Dr Girija Wagh, Obstetrician, Gynecologist, IVF expertMD, FICOG, DIP ENDO, FICS
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Delivery of the baby is a natural process which is scientifically classified for a better understanding of the process and to deliver mothers and babies safely through it. The labour is divided into 3 stages and let us see what this means here.
Stages of labour : the delivery process has well-defined sections called the stages
The stages of labour are well identified and defined and this wisdom has been a result of scientific observation of the labor processes over many years. Doctors catering to pregnancy-related situations and especially the delivery related issues are called as obstetricians. Obstetrics is a science of pregnancy and delivery. Obstetrics is a skill science and the obstetricians have to be specialised in these skills.
The delivery process is divided into parts and this helps the birthing attendants to correctly document and monitor the proceedings, identify abnormalities and to ensure safe delivery. This has to be a process because the womb(uterus) which has been holding the baby during pregnancy now has to first gently and then firmly deliver the baby outside. This is possible by the squeezing of the womb which is called as contraction perceived as a labour pain by the mother and the gradual opening of the womb neck (called the cervix) by the process which is called as dilatation. Thus the womb which was quiet and silent, gradually growing to accommodate the growing baby and holding it with a firmly closed cervix( the opening of the womb ) with a quiet stance now has to double up into a vehicle which will guide and push the baby through the delivery tract which is made up of the bony pelvic girdle, pelvic muscles and the vagina.
The birthing process is divided into three stages as under
The first stage: during which the womb opening the cervix opens to allow the baby to pass through
The second stage: when the baby negotiates the mothers bony and soft tissues and finally is delivered outside of her body to take its first breath and cry
The third stage: when the placenta and the membranes are delivered out of the uterus (womb ) and the womb tries to close up after delivery
The fourth stage: is the stage of observation after delivery has completed where the mother’s and the baby’s vitals ( pulse rate, blood pressure, respiration rate, bleeding ) are checked and breastfeeding is initiated.
There is a preparatory phase before the actual labour begins. During this phase, the Braxton Hicks contractions ( painless firming up of the womb perceived towards the end of pregnancy ) become more profound. The mother perceives mild pain, heaviness in the lower side of the tummy and some changes in the vaginal secretions. Back pain can also be associated along with tightening of the womb.
During the first stage, the womb contracts periodically and progressively help in pushing the baby towards the lower delivery tract and also causes the cervix to open out. This phase takes a while and has two passes. The latent phase is the time when the tightenings ( contractions ) of the womb are milder occurring at regular frequency but maybe only about 2 or so in an hours time and lasting for about 20 to 25 seconds. These gradually start growing in duration and intensity and help in opening the cervix which is called as cervical dilatation. This process of cervical dilation is further enhanced by the pressure from the baby through the bag of waters and thus the womb gradually opens to facilitate the delivery of the baby.
Inside the womb, the baby is surrounded by fluid which is called as amniotic fluid or liquor amni. This is meant to protect the baby from the pressure of the firm womb and allows it to move about and swallow. This fluid is actually the result of baby’s urine and also helps during the delivery process. The womb contraction force is equally distributed due to the fluid and thus ensures the smooth dilation of the cervix. This fluid in encompassed by special lining tissue which is very delicate and smooth and turns into a tense bag during labour. It is a sign of progressive cervical dilation. This bag ruptures spontaneously or is ruptured deliberately. This helps labour progression and assessment of the baby’s wellbeing.
When the womb completely opens up which is assessed as fully dilated cervix, the second stage begins. The baby’s head now enters the pelvic girdle which is made up of the bony pelvis, soft tissues and muscles and the vagina. The baby’s head gradually depends with each ensuing contraction and tries to accommodate through the birth passage. The uterine contractions are now more intense and of longer duration. During this stage, the baby delivers after negotiating the bony and the soft tissues and takes a duration of 1 – 3 hours.
When the baby is just about to come out of your body there is a stretching of the soft tissues and pressure on the rectum. This real pressure makes the mother feel like defecating. Also, the mother has a strong urge to push the baby outside which is called as ‘bearing down’. Bearing down movements are the voluntary efforts done by the mother to push the baby out. This also causes increased pressure on the womb and helps the delivery of the baby. Sometimes the assisting birth attendant applies a gentle pressure on the womb to assist the delivery of the baby.
If the opening of the vagina is found to be way too tough, or rigid, a cut is taken on the vaginal opening to help the delivery of the baby and to prevent injury to the baby and the perineum( bottom surface of the mother’s body ). This may also be considered in cases where assisted delivery is performed or when the baby is premature in order to protect the mother’s soft tissues and the baby from injuries. This is given after administration of a local anaesthetic ( pain-relieving medicine ). Also, it is not taken always. It is done only if needed.
Assisted delivery is also called as instruments delivery. In this instruments such as the ventouse ( vacuum cup ) or obstetric forceps are used to deliver the baby. These, of course, need skills and judicious decision making and are used to enhance the safety of the delivery process.
This lasts for about 15 mins to half an hour and is currently universally shortened by some useful medications to help squeeze and tighten the womb and separate the placenta faster to avoid unnecessary bleeding from the placental site. During this stage the uterus contracts further and expels the placenta and the cord and the membranes out and the womb further contracts to harden.
The pain perceived by the patient is actually the indicator of the fact that your baby is now wanting to come out. In the start of the process, the womb starts being firmer periodically and then intensity gradually increases. It is actually a bearable pain. The pain has two components the squeezing of the muscles and the opening of the cervix. These are transferred to the back as the nerves from the spinal cord at that level are responsible for this pain management. The last one or two contractions are strong and painful and are usually not perceived as the mother is more occupied in pushing the baby out. Many women are unduly scared of this pain and this condition is called as ‘tocophobia‘
A proper knowledge and positive attitude go a long way in helping mothers bear the pain and sail through labour, comfortably. Undue fears, ignorance can cause more pain and need medications to relieve the pain. Some medications are administered by the doctor or some pain relieving gases are inhaled by the mother. Some exercises such as breathing, perineal stretches with the exercise ball, moving about, squatting, meditation, mind modulation helps overcome the pain. Epidural analgesia is a type of pain relief measure wherein the medication is delivered through a fine tube into the epidural space near the nerves responsible for the pain. This helps in reducing the severe perception of pain and ensures delivery of the baby safely. It is a safe procedure.
In all, delivery is a wonderful experience. The complete knowledge, the right attitude, and communication with your birth assistant and the obstetrician help you appreciate this experience in a beautiful way.
Dr. Girija Wagh, MD (Obstetrics & Gynaecology), FICOG, FICP, Diploma (Endoscopy, Infertility), Fellowship of Indian College of Ob-Gynec, Women health care specialist, Academician, Acclaimed Orator & Researcher, B. J. Medical 1990-1992, Topper University Of Pune 1992
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