Department of Family and Community Medicine and St. Michael’s Academic Family Health Team
Pregnancy - Labour and delivery
Am I close doc?
As you near the term of your pregnancy (your baby is at term after 37 weeks and before 42 weeks) there may be some new things going on with your body which tell you that your body is getting ready for delivery. The first is called ‘nesting’ and happens when you feel the need to get your home ready for the baby. You may feel like cleaning the house, getting the baby room organized and prepared, or even wishing to stay close to home rather than leave on a trip ‘in case the baby comes’. Although all of the above may seem to be ‘just normal thinking when you’re having a baby’, some women start to truly focus on these things in the two to three weeks before delivering.
Secondly, the uterus may move lower in the tummy. This is what some people call ‘your stomach dropping’ and happens so that the baby’s head is down inside the pelvis to get ready for delivery. Although not exact (nothing is 100 per cent predictable in pregnancy medicine) this may happen one to two weeks before delivery, however some women experience this much earlier on. As the uterus lowers you may feel that breathing becomes easier for you and that your need to urinate increases. This is because your baby (inside the uterus) is moving farther away from the muscles that help you breathe and closer onto your bladder. Feeling the need to urinate more often is normal and, (unless you are also experiencing painful urination, fever, nausea, vomiting, mid-back pain) not a sign of a urinary infection. Thirdly you may ‘lose your mucus plug’ several days before your labour begins. The mucus plug is a palm-sized clear-reddish jelly material which sits on the cervix and protects the uterus/placenta/baby from infecting organisms which may otherwise move up from the vagina. The plug acts like a protective barrier between the external surface of the vagina and your insides of your uterus and baby. Shortly before delivery, this drops out from the cervix as it softens and becomes more open. The mucus plug may come out all at once and be visible as a jelly clump in the toilet or bathtub, or otherwise may come out bit by bit and be very small or it might even happen without you realizing it.
Finally, your ‘water may break’ which happens when the balloon of fluid around the baby develops a hole through which fluid flows into the vagina and, eventually, into the underwear. This also may happen as a large fluid gush from the vagina, which is unmistakable and will not be missed. However, if the hole in the ‘balloon’ is very small, the leaking from the vagina will be in very little amounts and may be hard to notice. If your underwear feels wetter than usual (ex. as though someone keeps pouring water over them) change your underwear, dry yourself off and check again in one to two hours. Should you, once again, notice wet underwear that are soaking through to your pants you should report to your delivery hospital (at maternal triage) to be checked to see if your water has broken.
If you think your water may have broken, by a small leak or a large gush, you should report to your delivery hospital to be checked and managed appropriately.
When am I in labour?
As your pregnancy nears its end you (and perhaps your partner) may find yourself worrying about when to go to the hospital. Will you know when? Is this a false alarm? What if you wait too long and don’t make it to the hospital in time?
The first point of reassurance is that labour is never hard to miss - no matter whether it’s your first or your tenth baby, your labour will never go unnoticed. The true question is now long to wait with discomfort at home before driving into St. Michael’s to be assessed for admission. If this is not your first baby then you already may remember how you feel when in labour and, as soon as you feel this way you should drive to the hospital to be checked out. Generally, if it’s not your first, every labour lasts shorter than the one before and so you should speak to us about when you should head to hospital (ex. If last labour lasted three hours from feeling strong pains to the baby coming out, then it will likely be even shorter this time). The following is for information on labour in a first time mom:
The beginning of labour is called LATENT LABOUR and during this stage you will have irregular contractions which over time get stronger and closer together (ex. at first you may notice that every 15 minutes you feel period cramping in your lower belly and your lower back. As the time goes on, you feel the pains getting stronger and there is less time between pains). These cramps are slowly softening and stretching your cervix (the doorway to the womb). Once your cervix is 3-4 cm open you have begun ACTIVE LABOUR. If laboring mothers are admitted to the ward before they are in active labour, they are overtreated and are more likely to end up having a C-section. Because of this, we do not admit mothers in latent labour to the ward. This can be frustrating when you are experiencing pain and distress, however it is in your best interest and done for you and your baby’s protection.
So how do you know at home if you are in latent labour or active labour? The general rule is that if you are having strong contractions every four to five minutes or less, when these contractions are lasting one or more minutes, and when this is happening for one or more hours, you should drive to hospital to be checked for how open your cervix is. Also, if you are having any bleeding from the vagina (which can be a normal), any leaking of water into your underwear, or any symptoms not generally part of normal labour (fever, jaundice, rashes, diarrhea, difficulty breathing, etc..) you should go to St. Michael’s to be checked. After being checked your first time at the hospital, we will tell you when you should come back, or will admit you to the hospital if it is time for the baby to come.
Way past the due date: post-term pregnancy
If a pregnancy reaches 42 weeks gestation it is called post-term. After this age, life for the baby becomes more dangerous inside the womb than outside. Because of this, pregnancies are not recommended to continue beyond 42 weeks, and an INDUCTION of labour is offered between 41 and 42 weeks’ gestation. During this last week, we also monitor the baby more closely. Should your pregnancy reach post-term, your doctor or nurse practitioner will explain the risks and benefits of inducing (medically starting) your labour.
You will know when to come to maternal triage to start your induction (bring your bags and be ready to be admitted to the delivery floor). Inducing a pregnancy usually involves checking your cervix to see how ready it is for labour. Depending on how ready it is (how soft, open etc.) the doctor may insert a medication (or a catheter) to get the cervix softer and more open. The doctor taking care of you in the hospital will explain to you exactly how it will be done.
What should I expect when I get to triage?
Once you do arrive at the hospital you will have to report to the triage desk on the maternity wardlocated on 15th floor of Cardinal Carter South. If you do not know where this is you can ask at any desk and you will be directed. The nurse is the first to see you and get an idea of what brings you in. She will ask you about how frequent your pains are, what they feel like, and if you’ve had anything unusual coming out of the vagina. She will put you in a bed and ask you to change your underwear (even to put a gown on in some cases). She will put a baby monitor on your belly to measure the baby’s heart rate as well as your contractions. She may check your vagina to see how dilated you are and if the doctor needs to check you right away. She will also take your blood pressure, temperature and pulse. Depending on how you are feeling she may ask you to do other tests and even start some blood work or an IV.
You’ve made it! In labour! Now what?
Once you are in active labour you will be admitted to the ward and put into your own private room for the delivery (if you’re being induced you are already there). This room has a private shower and some have jacuzzis for your use if it’s safe to do so. You will stay in this room until one to two hours after having your baby. After, you’ll be transferred to a semi-private or private room depending on availability and your insurance coverage.
In the delivery room, you may continue to be monitored (fetal heart rate, blood pressure, contractions) or you may be free to walk around. Your supports can come in with you, however there is a limit of two helpers in your room at one time. During the contractions, it will help to have someone with you. This person should be someone you know, you trust, who makes you feel safe and most importantly someone who relieves stress and fear. It has even been proven in research that having such a person with you helps the progress of your labour.
You will be taken care of by a nurse who has special training and experience in deliveries. From time to time a doctor may examine you and discuss your progress as well as any worries as they arise. Worries do sometimes arise during delivery and most of the time there is ample time to explain interventions with you, so that you understand and consent to any procedure (knowing how you will benefit from it and what the risks are). There are unfortunately some instances where something happens quickly (with you or with the baby) which requires fast treatment. If this happens, the medical team will have to treat quickly and will explain the situation later. It is important to remain calm, let them proceed with what they need to do, and ask them to let you know when you can ask questions.
In fact, the most important factor during delivery is to remain calm. If there is anything abnormal or unhealthy occurring this will be explained to you in due course. If no one has said that anything is out of the ordinary, keep in mind you are experiencing the normal discomfort of labour. This is one of the rare medical crises that is happy and with an unbelievably amazing result. Remind yourself of this... take comfort from your partner, family members or friends (and choose people around you who decrease anxiety and distress). Remaining in control of yourself and your fear is the one major way for you to help your labour along. Let the doctors worry about any abnormalities and, if none have so far been discussed with you, rely on their care for you and your baby. You are there to breathe and cope and push the baby out when the time comes.
Who should be there with me?
Research has proven that good support (from family, partner, friend, doola) improves the progress in labour and decreases the amount of medication given for pain during labour. This could mean that less pain is felt by you or that you simply deal better with it. In fact, your ability to remain under control and not panic is vital to good labour (both in terms of oxygen delivery to the baby and the speed/ease/flow of labour itself). Choose someone who you trust, has the ability to make you feel assured/safe/less anxious/more brave. It is okay to have loving, intimate family members wait outside the room if they do not have this effect, and especially if they have the opposite effect.
So… I’m worried about the pain
Pain during labour is one of the things most patients ask about when talking to their practitioner about the actual delivery. It’s important to remember that there are good pain relieving options that are not medications: peanut balls, yoga balls and the use of the shower or Jacuzzi really does help us to cope with the pain. One can never understate the importance of your helpers for this support as well. The following are the medication aids that are available to you during your labour at St. Michael's.
This medication is on the labour floor at St. Michael's. It comes in a pressurized container with a mouthpiece. You will hold the mask over your mouth and nose as the contraction builds, and breathe through it to the end of the contraction. The gas works so fast, that as soon as you stop breathing it, it’s out of your body. This means it has no effect on how the baby will breathe/ cry/ eat after birth. Nitrous oxide doesn’t stop pain, but lifts you above it so that you can cope with the tough contractions as you become fully dilated and are ready to push.
Medications given into the muscle, fat under the skin or intravenously are called narcotic pain medication. They are more effective than nitrous oxide in decreasing pain. They do not stop pain altogether but they do decrease it which allows you to relax a little (side effects include itching, nausea, vomiting, and fatigue). They do enter the blood, cross the placenta, and enter into the baby. Because of this there is a risk that the baby will be sleepier after birth. This is why, once you are close to delivering, we may not be able to give them to you. There needs to be enough time for your body to get rid of the medication so that your baby can breathe well once he/she comes out.
Epidural medications are usually a mix of local anesthetic and narcotic. They are injected in a space around the spinal column and are the only medication that can stop contraction pain. After the first injection of medication, a small tube is left inside the space so that more medication can drip in to keep your pain away for the remainder of the labour. Once the epidural is running the baby has to be monitored continuously, you may have to have a tube into your bladder to empty it, and your legs will not be strong enough for you to walk. None of this is dangerous but it does mean you will have to stay in bed until the epidural is switched off and you have recovered from the leg weakness.
There are many misconceptions about the epidural, some of which are explained below. If after reading you still have questions please ask your doctor or nurse practitioner, so as to understand this tool for pain relief before the time when you may need/want it. Many believe that epidurals cause long-term back pain after delivery, however they definitely do not. (Pregnancy for nine months, breastfeeding for long periods and carrying an ever increasing bundle of joy cause back pain after delivery). Secondly, patients tend to worry about damage to the spinal column during the procedure. Although this risk exists, it is extremely rare (you are more likely to win the lottery). Epidurals are done safely and without harming patients a minimum of ten times/day in any major hospital across the world. The main risks to an epidural are severe headache (which is very unlikely with the small needle size used nowadays), infection, and bleeding all of which are very rare. The anesthetist performing the procedure will discuss with you any risks in detail if you request an epidural.
Cord blood options
The option to collect cord blood is a new, and for some exciting, possibility for pregnant parents to consider while expecting their baby’s arrival. There is a free public cord blood bank available for donation through the Canadian Blood Bank Services (compared to the private cord blood banking companies which charge a $1-2000 fee for collection alone, followed by $1-200 yearly cost thereafter for a maximum of 18 years). It is important to do your research before investing in this interesting, expensive and very very rarely beneficial procedure. The following facts may be of interest:
- cord blood is used mostly in transplanting patients with blood borne diseases such as leukemias, lymphomas, haemoglobinopathies (all scary but thankfully very rare conditions). Treating Diabetes, Parkinson’s disease and acquired brain injuries are all just dreams for the future.
- due to the link between many of these diseases and genes, the use of an infant’s own cord blood to treat his/her own disease is rare (ex. if a child develops lymphoma, his/her own cord blood will become unusable for transplant due to the risk of the developing this disease again after transplant.)
- although difficult to calculate, the likelihood of needing a stem cell transplant is 2-10/1000
- the likelihood your child will benefit from his/her own cord blood transplant is estimated at 1/2700 or less
Ask your provider for patient information on the pros and cons of this procedure. Here are some resources for your own research:
What do I pack?
Below are just some suggestions for what may be useful. It is by no means comprehensive, nor should you feel you have to bring all of these items:
- Your birth plan and prenatal medical records
- Robe, dressing gown, wrap sweater. This will be useful if you end up pacing hospital corridors in early labour and you'll need one for after if you’re staying overnight. Hospitals can be very warm, so a lightweight one may be better.
- Socks. Believe it or not, your feet can get cold during labour.
- Massage oil or lotion if you would like to be massaged during your labour.
- Lip balm (believe it or not people find this soothing during labour)
- A headband or elastic. If you have long hair, you might want it tied up.
- Music to listen to: Make sure your batteries are charged, as some hospitals won't let you plug things in.
- Water spray, or a hand-held fan to keep cool down the mom-to-be while she's in labour.
- Comfortable shoes. You may be pacing the corridors!
- A change of clothes
- Watch with a second hand, to time contractions.
- Address book or a list of phone numbers. You and your partner will be able to use a mobile phone in parts of the hospital, but bring lots of change or a prepaid phone card just in case, for all the calls you may want to make.
- Snacks and drinks. You don't want a dehydrated, hungry birth partner looking after you and if you take some with you, they can stay with you rather than leaving the room to search for food!
- A going-home outfit: You'll need loose comfortable clothes to wear while you're in hospital and for the journey home. It will take a while for your belly to go down, so you'll be still wearing maternity clothes when you come home - sorry!
- Nursing bras: Take two or three.
- Breast pads
- Maxi pads: Bring a couple of packs.
- Nightshirt wrap or T-shirt. Front-opening shirts are useful in the early days of breastfeeding.
- Towels, hairbrush, toothbrush and toothpaste.
- Old or cheap underwear, or disposable panties. Don't bring your best ones as they will get messy.
- Ear plugs, in case you end up in a crowded room!
- An infant car seat: Some hospitals won't let you leave by car without one.
- One outfit for the trip home (all-in-one stretchy outfits are easiest). Two or three sleepers for baby to wear while you are in hospital.
- Baby blanket. Take a warm one if the weather is cold.
- One pair of socks or booties
- Jacket or snowsuit for winter babies