Labour Interventions: Should I go for epidural, induced labour or c-sect?

As I read the conversation going on in my WhatsApp mummies group, I wished more mothers know what I know. I wanted to tell them what I’ve learned from Leila of ‘Leila and Co(Join her antenatal class!). Yet, I don’t feel like I’m qualified to tell them how they should “stand up” to or to challenge their gynaecologists who are not always right.

We as parents need to know the right question to ask to make sure we get the right care. Some gynaes might not have the patient’s best interests but have their own agendas — like earning more money, scheduling time convenient for themselves, or simply taking the easy way out.

I was overwhelmed with information after I attended the antenatal class by Leila, more on that in my next post. Hence, I decided to summarise the labour notes here, highlighting misconceptions and points I might need to refer to in future. What I’m sharing here is just a tip of the iceberg of what was shared by Leila. So…go attend her class and be informed parents!

This post is written not to scare you. It is to guide you in making the right choices for the mummy and baby. In any case, like what Leila said in class, “no expectations means no disappointments”. So go with the flow! 🙂

For Christians, pray! Pray for godly wisdom over yourself and your healthcare professionals team. Trust that the Lord is helping and guiding your baby to be born.


p.s. Even if you embrace natural labour without medical interventions, you are still at the “mercy” of your doctor and hospital. Best if you can do a home birth, if not, try to choose a doctor that’s pro natural – discuss your desire for natural birth during the initial check ups. And choose a hospital that supports doula, because this indicates how receptive they are to your natural birth plan.

Parkway East Hospital is more risk averse and will ask doula to leave during the pushing stage. Thomson Medical is more natural and open to doula. As for NUH, only registered doula can enter the delivery suite.


Drug Free Labour


Pain reducing medications used during labour:

  • Entonox (laughing gas and air): Take this when you feel the pain building up (in between contractions), because it takes time to take effect.
  • Pethidine: Stays in the body for 2 weeks (affects breastfeeding). This medications goes more to the baby than epidural because it goes direct into the mother’s bloodstream. Sleepier baby as a result. This is not as recommended as epidural but sometimes used because nurses can administer this, and the effect is faster than epidural.
  • Epidural: Stays in the body for 2 weeks (affects breastfeeding). 70% chance of effectiveness. Epidural is common and even recommended by some doctors, but that doesn’t mean it is natural.

What happens when you remove pain with drugs?

  • Once you use pain relief, you cannot get off the bed. Getting off bed enables you to get into different positions to aid the labour process.
  • You don’t respond to contractions or pressure.
  • Your body doesn’t release oxytocin and endorphins.
  • Birth canal might damage more because without pain, you don’t know how hard to push.
  • Medication affect breastfeeding because it usually causes sleepy babies.
  • Natural birth transforms woman to mother. Overcoming a challenge inevitably leaves us feeling more capable (in childbearing).

Give epidural when you cannot bring the mother back to breathing, or she hasn’t slept for two nights. There’s a difference between pain and suffering. If she’s suffering, go for epidural.


Stages of Labour


Latent labour: Beginning with maternal perception of regular contractions

Active labour: The point at which rate of change in cervical dilation significantly increases. Not considered to begin until the cervix has dilated to about 6cm.

If you hear of labours going over 10 hours, these duration usually includes latent labour.

Here are some scenarios when you need to troubleshoot the labour:

  • Prodromol Labour
  • Back Labour
  • Slow Labour
  • Rapid Labour

Prodromal labour / Asymmetrical labour seems to be more common for second time mothers. Perhaps because of how busy they are with the elder one, and only get to rest at night for labour to begin.

  • Contractions start and stop, and usually picks up at night
  • Tired/exhausted mother
  • Try to relax, swim, walk, or go for chiropractic sessions.

Things to do to help speed up slow/arrested labour:

  • Empty bladder frequently
  • Move around/change positions
  • Nipple Stimulation
  • Eat/Drink
  • Use relaxation techniques. Hubby to massage, reassure and encourage.

Medical Interventions: When?


Usual scenarios for intervention:

  • Big baby/head
  • Small baby
  • Low amniotic fluids
  • EDD
  • Nuchal cord/cord round neck
  • Breech

What you should ask or know for the above scenarios:

Big Baby

  • How big is big?
  • Latest research does not recommend induction for suspected big baby. Ultrasounds have a +/- 20% error.
  • The risk is shoulder dystocia, that is baby’s shoulder gets caught above the mother’s pubic bone and cannot come through. The medical officers would break the bone, but it will heal in 24 to 48 hours.
  • You can change position to assist baby to come out.

Small Baby

  • How small is small?
  • IUGR (intra uterine growth restriction) means baby is not growing inside anymore. Placenta is not giving enough.
  • Intervene if baby’s weight percentile keeps dropping. Could be a medical condition, check with care provider.
  • No need to intervene if the percentile has been constant on the low side or it had bounced back to the original percentile.

Low Amniotic Fluid

  • How does it affect baby and me?
  • Drops towards the labour EDD to prepare for labour.
  • Could be due to placenta not providing, maternal medical conditions (pre-eclampsia/diabetes), leaking or ruptured membranes, maternal dehydration, etc.
  • Fluctuates daily and based on maternal activities – try resting and increasing fluid intake.
  • Risks of compressing cord, meconium staining, IUGR.

Past EDD (“Overdue” baby)

  • EDD is based on a 28 day menstrual cycle. It’s estimated due date, not expiry date.
  • Suspects post maturity – declining placenta functions.
  • Gynae will say the risk of stillbirth is higher in 42 weeks than 40 weeks. Note that it is relatively higher but still considered low risk.

Nuchal Cord/Cord round neck

  • Baby is breathing through placenta and cord. So the baby will not be strangled at neck. It’s the risk of cord being cut off supply. And the cord is very thick and risk of supply cut off is low.

Breech

  • What kind of breech?
  • 34 weeks baby will be at head down position. If not the doctor will usually suggest c-sect at 36-37 weeks. However, by week 40, only 1-2% baby will remain in breech position.
  • If baby is low lying, there’s still a chance he/she will move up.
  • C-sect if in placenta previa position.

Types of Medical Interventions


Common medical interventions during labour include assisted delivery, induced labour and cesarean delivery (“c-sect”).

Assisted delivery

Assisted delivery includes the use of forceps and vacuum. The suction is very strong, and that’s why the baby’s head will be lopsided after being sucked out.

Higher chance of assisted delivery for induced labours.

Induction

Induced contractions may be more powerful and longer than non-induced labour, so a more painful labour might result. This increases the chance of pain medication to be used, and thus the possibility of risks related to pain medication.

The longer and stronger contractions can interrupt blood flow and oxygen to the fetus and lead to drop in baby’s heart rate, so continuous monitoring or more interventions are needed.

Induced labour means the baby is constantly on stress without space to breath. Like they are constantly pushed to come out. Natural labour has moments of rest between contractions. With baby always put on stress, the labour has a higher chance of ending up with a cesarean. For first time labours, inductions increase risk of cesarean by two to three times.

There are other risks to induction such as longer labour time, uterine rupture, more blood loss post birth, and increase chances of infection.

However, sometimes there are medical reasons for induction:

  • placenta begins to separate from the inner wall of the uterus before birth,
  • infection in the uterus,
  • high blood pressure caused by pregnancy,
  • premature rupture of membranes (bag of water released too early),
  • post-term pregnancy (more than 42 weeks),
  • mother’s health problem, such as kidney or lung disease,
  • baby is not growing as should and /or environment in utereus no longer safe for baby, or
  • if labour slows, stops or is prolonged. Read under stages of labour to see how you can help hasten slow labour naturally.

Note: Large or even very large baby is NOT a medical reason to induce.

Cesarean (“C-sect”)

Planned C-Sect

A few reasons for planned c-sect:

  • Placenta previa, or a large uterine tumor which blocked the cervix,
  • Malformed or injured pelvis,
  • Servere preeclampsia,
  • Genital herpes / HIV,
  • Breech,
  • and many more.

Emergency C-Sect

Most of the so called emergency c-sect by gynaes in Singapore is not an emergency. So ask if you can delay the decision to c-sect for a while more and see how the labour progresses. You might not need a c-sect in the end.

Because in true emergency, the doctor will most likely push you straight to the operating theater without much discussion.

Situations when emergency c-sect is required: Placental abruption, prolapsed cord, uterine rupture (higher possibility in VBACs), or urgent maternal or fetal health situations.

Unplanned C-Sect

Common reasons for unplanned c-sect:

  1. Failure to progress
    • Labour is taking longer than expected to dilate to 10 cm. Guideline is 1 hour 1cm.
    • Baby is taking longer than expected to birth during the pushing phase
  2. Fetal distress
    • “Non-reassuring fetal heart rate”
    • “Fetal intolerance of labour”

Questions to ask when c-sect is recommended for the above reasons:

  • Failure to progress
  • Fetal distress
    • Is it serious? How serious is it?
    • How much time to make a decision?
    • Will other care provider who look at the same heart rate monitoring recommend a c-sect?
    • Can we try changing positions or walking around?
    • Can we try giving oxygen or IV fluids to labouring mother?
    • Can we begin Pitocin or remove Pitocin?

C-sect for active phase arrest should be reserved for women

  • at or beyond 6 cm dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity or
  • at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

Some mothers may opt for c-sect for non-medical reasons such as fear, avoiding pain, and convenience. However like any other surgery, c-sect has its own risks on the mother, baby, and future pregnancies.

So weigh the pros and cons and make a wise decision!

In any case, like what Leila said, “no expectations means no disappointments.” So go with the flow! Pray! 🙂


Disclosure: This is an editorial review. I was sponsored to attend the course but was not paid for publishing my experience with this service. All opinions are of my own and are genuine.



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