Vaginal labour called normal delivery; it is triggered by the baby’s ready to go out to the outside world from the birth in the womb.
The act of birth is divided into three stages:
1st Stage: With regular uterine contractions, the uterus is opened and the baby progresses slowly in the birth canal.
2nd Stage: It is the stage of taking the baby out with leanings.
3rd Stage: Placenta and membranes are ejected.
How many weeks does the birth take place?
The birth action is on 37th-41st week of pregnancy, it can take place any week in between. The probability of giving birth on the day of the 40th week given as a possible date of birth is only 3-5%. The possible date of birth means that only 40 weeks have completed. After this date, it means that your day is past (passing through) and your baby and you will be seen more frequently.
If pregnancy is comfortable and normal, your weekly checks after 36 weeks; Amniotic fluid amount can be made two or three times a week after 40 weeks according to NST and baby’s well-being.
How do we know when it’s time for birth and when should we go to the hospital?
Mother candidaters may have anxiety that they cannot understand that their birth has begun. However, the expectant mother will definitely understand that birth has started. It often starts with pain first. Less frequently, fluid comes first. From time to time, there may be a bloody mucus discharge, known as an engagement among the public.
The coming bloody mucus (sign), which means the removal of a mucus plug in the cervix, is intended to protect the baby from infection and consists of cervical secretions. Often, the birth will take place within three days of the engagement. It is appropriate to inform your doctor about the engagement in pregnancies that are currently followed-up and where the mother and baby have no health problems. However, you may not need to go to the emergency hospital. It is useful to wait until the more obvious conditions for labour at home occur for a while.
During pregnancy, uterine contractions are suppressed in order to keep the baby in the womb and prevent low or premature births. However, in the near future, this pressure begins to decrease and the uterine muscles, which are suitable for contraction, begin to contract. Uterine contractions called ‘Braxton Hicks’ can be felt as pain by the expectant mother. But it is not regular, it takes less than 30 seconds, and after a while it relaxes at rest. Birth pains will feel more pronounced pain perception and will come regularly. Initially it can come once in 30-20-15 minutes and every 10 minutes. However, in real labour, three painful contractions per minute and each contraction are expected between 40-60 seconds. You can easily feel the contractions with your hands. Going to the hospital before the pain reaches this level will prolong the hospitalization period and you will be deprived of the comfort of your home environment. Therefore, it is useful to wait for the pain to come to this level and apply to the hospital as such. Of course, an inexperienced mother who is her first birth cannot be expected to make this timing comfortable. Therefore, if you need to apply to the hospital, your doctor can send you home again and tell you the appropriate time application. Remember that your ‘false alarm’ right exists at all times.
The opening of the amniotic membrane and the arrival of fluid is a condition that requires you to apply to the hospital. The amniotic membrane barrier, which now protects the baby against infections from vagina, has disappeared. Since the possibility of cord sagging may also be brought to the agenda, the first assessment of the baby and mother is made and the process is monitored in the hospital. Antibiotic requirement is a condition that can be decided by your doctor, together with the duration of fluid arrival and the results of infection tests.
Apart from these, bleeding and decreased baby movements are urgent to apply to the hospital and require urgent evaluation of the mother and baby.
What are the evaluations made at the first admission to the hospital?
First of all, the general course of the pregnancy since the beginning of the pregnancy, the assessments made, the evaluations made during the follow-up are reviewed and a detailed history is taken about the application complaint.
If ultrasonography has not been done before, the ultrasonography is performed to evaluate the baby’s arrival position (head or breech arrival), placental location and amount of amniotic fluid. If it is your own doctor who has done the ultrasonography recently and examines you, your doctor will decide whether to do further ultrasonography or not.
Then, the vaginal examination is done for the pelvic evaluation (roof examination). During the vaginal examination, both the pelvis and cervix, the arrival of the baby, and the harmony between the baby and the pelvis are evaluated. The structure and angles of the pelvic bones, the features of the birth canal and the location of the cervix, the amount of softening and opening are evaluated. The level of the baby’s head in the pelvic canal is checked.
Then, the baby’s well-being is evaluated, the contractions are recorded and the baby’s heart rate is evaluated during the contraction. NST (non stress test) should be taken for at least 20 minutes.
By considering all of these conditions together, it will be determined whether you will be hospitalized or not.
If the active labour has not started yet, your fluid has not come and the baby’s heartbeat evaluations have been made and found normal, you can go home again and wait for the pain to increase. However, if your anxiety level is high, you can choose to stay in the hospital, or, if your active labour has not started yet, your doctor may recommend hospitalization for any risk.
If it is decided that your active is started or if you have fluid pouring out, it is time to go to hospital. Timing in this process is all about the way the labour begins. It will start with the leakage of fluid from time to time with pain and sometimes without pain. Active action is when pain occurs every three minutes, and effective cervical opening can only occur with these contractions.
1st stage of labour:
The first stage is the wiping of the cervix, its coming to the midline and opening. It refers to the time that passes from the moment the cervix is closed to the 10 cm span called full open. The duration of the first phase is approximately 12 hours in the first birth woman and 6-8 hours after the second birth.
Pain in the early period gradually increases and the first 3-4 cm is called the latent phase. After this period, an active delivery process will start, which will open 1 cm cervix every hour. The frequency of vaginal examination is completely adjusted according to the speed of the process. When performing an examination every 1-2 hours at the beginning of the action, it can be done more frequently towards the end of the action. If amniotic fluid is spontaneous, vaginal examination should be performed immediately to evaluate the possibility of cord sagging. If there is no liquid yet, the risk of infection is less during the examination and the examination is safer. However, the frequency of examination should be reduced since we can carry up the protective normal flora bacteria in the vagina after fluid arrival. In all cases, sterile gloves are used for vaginal examinations.
In the 1st stage, NST follow-up is again made according to the pace of birth and the condition of the baby. If everything is normal and normal, NST can be done every 2 hours. In the meantime, a baby heart rate should be listened to at least every half an hour. It will be comforting for the heart beat to rest especially during contractions and the heart rate does not decrease with the contraction. In high-risk patients, NST should be withdrawn continuously during labour.
During the delivery process, opening the fluid bladder in a controlled time and placing it on the cervix of the head will increase the speed of action. It will also provide an assessment of whether amniotic fluid is meconium.
If the order and severity of the pain remains insufficient and the desired level is not achieved despite the waiting, artificial pain may be applied to strengthen the pain. For the application of artificial pain, the cervix must meet Bishop criteria (sufficient erasure and clearance must be present). In cases where the cervix is not suitable, it is very difficult for artificial pain to be effective.
Meanwhile, the mother’s heart rate, blood pressure, and fever are regularly evaluated and antibiotics can be decided to start when fluid arrival exceeds 12 hours but birth has not yet taken place. However, the use of antibiotics has no place in the course of labour, except in special cases. If β hemolytic steptococcus is detected in the vagina, antibiotics are performed during the action.
Adequate fluid intake is important during the woman’s labour. In the latent phase, water and liquid food can be taken until the active phase begins. However, when the active phase starts, fluid should be given through the vascular access if necessary. In the meantime, it will be useful to empty the bladder every two hours. It is not appropriate to take solid foods, especially after increased painful contractions after 3-4 cm of openness can stimulate the vomiting reflex. It is not preferred due to the risk of vomiting and subsequent solid food leakage (aspiration) into the lung. Due to the possibility of urgent caesarean requirement, it will be appropriate not to take solid food.
It is a useful practice to make an enema during labour and expelling the stool in the last part of the intestine. It can both help advance the labour and prevent defecation during straining.
2nd stage of labour:
It refers to the period from the period when the cervix is fully open to the birth of the baby. It can last between 30 minutes and 2 hours.
Intense pain experienced in the first phase somewhat decreases in this period. The severity and duration of contractions may be somewhat shorter. If the baby’s head is up and the baby’s heartbeat is regular and good, it is useful to wait for a while before coming out. In this process, the patient can be kept standing or squatting so that the baby’s head can be lowered to a more appropriate point. Meanwhile, the mother who has partially relieved her pain is given the opportunity to rest. When the baby’s head rests on the pelvic opening, the active participation of the mother, who is now on the obstetrics table, has begun. Of course, the mother who was passive in the first stage she suffered was very tired during this process, but the role and cooperation of the mother is very important in the healthy course of the second stage. The birth canal is not a straight path, and the baby’s head and body go down with turns suitable for these angles. Thanks to the openings between the bones at the beginning of the baby, the bone structure changes in the birthway are adapted.
The mother lies in a supine lithotomy position on the obstetrics table. When the contraction comes, she cooperates with his doctor and becomes strained when the severity of the contraction increases. During the contraction, the mother should pull the support units on the edge of the table towards herself and take the C shape by leaning her head against her chest. Starting to get up early before the baby’s head is completely tiring and unnecessarily prolonging labour and it is appropriate to wait for your doctor’s warning in order to determine the correct time of straining. For proper strain, you should trap your breath by filling your breath into the lung at the most intense moment of contraction and push the baby towards the breech with all your strength. Here, breathing in and out, shouting while getting out, and swelling your throat or belly while getting out can prolong stage 2. If the woman, who is already tired and exhausted while suffering from pain in the first stage, is able to get right in cooperation with her doctor during the action, the process will facilitate on her behalf.
At each strain time, the head of the baby goes down a bit. During the break, the baby’s head is pulled up a bit, but it always stays a little below. In the absence of contractions, the woman should try to rest well and breathe regularly, if necessary, oxygen should be breathed. When the baby’s head presses on the neural network on the rectum, the strain will also occur involuntarily (Ferguson reflex). Effective management of clearing with appropriate timing facilitates action. When the baby head emboses the skin area called the perineum (crowning), episiotomy can be opened with local anesthesia. Episiotomy will make the baby’s head more comfortable and prevent unnecessary tears in the woman’s perineum. Your doctor will protect your perineum with your hands to prevent it from rupturing while the baby is in the head.
Strain should be stopped to prevent tears of the perineum when the baby’s head comes out. The secretions in the mouth and nose clear quickly as soon as you cope. The head is turned to the right or left according to its own tendency and brought to the front-back position with the shoulder. The front shoulder and then the back shoulder are removed, and then the baby’s body is born. If the baby is comfortable and the birth apgar is good, it can be left on the mother’s lap and first care can be done here. It can be kept here by controlling the temperature of the vein in the cord until it stops and the first bond with the mother is easily provided. Then the umbilical cord is cut 4-5 cm from the baby’s navel by clamping. With the birth of the baby, the second stage of birth is completed.
In cases where the mother’s inadequate strain (especially due to the lack of perception of the head of the baby in epidural anesthesia), and when the baby’s heartbeat falls and there is no possibility of waiting, overpressing the abdomen of the mother called crystals can be applied. However, this maneuver can reduce the woman’s satisfaction with birth. In cases where the baby is in full hatching, that is, the level of the head is very low, the mother’s discomfort is insufficient, and if the baby needs to be removed as soon as possible after the heart rate drops, vacuum may be required. In vacuum application, it is possible to rupture the perineum.
In this period, I would like to emphasize again that if the conditions are suitable, the baby should be given to the mother’s lap immediately. It should be dried and wrapped with a dry material to prevent heat loss. First contact with the mother is the mother’s reward at the end of the difficult birth process. The first contact of the baby, which has just been separated from the mother’s body, will be provided in the same environment. The first contact is very important for the establishment of a relationship of trust, spiritual relaxation of the mother and the triggering of breast milk.
3rd stage of labour:
After the baby is born, the pain ceases for a short time. Afterwards, uterine contraction begins again in order to remove the placenta, the main life source of the baby during pregnancy. These contractions are never as severe as birth pains and can be easily tolerated.
It may take 5-30 minutes to remove the placenta. On the baby facing part of the placenta, there is a slippery membrane structure and a widespread vascular network underneath, followed by blue gray color. On the face of the mother, the cotyledons that provide the exchange between the mother and the baby will be united like liver pieces and will be observed in red.
With uterine contractions, bleeding occurs in the veins behind the placenta, and with this bleeding, the placenta is removed from the edge or the middle, gradually leaving the uterine wall. Here it is useful to gently strain the placenta after it is fully painful. In the meantime, your doctor will pull the cord gently and remove the placenta.
It is very natural to have some bleeding after the exit of the placenta. The vessels of the vessels that are exposed during the separation of the placenta are closed rapidly by contracting the muscles of the uterus containing cross fibers and bleeding control is provided. To facilitate this, uterine cervical medications can be given from the vascular or hip and massaged outside the uterus.
If the bleeding is high after the placenta has come off, the inability of uterine contraction called atonia bleeding may have occurred. For this, uterine muscle drugs, effective uterine massage and, if necessary, more serious measures will be taken. The reason for the lack of bleeding and contraction may be that a part of the placenta has remained inside. Therefore, when the placenta is first removed, the integrity of the mother’s face is checked. Intrauterine tissue is checked by ultrasonography, and if there is any remaining piece, the intrauterine tissue is cleaned. One reason for bleeding may be tears that occurred while a baby was coming out of the cervix. Therefore, the cervix should be checked in detail and the tears should be repaired, if any.
If the placenta does not come out within 30 minutes, as in cesarean, your doctor will remove the placenta by hand (aunt).
If it is made behind the exit of the placenta, the episiotomy site is repaired. If an episiotomy has not been performed, it is checked for tears and if there is a large bleeding hemorrhage, the stitches are discarded. Non-bleeding foci, which we call tiny laceration, will heal by themselves.
If epidural anesthesia is performed, local anesthesia is not required when sewing. If it is not done, local anesthesia is performed and then stitches are sutured. In large tears, stitches can also be sutured to see the deep part of the vagina or under general anesthesia at the request of the mother.
It is natural that there is some tremor after the exit of the placenta. After the third stage of the delivery process, the perineum is cleaned and the woman is taken to the room. The comfortable process, which is now the reward for normal birth, has begun. You can take your shower comfortably without waiting, eat and drink anything you want. You can accept your visitors. You can easily breastfeed your baby in any position. Perineum care will be taught to you by your healthcare staff and will be taught in the meantime. Although postpartum pain is not much felt, you can take painkillers recommended by your doctor if necessary.
If it is deemed suitable for you or the baby and it is natural in the postpartum period, you can go home 24 hours after birth.