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Birth of a Child
Introduction

Birth is the act of expelling the young from the mother's body the emergence from the mother's womb (uterus) marking the beginning of an independent life. The birth process is triggered by hormonal changes in the woman's bloodstream.

Mild labor pain (contractions of the muscles of the uterus) is usually the first sign that a woman is about to give birth. This is the fist stage of labor, usually l

asting about 14 hours. The contractions push the baby downwards, usually head first, which breaks the membranes surrounding the baby, and the amniotic fluid escapes. (Sometimes however, the 'waters' break before there are any contractions.)

In the second stage of labor, stronger contractions push the baby through the cervix and vagina (the birth canal). This is the most painful part and us

ually lasts less than two hours. Anesthetics or analgesics are often given, and delivery aided by hand or obstetric forceps. A Caesarean section (surgical removal of the baby) may be performed if great difficulty occurs. Some women choose natural childbirth in which no painkillers are used, but pain is minimized by the distraction of relaxation exercises. As soon as the baby is born, its nose and mouth are cleared of fluid and breathing starts, whereupon the umbilical cord is cut and tied.

In the third stage of labor, the placenta is expelled from the uterus and bleeding is stopped by further contractions.

There are three stage of labor. In the first, the cervix gradually opens up (dilates). In the second stage, the baby is pushed down the vagina and is born. And in the third stage, the placenta comes away from the wall of the uterus and is also pushed out of the vagina.

The cervix is usually closed at the start of labor (1). Gradually the contractions opens it (2) until it is about 10 cm (4in) in diameter. It is then called 'fully dilated- that is, open wide enough to let the baby through. Gradually the contractions will become stronger and more painful. The relaxation and breathing techniques learned during pregnancy can now be really helpful. Towards the end of the first stage, as each contraction

comes, the woman may begin to feel that she wants to push. The midwife or doctor will tell the woman when her cervix is fully dilated and the baby's head is showing. The second stage does not last very long- probably about one to two hours, although it varies a lot. The baby's head moves down the vagina until it 'crowns', that is, when about half of the head can be seen at the vaginal opening (3). Then the doctor or midwife will tell the woman to stop pushing, or to push very gently, and to pant in quick, short breaths, in and out through the mouth. The skin and muscle of the perineum (the area between the vagina and back passage) becomes very stretched as the baby's head is born, and this sometimes tears. If the head is born slowly, the skin has more chance to stretch and often a tear can be avoided.

Once the head is born (4), most of the hard work is over. With one more gentle push, the rest of the body is born quite quickly and easily (5).

Child Birth I
First stage

It is usually difficult to determine with any accuracy when labor begins. Established labor is characterized by regular coordinated uterine contractions, which become progressively more painful. However, some women may have apparently strong uterine contractions that do not develop into established labor, and it is impossible to distinguish these false labor pains from true labor other than by observation over a period of hours to see if they are progressive. It addition, a small minority have no first-stage-of-labor pains at all. Initially, though, contractions are often felt as a dull ache low in the back but later they become more severe and are felt most in the lower abdomen.

The onset of painful uterine contractions may be preceded by a vaginal discharge of blood and mucus, often referred to as a 'show'. This may vary from a slight pink discharge to obvious bleeding and is due to the cervix beginning to soften, so allowing the cervical plug of mucus to escape into the vagina. It may be difficult to distinguish between a heavy show and hemorrhage due to separation of the placenta from the uterus wall. In a minority of women the onset of uterine contractions may coincide with, or be preceded by, rupture of the foetal membranes and the escape of amniotic fluid via the vagina- the 'breaking of the water'. It is not known why the membranes should rupture early in labor in some woman while in the majority they remain intact until the second stage. Rupture of the membranes is usually followed by the onset of uterine contractions within 24 hours.

As the first stage of labor progresses, uterine contractions increase in strength and frequency. In well-established labor, contractions should occur every two to four minutes and last 40-60 second. Less frequent or shorter contractions may be relatively ineffective contractions may be harmful to the foetus.

The attending midwife or doctor has three responsibilities during the conduct of the first stage of delivery:
1. To detect early sign of impending danger to the foetus by regular listening to the foetal heart and the inspection of amniotic fluid.
2. To ensure that the mother is as comfortable as possible and is not at unnecessary risk.
3. To observe that steady progress in terms of dilation of the cervix and descent to the head is being made. Descent of the head is usually recognized by abdominal palpation but it may be necessary to repeat the vaginal examination.

The average duration of the first stage of normal labor for a first child is about 14 hours, and is usually 7-8 hours for the second and following children. However, there is a wide variation in its length and pattern. The rate of dilation of the cervix is not even.

Child Birth II
Labor Pain
Second stage
Towards the end of the first stage the character of the contractions alters. As the head reaches the pelvic floor it stimulates a reflex, a sensation to bear down during each uterine contraction. Most women welcome this change because they feel that they can actively help to expel the baby. However, if this sensation occurs before the cervix is fully dilated, this impulse should be resisted because any attempt to expel the baby before full dilation may result in the cervix being pushed down the birth canal in front of the head, where it becomes trapped. This desire to bear down is often accompanied by a desire to defecate. As the cervix reaches full dilation small tears may occur and cause slight bleeding. Furthermore, the membranes commonly rupture spontaneously.

Consequently, the signs, which heralds the onset of the second stage are:
1. The desire to bear down and possibly defecate.
2. Vaginal bleeding.
3. Spontaneous rupture of the membranes.

If these features are missed, the next sign may be bulging and gaping of the vagina and appearance of the foetal head. The importance in recognizing the onset of the second stage is to allow time to prepare for delivery and to access the rate of progress.

The position the woman adopts for delivery is largely one of custom and convenience. In many primitive cultures, women deliver in the crouched, squatting position that adds gravity to the force of uterine contractions. This position is becoming more and more popular among European women. In most Western countries, women deliver lying on their backs with their legs open and held up in stirrups. This position is relatively comfortable for the woman and, perhaps more significant, convenient for the attendants.

During each uterine contraction, the woman is encouraged to bear down for as long as possible at each contraction. When the head shows at the entrance of the vagina, the perineum (the skin area between the vagina and anus) is swabbed with an antiseptic solution, and the legs and thighs are draped with sterile towels. After the head first appears, it usually advances with each contraction and retreats less each time until the skin of the perineum stretches thinly; this stage is often called the 'crowning' of the head. If the perineum becomes very stretched and looks as if it may tear, a small relieving incision or episiotomies is made.

And episiotomies may minimize damage to the perineum, reduce the length of the second stage and possibly prevent damage to the fetal head by prolonged arrest on the pelvic floor. However, episiotomies may also cause substantial bleeding and its repair can cause extreme discomfort in the puerperium (the six-week period following delivery).

As the head is delivered, the perineum is supported by a pad held in the right hand of the attendant while the fingers of the left grasp the top of the head of the baby to control its delivery. Every effort is being made by the midwife or doctor to ensure slow delivery of the head by obtaining the woman's cooperation, because a rapid, uncontrolled delivery of the head may cause brain damage and tear the perineum severely. It is often possible to delivery the head gently between contractions.

Once the head is delivered, the midwife or doctor uses a finger to feel if there is a loop of umbilical cord around the neck of the baby. After the head has rotated externally it is grasped between the palms of the hands without exerting pressure on any one area.

By exerting pressure from the back during the next uterine contraction, the shoulder in front can be induced to slip out. The head is then lifted so that the shoulder in the back and the rest of the baby follows.

When the baby has been delivered, it usually cries spontaneously, taking several deep breaths that expand its lungs. The umbilical cord is clamped in two places and then cut, and the umbilical stump is safely secured either by a rubber band or by a small disposable plastic clamp. There is considerable argument over the optimal time at which the cord should be clamped. At the time of delivery the blood volume of the infant is about 300 ml (just over 1/2 pint), another volume of 100 ml (about 3 1/2 fl. oz) of blood is trapped within the placenta. If clamping of the cord is delayed for a few minutes and the infant is held at a level below the uterus, a major part of the placental blood volume is transferred to the infant; conversely, immediate clamping withholds this volume of blood from the infant.

The average duration of the second stage is about 50 minutes (maximum about two hours) in women who deliver for the first time and about 20-25 minutes in other women.

Child Birth III
Labor Pain
Third stage
Immediately following delivery of the baby, the upper part of the uterus may be felt just below the navel. Contractions of the uterus continue intermittently and the placenta separates and descends into the lower part of the uterus and vagina. Placental separation usually occurs within three to four minutes of delivery but is expulsion from the uterus may be delayed longer either by weakness of the uterus muscles or by being held in place by uterine spasm.

After delivery of the infant, there is usually a steady trickle of blood from the vagina and, when the placenta separates, an additional gush of blood. Descent of the placenta is indicated by the lengthening of the umbilical cord. When the placenta is expelled from the uterus, a length of about 75 mm (3 in) of cord descends with it. At the same time the uterus assumes a globular shape and rises to a slightly higher level in the abdomen, at or just below the navel.

The classical signs of placental separation and descent are:
1. Fresh vaginal bleeding.
2. Lengthening of the umbilical cord.
3. Change in the shape and height of the uterus.

Relief of pain in labor

Labor is almost invariably painful but the enthusiasm with which midwives and doctors attempt to relieve this pain varies widely throughout the world. Many women demand and are given painless labor by the regular use of regional and inhalation anesthesia. Others labor without anesthesia or with only small doses of the narcotic pain reliever.

All the analgesic and anesthetic agents in routine use (except spinal anesthetics) freely cross the placenta and may affect the fetus. Unfortunately most of them cause a slowing of breathing. Although this is usually insignificant in the woman, it may be critical for the fetus at the time of delivery when there must be a rapid and efficient transition from breathing via the placenta to breathing via the lungs.

The fetus may also be influenced by the actions of anesthetics on the woman. Thus use of some inhalation analgesics such as a mixture of nitrous oxide and air ('gas and air)' may reduce the oxygen content of air breathed in, while methods that induce maternal hypertension (lowering of blood pressure) may reduce the amount of blood going to the placenta. These fetal hazards are aggravated if the fetus is already at risk, either because of some prolonged complication such as high blood pressure, or by an episode of hypoxia (decrease of oxygen in the blood).

Regional anesthesia (numbing of only specific part of the body) can be achieved in various ways. The pain of labor is transmitted by sensory fibers from the uterus and cervix that enter the spinal cord at the lower thoracic and upper lumbar levels. The pain experienced at the time of delivery is transmitted mainly by the nerves of the vulva and perineum (those in the area between the legs). Consequently a nerve block can be effective if made in the epidural space of the spine up to the level of the tenth thoracic segment. Low spinal anesthesia involves the injection of a local anesthetic into the cerebrospinal fluid (that which surrounds the spinal cord), but this method often causes headache. Epidural anesthesia (where an injection is made near the spinal canal but not into it) has less risk of causing headache and is easier to control. Most local anesthetics are effective for only one or two hours.