Childbirth, also known as labour and delivery, is the ending of a pregnancy by one or more babies leaving a woman's uterus by vaginal passage or C-section. In 2015 there were about 135 million births globally. About 15 million were born before 37 weeks of gestation, while between 3 and 12% were born after 42 weeks. In the developed world most deliveries occur in hospital, while in the developing world most births take place at home with the support of a traditional birth attendant. The most common way of childbirth is a vaginal delivery. It involves three stages of labour: the shortening and opening of the cervix, descent and birth of the baby, and the delivery of the placenta. The first stage typically lasts twelve to nineteen hours, the second stage twenty minutes to two hours, and the third stage five to thirty minutes. The first stage begins with crampy abdominal or back pains that last around half a minute and occur every ten to thirty minutes. The crampy pains become stronger and closer together over time. During the second stage pushing with contractions may occur. In the third stage delayed clamping of the umbilical cord is generally recommended. A number of methods can help with pain such as relaxation techniques, opioids, and spinal blocks. Most babies are born head first; however about 4% are born feet or buttock first, known as breech. During labour a woman can generally eat and move around as she likes, but pushing is not recommended during the first stage or during delivery of the head, and enemas are not recommended. While making a cut to the opening of the vagina, known as an episiotomy is common, it is generally not needed. In 2012, about 23 million deliveries occurred by a surgical procedure known as Caesarean section. Caesarean sections may be recommended for twins, signs of distress in the baby, or breech position. This method of delivery can take longer to heal from. Each year, complications from pregnancy and childbirth result in about 500,000 maternal deaths, 7 million women have serious long term problems, and 50 million women have health negative outcomes following delivery. Most of these occur in the developing world. Specific complications include obstructed labour, postpartum bleeding, eclampsia, and postpartum infection. Complications in the baby include birth asphyxia.
Signs and symptoms, fibula showing a woman giving birth between 2 antelopes, ornamented with flowers, Iranian, 1000 to 650 BCE) at the Louvre museum]] The most prominent sign of labour is strong repetitive uterine contractions. The distress levels reported by labouring women vary widely. They appear to be influenced by fear and anxiety levels, experience with prior childbirth, cultural ideas of childbirth and pain, mobility during labour, and the support received during labour. Personal expectations, the amount of support from caregivers, quality of the caregiver-patient relationship, and involvement in decision-making 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.
DescriptionsPain in contractions has been described as feeling similar to very strong menstrual cramps. Women are often encouraged to refrain from screaming, but moaning and grunting may be encouraged to help lessen pain. Crowning may be experienced as an intense stretching and burning. Even women who show little reaction to labour pains, in comparison to other women, show a substantially severe reaction to crowning. Back labour is a term for specific pain occurring in the lower back, just above the tailbone, during childbirth.Harms, Rogert W. Does back labor really happen? , mayoclinic.com, Retrieved 8 September 2014
PsychologicalChildbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface. Abnormal and persistent fear of childbirth is known as tokophobia. The prevalence of fear of childbirth around the world ranges between 4-25%, with 3-7% of pregnant women having clinical fear of childbirth.Jaju S, Al Kharusi L, Gowri V. Antenatal prevalence of fear associated with childbirth and depressed mood in primigravid women. Indian journal of psychiatry. 2015 Apr;57(2):15Lukasse M, Schei B, Ryding EL, Bidens Study Group. Prevalence and associated factors of fear of childbirth in six European countries. Sexual & Reproductive Healthcare. 2014 Oct 31;5(3):99-106. During the later stages of gestation there is an increase in abundance of oxytocin, a hormone that is known to evoke feelings of contentment, reductions in anxiety, and feelings of calmness and security around the mate. Oxytocin is further released during labour when the fetus stimulates the cervix and vagina, and it is believed that it plays a major role in the bonding of a mother to her infant and in the establishment of maternal behavior. The act of nursing a child also causes a release of oxytocin. Between 70% and 80% of mothers in the United States report some feelings of sadness or "baby blues" after giving birth. The symptoms normally occur for a few minutes up to few hours each day and they should lessen and disappear within two weeks after delivery. Postpartum depression may develop in some women; about 10% of mothers in the United States are diagnosed with this condition. Preventive group therapy has proven effective as a prophylactic treatment for postpartum depression.
Vaginal birthHumans are bipedal with an erect stance. 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, in women, three channels to pass through it: the urethra, the vagina and the rectum. The infant's head and shoulders must go through a specific sequence of maneuvers in order to pass through the ring of the mother's pelvis. Six phases of a typical vertex (head-first presentation) delivery:
- 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.
- Descent and flexion of the fetal head.
- 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.
- 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.
- Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.
- External rotation. The shoulders repeat the corkscrew movements of the head, which can be seen in the final movements of the fetal head.
Onset of labourThere are various definitions of the onset of labour, including:
- Regular uterine contractions at least every six minutes with evidence of change in cervical dilation or cervical effacement between consecutive digital examinations.
- Regular contractions occurring less than 10 min apart and progressive cervical dilation or cervical effacement.
- At least 3 painful regular uterine contractions during a 10-minute period, each lasting more than 45 seconds.
First stage: latent phaseThe latent phase of labour is also called the quiescent phase, prodromal labour, or pre-labour. It is a subclassification of the first stage. The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. In contrast, Braxton Hicks contractions, which are contractions that may start around 26 weeks gestation and are sometimes called "false labour", should be infrequent, irregular, and involve only mild cramping. The signaling mechanisms responsible for uterine coordination are complex. Electrical propagation is the primary mechanism used for signaling up to several centimeters. Over longer distances, however, signaling may involve a mechanical mechanism. Cervical effacement, which is the thinning and stretching of the cervix, and cervical dilation occur during the closing weeks of pregnancy and is usually complete or near complete, by the end of the latent phase. The degree of cervical effacement may be felt during a vaginal examination. A 'long' cervix implies that effacement has not yet occurred. Latent phase ends with the onset of active first stage, and this transition is defined retrospectively.
First stage: active phaseThe active stage of labour (or "active phase of first stage" if the previous phase is termed "latent phase of first stage") has geographically differing definitions. In the US, the definition of active labour was changed from 3 to 4 cm, to 5 cm of cervical dilation for multiparous women, mothers who had given birth previously, and at 6 cm for nulliparous women, those who had not given birth before. Obstetric Data Definitions Issues and Rationale for Change , 2012 by ACOG. This has been done in an effort to increase the rates of vaginal delivery. A definition of active labour in a British journal was having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more. In Sweden, the onset of the active phase of labour is defined as when two of the following criteria are met: Sjukvårdsrådgivningen (In Swedish) - Official information of the County Councils of Sweden. Last updated: 2013-01-16. Reviewer: Roland Boij, gynecologist and obstetrician
- three to four contractions every ten minutes
- rupture of membranes
- cervical dilation of 3 to 4 cm
Second stage: fetal expulsionThe expulsion stage (stimulated by prostaglandins and oxytocin) begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, women may have the sensation of pelvic pressure and an urge to begin pushing. 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 (opening). This is assisted by the additional maternal efforts of "bearing down" or pushing. The appearance of the fetal head at the vaginal orifice is termed the "crowning". At this point, the woman will feel an intense burning or stinging sensation. 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 "delivery en caul". Complete expulsion of the baby signals the successful completion of the second stage of labour. The second stage of birth will vary by factors including parity (the number of children a woman has had), fetal size, anesthesia, and the presence of infection. Longer labours are associated with declining rates of spontaneous vaginal delivery and increasing rates of infection, perineal laceration, and obstetric hemorrhage, as well as the need for intensive care of the neonate.
Third stage: placenta deliveryready to be clamped]] The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage. Placental expulsion begins as a physiological separation from the wall of the uterus. 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. 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. Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance. Active management is described as the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, followed by performance of uterine massage every 15 minutes for two hours. In a joint statement, World Health Organization, the International Federation of Gynaecology and Obstetrics and the International Confederation of Midwives recommend active management of the third stage of labour in all vaginal deliveries to help to prevent postpartum hemorrhage. Delaying the clamping of the umbilical cord until at least one minute after birth improves outcomes as long as there is the ability to treat jaundice if it occurs. In some birthing centers, this may be delayed by 5 minutes or more, or omitted entirely. Delayed clamping of the cord decreases the risk of anemia but may increase risk of jaundice. Clamping is followed by cutting of the cord, which is painless due to the absence of nerves.
Fourth stageThe "fourth stage of labour" is the period beginning immediately after the birth of a child and extending for about six weeks. The terms postpartum and postnatal are often used to describe this period. The woman's body, including hormone levels and uterus size, return to a non-pregnant state and the newborn adjusts to life outside the mother's body. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period. Following the birth, if the mother had an episiotomy or a tearing of the perineum, it is stitched. The mother has regular assessments for uterine contraction and fundal height, vaginal bleeding, heart rate and blood pressure, and temperature, for the first 24 hours after birth. The first passing of urine should be documented within 6 hours. Afterpains (pains similar to menstrual cramps), contractions of the uterus to prevent excessive blood flow, continue for several days. Vaginal discharge, termed "lochia", can be expected to continue for several weeks; initially bright red, it gradually becomes pink, changing to brown, and finally to yellow or white. Some women experience an uncontrolled episode of shivering or postpartum chills, after the birth. Most authorities suggest the infant be placed in skin-to-skin contact with the mother for 1 –2 hours immediately after birth, putting routine cares off till later. Until recently babies born in hospitals were removed from their mothers shortly after birth and brought to the mother only at feeding times. Mothers were told that their newborn would be safer in the nursery and that the separation would offer the mother more time to rest. As attitudes began to change, some hospitals offered a "rooming in" option wherein after a period of routine hospital procedures and observation, the infant could be allowed to share the mother's room. However, more recent information has begun to question the standard practice of removing the newborn immediately postpartum for routine postnatal procedures before being returned to the mother. Beginning around 2000, some authorities began to suggest that early skin-to-skin contact (placing the naked baby on the mother's chest) may benefit both mother and infant. Using animal studies that have shown that the intimate contact inherent in skin-to-skin contact promotes neurobehaviors that result in the fulfillment of basic biological needs as a model, recent studies have been done to assess what, if any, advantages may be associated with early skin-to-skin contact for human mothers and their babies. A 2011 medical review looked at existing studies and found that early skin-to-skin contact, sometimes called kangaroo care, resulted in improved breastfeeding outcomes, cardio-respiratory stability, and a decrease in infant crying. A 2016 Cochrane review found that skin-to-skin contact at birth promotes the likelihood and effectiveness of breastfeeding. Evidence on physiological outcomes, such as crying or temperature was unclear. As of 2014, early postpartum skin-to-skin contact is endorsed by all major organizations that are responsible for the well-being of infants, including the American Academy of Pediatrics. The World Health Organization (WHO) states that "the process of childbirth is not finished until the baby has safely transferred from placental to mammary nutrition." They advise that the newborn be placed skin-to-skin with the mother, postponing any routine procedures for at least one to two hours. The WHO suggests that any initial observations of the infant can be done while the infant remains close to the mother, saying that even a brief separation before the baby has had its first feed can disturb the bonding process. They further advise frequent skin-to-skin contact as much as possible during the first days after delivery, especially if it was interrupted for some reason after the delivery. The National Institute for Health and Care Excellence also advises postponing procedures such as weighing, measuring, and bathing for at least 1 hour to insure an initial period of skin-to-skin contact between mother and infant.
ManagementDeliveries are assisted by a number of professionals including: obstetricians, family physicians and midwives. For low risk pregnancies all three result in similar outcomes.
PreparationEating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes, 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. A 2013 Cochrane review found that with good obstetrical anaesthesia there is no change in harms from allowing eating and drinking during labour in those who are unlikely to need surgery. They additionally acknowledge that not eating does not mean there is an empty stomach or that its contents are not as acidic. They therefore conclude that "women should be free to eat and drink in labour, or not, as they wish." At one time shaving of the area around the vagina, was common practice due to the belief that hair removal reduced the risk of infection, made an episiotomy (a surgical cut to enlarge the vaginal entrance) easier, and helped with instrumental deliveries. It is currently less common, though it is still a routine procedure in some countries even though a systematic review found no evidence to recommend shaving. Side effects appear later, including irritation, redness, and multiple superficial scratches from the razor. Another effort to prevent infection has been the use of the antiseptic chlorhexidine or providone-iodine solution in the vagina. Evidence of benefit with chlorhexidine is lacking. A decreased risk is found with providone-iodine when a cesarean section is to be performed.
Active managementActive management of labour consists of a number of care principles, including frequent assessment of cervical dilatation. If the cervix is not dilating, oxytocin is offered. This management results in a slightly reduced number of caesarean births, but does not change how many women have assisted vaginal births. 75% of women report that they are very satisfied with either active management or normal care.
Labour induction and elective cesarean.]] In many cases and with increasing frequency, childbirth is achieved through induction of labour or caesarean section. Caesarean section is the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth. 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. Induced births and elective cesarean before 39 weeks can be harmful to the neonate as well as harmful or without benefit to the mother. Therefore, many guidelines recommend against non-medically required induced births and elective cesarean before 39 weeks. The rate of labour induction in the United States is 22%, and has more than doubled from 1990 to 2006. Health conditions that may warrant induced labour or cesarean delivery include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and post-term pregnancy. Cesarean section too may be of benefit to both the mother and baby for certain indications including maternal HIV/AIDS, fetal abnormality, breech position, fetal distress, multiple gestations, and maternal medical conditions which would be worsened by labour or vaginal birth. Pitocin is the most commonly used agent for induction in the United States, and is used to induce uterine contractions. Other methods of inducing labour include stripping of the amniotic membrane, artificial rupturing of the amniotic sac (called amniotomy), or nipple stimulation. Ripening of the cervix can be accomplished with the placement of a Foley catheter or the use of synthetic prostaglandins such as misoprostol. A large review of methods of induction was published in 2011. The American Congress 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 optimal health of the newborn when considering elective induction of labour. Per these guidelines, the following conditions may be an indication for induction, including:
- Abruptio placentae
- Fetal compromise such as isoimmunization leading to hemolytic disease of the newborn or oligohydramnios
- Fetal demise
- Gestational hypertension
- Maternal conditions such as gestational diabetes or chronic kidney disease
- Preeclampsia or eclampsia
- Premature rupture of membranes
- Postterm pregnancy
Non pharmaceuticalSome women prefer to avoid analgesic medication during childbirth. Psychological preparation may be beneficial. Relaxation techniques, immersion in water, massage, and acupuncture may provide pain relief. Acupuncture and relaxation were found to decrease the number of caesarean sections required. Immersion in water has been found to relieve pain during the first stage of labor and to reduce the need for anesthesia and shorten the duration of labor, however the safety and efficacy of immersion during birth, water birth, has not been established or associated with maternal or fetal benefit. Some women like to have someone to support them during labour and birth; such as a midwife, nurse, or doula; or a lay person such as the father of the baby, a family member, or a close friend. Studies have found that continuous support during labor and delivery reduce the need for medication and a caesarean or operative vaginal delivery, and result in an improved Apgar score for the infant. The injection of small amounts of sterile water into or just below the skin at several points on the back has been a method tried to reduce labour pain, but no good evidence shows that it actually helps.
PharmaceuticalDifferent 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 53% nitrous oxide, 47% oxygen, known as Entonox; in the UK, midwives may use this gas without a doctor's prescription. Opioids such as fentanyl may be used, 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 epidurals (EDA), 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. Generally, pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but rise again later. Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. 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.
AugmentationAugmentation 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 labour. loop.]] Administration of antispasmodics (e.g. hyoscine butylbromide) is not formally regarded as augmentation of labour; however, there is weak evidence that they may shorten labour. There is not enough evidence to make conclusions about unwanted effects in mothers or babies.
EpisiotomyVaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum (episiotomy) to make the baby's birth easier and prevent severe tears that can be difficult to repair. A 2017 Cochrane review compared episiotomy as needed (restrictive) with routine episiotomy to determine the possible benefits and harms for mother and baby. The review found that restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth.
Instrumental deliveryObstetric forceps or ventouse may be used to facilitate childbirth.
Multiple birthsIn cases of a head first-presenting first twin, 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.
SupportHistorically women have been attended and supported by other women during labour and birth. However currently, as more women are giving birth in a hospital rather than at home, continuous support has become the exception rather than the norm. When women became pregnant any time before the 1950s the husband would not be in the birthing room. It did not matter if it was a home birth; the husband was waiting downstairs or in another room in the home. If it was in a hospital then the husband was in the waiting room. "Her husband was attentive and kind, but, Kirby concluded, Every good woman needs a companion of her own sex." Obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. Supportive care during labour may involve emotional support, comfort measures, and information and advocacy which may promote the physical process of labour as well as women's feelings of control and competence, thus reducing the need for obstetric intervention. The continuous support may be provided either by hospital staff such as nurses or midwives, doulas, or by companions of the woman's choice from her social network. 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. A recent Cochrane review involving more than 15,000 women in a wide range of settings and circumstances found that "Women who received continuous labour support were more likely to give birth 'spontaneously', i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. Their babies were less likely to have low five-minute Apgar scores."
External monitoringFor monitoring of the fetus during childbirth, a simple pinard stethoscope or doppler fetal monitor (" doptone") can be used. A method of external (noninvasive) fetal monitoring (EFM) during childbirth is cardiotocography, using a cardiotocograph that consists of two sensors: The heart (cardio) sensor is an 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. Online version accessed. Monitoring with a cardiotocograph can either be intermittent or continuous.
Internal monitoringA mother's water has to break before internal (invasive) monitoring can be used. More invasive monitoring can involve a fetal scalp electrode to give an additional measure of fetal heart activity, and/or intrauterine pressure catheter (IUPC). It can also involve fetal scalp pH testing.
Collecting stem cellsIt is currently possible to collect two types of stem cells during childbirth: amniotic stem cells and umbilical cord blood stem cells. They are being studied as possible treatments of a number of conditions.
Complicationsfor maternal conditions per 100,000 inhabitants in 2004. ]] for perinatal conditions per 100,000 inhabitants in 2004. ]] The "natural" maternal mortality rate of childbirth—where nothing is done to avert maternal death—has been estimated at 1500 deaths per 100,000 births. (See main articles: neonatal death, maternal death). Each year about 500,000 women die due to pregnancy, 7 million have serious long term complications, and 50 million have negative outcomes following delivery. Modern medicine has decreased the risk of childbirth complications. In Western countries, such as the United States and Sweden, the current maternal mortality rate is around 10 deaths per 100,000 births. As of June 2011, about one third of American births have some complications, "many of which are directly related to the mother's health." Birthing complications may be maternal or fetal, and long term or short term.
Pre-termNewborn 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"). Researchers found benefits to going full term and "no adverse effects" in the health of the mothers or babies. 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. The American Congress 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-labour at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labour cesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery before 39 weeks.
Labour complicationsThe second stage of labour may be delayed or lengthy due to:
- malpresentation ( breech birth (i.e. buttocks or feet first), face, brow, or other)
- failure of descent of the fetal head through the pelvic brim or the interspinous diameter
- poor uterine contraction strength
- active phase arrest
- cephalo-pelvic disproportion (CPD)
- shoulder dystocia
Obstructed labourObstructed labour, also known as labor dystocia, is when, even though the uterus is contracting normally, the baby does not exit the pelvis during childbirth due to being physically blocked. Prolonged obstructed labor can result in obstetric fistula, a complication of childbirth where tissue death preforates the rectum or bladder.
Maternal complicationsVaginal 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 .
- 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.
Mechanical fetal injuryRisk 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.
Neonatal infectionfor 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. ]] 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 before 37 weeks gestation)
- a sibling who has had a GBS infection
- prolonged labour or rupture of membranes
Neonatal deathInfant 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). 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. 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 asphyxiaIntrapartum 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.
Society and cultureChildbirth 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. 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). 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.
FacilitiesFollowing are facilities that are particularly intended to house women during childbirth:
- A labour ward, also called a delivery ward or labour and delivery, 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 maternity hospital is a hospital that specializes in caring for women while they are pregnant and during childbirth and provide care for newborn infants,
- A birthing center generally presents a simulated home-like environment. Birthing centers may be located on hospital grounds or "free standing" (i.e., not hospital-affiliated).