluid), there is also the risk of injuring the placenta.

1.6 THE BIRTH

The experience of giving birth is different for each woman, and the same woman can have very different experiences each time she gives birth to a new baby. Most of the mothers have in common a slight feeling of sadness when they physically separate from the baby. This feeling, very normal, disappears as soon as they hold and see the baby for the first time.

The birth experience 

Against most common ideas, the boy or girl is not a passive participant in the process of birth, it is actually the baby who determines many of the factors that will start the labor. In fact, the last few weeks in the uterus, the baby is getting ready to face the challenges and risks that may affect the development and growth of his body and brain.

When the date of the delivery is near, the uterus grows to hold the baby to his maximum size. When they stop growing, the muscles of the walls of the uterus distend, increasing the irritability and the capacity to contract.

On one hand, the size of the baby stimulates the uterus to contract and, on the other, the baby goes down to the pelvis and his head presses down on the neck of the uterus activating nervous endings that send messages to the brain of the mother to produce oxitocyn, the hormone that stimulates the contractions of the uterus.

The baby indicates when the delivery will start by means of some complex biochemical activities. When his endocrine glands mature, the baby starts to produce hormones that start a series of chemical reactions that make the prostaglandin substances appear in the uterus that, along with the oxitocyn ensure the coordination of the contractions that dilate the neck of the uterus to ease the exit of the baby.

For the baby, birth is the first physical and emotional impact he experiences and, according to some research work, he never forgets it.

Many authors, such as Dr. Thomas Verny, consider that birth is a fundamental fact recorded in the personality. He argues that the way of being born, painful or easy, tranquil or violent, will determine to a great extent the baby's future personality and how he sees the world around him.

THE STAGES OF THE BIRTH

As we have explained, for the baby to be born in a natural way, efficient contractions are needed, as well as that the neck of the uterus dilates sufficiently and the head of the baby has to go through the pelvis of the mother.

All natural births develop in three stages: the first one, is dilatation, the second one is expelling and the third one is the delivery.

Dilatation stage

During the months before the birth, the neck of the uterus has an opening of about 3 cm . The contractions make the neck shorten and begin to dilate. The first time a woman gives birth the neck dilates about 1 cm per hour and in the following occasions, about 2 cm per hour. The dilatation is considered complete when the neck is about 10 cm wide.

In this stage, the contractions usually break the sack of fluid so that the head of the baby can exert direct pressure on the neck of the uterus. The duration of the period of dilatation depends on having efficient contractions, the placement of the head of the baby and the number of babies the mother has had before.

Doctors usually recommend that the mother goes to the hospital when the contractions take place every 5 minutes during one hour or when the sac of fluid breaks or the plug is expelled.

Expelling stage

When the neck of the uterus has reached its maximum width, and there are long and frequent contractions, the stage of expelling begins.

The mother is taken to the delivery room and is placed face up on the table, with her legs spread and the feet on special stirrups at the end of the table. Her pubic hair is shaved and, if she has any difficulties to urinate, a catherer is placed. If she has not been monitored, the sensors are placed and she is connected to the fetal monitor until the end of the delivery.

The midwife or obstetrician will give the mother a series of instructions so that her efforts are efficient. In each contraction, the woman must inhale deeply, hold her breath and push two or three times, relaxing until the next contraction.

The expelling stage can last between 40 and 60 minutes when it is the first time the woman gives birth and between 15 and 30 minutes when she has had other children.

During this stage, the baby progresses by stages. With the neck of the uterus fully dilated, the head starts to go out of the uterus and go through the pelvis and when the muscles that separate the vagina from the anus (the perineum) is distended, the vagina dilates and the head shows up through the vulva. When the head is free, the shoulders go out and finally, the rest of the body.

After the birth, normally, the midwife will place the baby on the belly of the mother so that he feels safer. Almost always, the baby is covered with a whitish layer called vernix caseosa, some blood and he is slightly purple in color.

Immediately after that, the umbilical cord is cut and two clamps are placed. At that time, the neonatologist will reanimate and check the new born. Whenever necessary, the baby will be placed in a thermal cradle to give him some warmth.

The episiotomy

Sometimes, the doctor finds it necessary to make a cut in the perineum to avoid the muscles to tear when the head of the baby goes through the vulva. This cut can be vertical or oblique.

•  Vertical when it is made from under the vulva towards the anus. It can be done this way when there is enough space. This cut is easier to saw and is less bothersome during the healing but it must be done very carefully to avoid harming the sphincter.

•  Oblique when the cut goes from under the vulva towards one of the buttocks. This is done when there is not enough space between the vulva and the anus.

The episiotomy is not painful in most cases and it is done when the head of the baby is too big for the opening of the vulva, when the perineum is too tense or too weak, if it is necessary to speed up or ease the delivery or when it is necessary to use a forceps.

After the placenta has been expelled, the tissues of the vagina and the perineum that were cut will be sown using local anesthesia, except when epidural anesthesia was used.

The childbirth stage

After the baby is born, comes the stage of delivery which consists of expelling the placenta.

Some minutes after the birth, the contractions start again but now they are less intense and painful. These contractions are to detach the placenta from the wall of the uterus and expel it outside.

When the birth has not been spontaneous, the doctor will withdraw the placenta by introducing his hand inside the uterus after applying anesthesia unless epidural anesthesia has been used.

After expelling the baby, it is normal for the mother to lose some blood but if the losses are large, it is considered as a delivery hemorrhage. In these cases, the doctors usually apply some anesthesia and artificially extract the placenta.

When the placenta is out, the doctor will examine it to verify that it is complete and that no remains have been left in the uterus.

After this process is over, the wound made during the episiotomy is sown and for a period of about two hours, the mother's temperature, blood pressure and losses of blood are controlled. If her evolution is correct, the mother is taken to her room after this time.

The normal thing is that the pregnancy and the birth go on without any difficulties and this happens in most cases.

Medical control during the pregnancy allows to predict any difficulties that may come up during the delivery and to set up a plan of action and, if necessary, to be ready to perform a Cesarean operation.

However, there can be complications that the medical team will have to evaluate and solve immediately.

•  TWISTED UMBILICAL CORD. In these cases, the umbilical cord rolls around the neck, legs, arms, chest or any other part of the body of the baby due to an excess of amniotic fluid or that the cord is too long.

Normally, the doctor will observe this in the ecographies during the pregnancy but it may only be detected when the mother is monitored prior to the delivery or during the expelling phase. In most cases it would be necessary to practice a Cesarean operation.

•  PROLAPSE OF THE CORD. This occurs when the umbilical cord comes out before the baby. It can be due to an excess of amniotic fluid, a premature birth or if it is necessary to puncture the membranes and the baby is positioned very high in the uterus.

In general, this is not discovered until the sac is broken. The cord may be compressed and reduce the supply of oxygen for the baby, and this is detected in the fetal monitor that will show the decrease of the heart beat; at times, the doctor does not observe it until he is checking the mother prior to the delivery. When the prolapse of the cord is observed, the doctor will proceed to conduct an emergency cesarean to avoid the risk of leaving the baby without an oxygen supply.

•  OBSTRUCTED CHANNEL. This problem that prevents the baby from being born can be caused by a disproportion between the size of the head of the baby and the size of the mother's pelvis, by tumors, cysts or other anomalies in the pelvis, ovaries, uterus or vagina. These complications are usually detected in the ecographies and the doctor opts to have a cesarean in most cases.

•  INEFFICIENT CONTRACTIONS. This occurs when the contractions do not happen as expected either because they are very weak, not very frequent or both. It can also happen that the rate of intensity is reversed and instead of being stronger in the upper half of the uterus they are in the lower part of the uterus, so that the dilatation is not effective and does not assist to the expel of the baby. In these cases, usually, the doctors prescribe an injection of oxitocyn.

•  PREVIOUS PLACENTA. The anomalies in the placenta are usually detected prior to the delivery but they may be discovered when it has begun.

This anomaly occurs when the placenta is placed in the exit area of the uterus, with the risk of obstructing the channel. This can occur when the placenta is bigger than normal or in multiple pregnancies. If the doctor observes that the placenta may block the exit, he may opt for a Cesarean operation.

•  DETACHMENT OF THE PLACENTA. Normally, this is detected during the pregnancy, when the mother feels that her abdomen is abnormally hard and the movements of the baby diminish. There may also be very dark blood in the vaginal secretion. At times, the detachment of the placenta is not detected until the mother is monitored upon arrival at the hospital. This complication occurs more often in multiple pregnancies, when the placenta is detached after the exit of one of the babies. If the woman has already gone into labor when the problem occurs, an emergency cesarean is performed.

CESAREAN OPERATION

In some pregnancies, the gynecologist considers it is necessary to schedule a cesarean operation but in many others this becomes an urgent option during the delivery. Of course, this is not the ideal form for a baby to be born but this intervention has saved millions of lives, both of mothers and babies.

Instances for a scheduled cesarean.

•  When in the ecography, it is confirmed that the head of the baby is larger than the mother's pelvis

•  If the baby is positioned in a crosswise position and when he is positioned on his buttocks.

•  In pregnancies of twins or multiple pregnancies if the first baby to be born is positioned on his buttocks.

•  If the baby is too weak to be born in the natural way or if there is delay in the birth.

•  In cases of previous placenta that obstructs the exit of the baby.

•  When there are scars on the uterus that may open with the effort of labor.

•  If the mother's genital organs are infected and it is necessary to prevent the baby from being in contact with them.

•  In case of illness of the mother, hypertension, or any other health problem.

As we saw in the previous chapter, there can be unexpected difficulties during the delivery that have not been detected in the ecographies and that may require an urgent cesarean.

In some hospitals, the mother is then taken from the delivery room to the operating room and in others the intervention is done right in the same room because it is fully equipped for these contingencies.

 

Anesthesia

There are three kinds of anesthesia for a cesarean, general, epidural or rachidean. If the intervention has been scheduled ahead of time, besides the preferences of the mother, the opinion of the anesthesist must be taken into account. When the doctor has decided to perform a cesarean because there have been complications during labor, the choice of anesthesia depends on the urgency of the operation.

Development

The intervention lasts between 45 and 60 minutes. Before starting, the mother's pubis is shaved and a catherer is placed to empty her bladder. Almost always, a horizontal cut is made above the pubis (more aesthetical than a vertical cut). The vertical cut is only used in extremely urgent procedures and when there is a previous scar, it is done in the same place.

To take the baby out of the uterus is a relatively short procedure and after that, the placenta is withdrawn, the open tissues are closed and the skin is sown. The doctor has to place some drainage in the abdominal muscles to avoid hematomas and he takes it out a few days later. The stitches are taken out 8 to 10 days after the operation.

A few hours after the operation or the next day at the latest, the mother should get up and walk to help blood circulation and two or three days later she can move almost normally.

Women who have given birth by cesarean due to the size of their pelvis will probably need cesareans again in future deliveries, but in many other cases (about 50% of the women who have given birth by cesarean) can have their following deliveries the natural way. The cesarean does not prevent breastfeeding, it may delay it a few hours if general anesthesia was used. A woman can have five or six deliveries by cesarean but there should be at least a year between each birth if there is the possibility of a natural birth.