Pearl obstetrics | gynaecology


Natural birth

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Natural birth | Normal birth | Glengarry Private Hospital

What is a natural or normal birth?

Many women would like a normal birth or natural birth, with as little intervention as possible. A normal birth has different meanings for different women. For most women it means simply to have a vaginal birth. They may aim to avoid induction of labour and start off naturally. They may wish to avoid pain relief, in particular an epidural. However, for most women, having pain relief doesn’t mean that the birth shouldn’t be regarded as a normal birth. Some women are more strict in their definition, aiming to give birth without anything additional at all. The majority of these women want monitoring of maternal and baby’s well-being through their labour and the reassurance of a skilled attendant.

Intervention

“Intervention” takes many forms, and is something of an umbrella term. It’s important to remember that there are clear & beneficial reasons for much intervention – this is why mortality rates have decreased hugely over time. Common interventions are: reducing pain & distress by using pain relievers such as epidurals; improving the likelihood & safety of vaginal birth by using induction or augmentation of labour; using antibiotics; improving safety by using continuous heart rate monitoring where there are risk factors; the obstetrician aiding delivery where the labour stalls or there is distress. Whilst aiming to avoid intervention is beneficial/reasonable in many cases, it’s important to be aware that not all women can cope with labour, and not all women have straightforward labours. When labour goes off course, pain relief & other interventions are very important to avoid trauma & poor outcomes. Risks often become evident during labour that require appropriate reaction. Despite all this, we do all that we can to safely help achieve natural birth &n normal birth for women at Glengarry who wish it. See our page of tips on how to improving vaginal birth rates. Even women with medical or obstetric problems, & labours that aren’t necessarily straightforward, can still aim for and achieve vaginal birth (although inevitably some end in emergency Caesareans or instrumental delivery).

Next birth

Women who have had straight-forward normal births previously will generally have a low need for any intervention in their next labour. An emergency Caesarean rate of less than 5% is seen. Even if a woman has had a ventouse or forceps delivery before, at the next birth the need for the obstetrician to an instrumental delivery is around 5-10%. There is evidence that use of an Epi-no can reduce this instrumental rate further still.

A small proportion of women will not want to repeat an attempt at vaginal birth having had a traumatic time previously, and their wishes will be absolutely supported here at Glengarry.

How does a normal birth/labour start?

The commonest way that labour starts is with irregular contractions that gradually become more regular, sustained and stronger. This is the latent phase of labour. It can be prolonged. Much of this phase can take place at home in first labours. Subsequent labours are much less predictable. Mobilising at home and using the shower or having a brief tepid bath is helpful. Always ring Glengarry maternity unit and tell the midwife what’s happening and get individualised advice. During the latent phase in first labours, the cervix is softening, thinning and dilating up to 4-5cm. This pattern is not necessarily seen in subsequent labours. It’s not rare for labour to be heralded by the waters breaking before contractions start. Often contractions will start soon after the waters break; but if not, then a period of time is allowed before intervening to prevent infection setting in.

What happens in the first stage of normal labour & birth

Usually, the contractions become more regular with time and may become more intense. Progressively, the baby’s head descends & rotates & the cervix dilates to full dilatation. The waters may break spontaneously during this phase of labour. If the contractions become less intense, or progress stalls you may be offered membrane rupture (if still intact) to encourage progress. We’re more likely to recommend this if you have an epidural in place, as it can intensify contractions. Long labours can be caused when babies facing your front (OP position) as the fit through the pelvis is more difficult. Epidurals and intervention from your obstetrician can often be needed in these labours.

Pain relief in normal birth

See our pain relief in labour page for information on the various options.

Pushing – the second stage of labour

The end stage of normal birth is when the cervix is fully dilated. It’s time to push if there is sensation & the head has descended (otherwise we wait). It’s ideal if pushing is instinctive and normal birth happens naturally without coaching. However, many women in first labours will need some help to find their pushing technique & rhythm. Upright & semi-recumbent positions are helpful for normal birth, as is the left lateral position. We avoid “flat on the back” positions. Pushing can take some time in first labours. Short second stages commonly occur in repeat labours. Prolonged pushing without progress is detrimental to the pelvic floor tissues and may be a sign of problems to come. Because of this, if there is no sign of progress after good pushing, we intervene sooner rather than later before exhaustion sets in and the risk of poor outcome rises. If however, there is reasonable progress, albeit slow, we can continue if spontaneous birth is likely.

Instrumental delivery

Vacuum or forceps deliveries are necessary when there is fetal distress, significant delay or no progress in the second stage of labour, or maternal exhaustion among other reasons. Greater than 90% of our instrumental deliveries are completed with vacuum, and significant tears are uncommmon eg. only one partial 3rd degree tear in the last 10 years. We avoid rotational forceps unless absolutely necessary, as they increase the chance of damage to the pelvic floor and perineum. On balance, if it’s safe, women who get to full dilatation with an engaged head & then need delivery are best delivered by their obstetrician using instruments than have a Caesarean performed at full dilatation – complications are higher and recovery is slower. Complex instrumental deliveries are often best carried out in the operating theatre.

Tears & episiotomies

We have a restricted use of episiotomy with our practice at Glengarry Private. However, a zero episiotomy rate is associated with an increase in severe tears. Sometimes, the balance of risk lies in favour of performing an episiotomy. Example situations would include severe fetal distress, no progress with significant perineal obstruction despite good pushing, most forceps deliveries, some ventouse deliveries, short perineal body & large baby risking third degree tear, and previous third degree tear. These decisions are always individualised & discussed. Use of Epi-No to prepare for natural birth reduces the risk of both tears & the need for episiotomy. There is good evidence that properly selected & performed 30 degree lateralised episiotomies reduce the risk of serious third degree tears. Using this technique in a resticted way, Dr Sillender has had only one partial 3rd degree tear and no “perineal explosions” in the last 10 years of his consultant obstetrician practice.

The third stage – placentas & cords

Active removal of the placenta using an injection reduces the risk of major haemorrhage by half, so is an important part of safe management of the third stage of labour. As part of this, we often apply gentle but firm controlled cord traction during a contraction when we see signs of placental separation. Delayed clamping of the cord has attracted a lot of press. In term infants in healthy women in Westernised countries delayed clamping has no important risks or benefits. We usually leave it unclamped/uncut for a minute or two if all is well, but are happy to leave it longer/until it stops pulsing if wished for. In pre-term births, delayed clamping is important, and should be aimed for.

Suturing

Suturing of tears or episiotomy is always done with “invisible” mending with dissolving stitches.


Our birth philosophy



Safety

The safety of mother & baby is the most important aspect of care. Decisions are hardly ever black or white however.


Choice

Women should have the choice to birth how they wish, with respect to safety considerations. This means in addition to natural births and standard Caesareans, we can offer request elective C-section births & VBACs to women who understand the benefits & risks of these types of births.


Optimise

Once your choice to birth your way has been made, we strongly recommend doing all that you can to reduce complications and interventions. For instance, training for a natural birth with the Epi-No has excellent results.


Holistic care

We recognise the value that midwives bring to maternity care. Our practice manager Michelle is an experienced registered midwife, so can anticipate and help you with your needs. There will of course be a midwife or two for your birth as well as Dr Sillender.


Natural birth

An aim for many.


PEARL obstetrics | gynaecology

Our office is situated opposite Glengarry Private Hospital in Perth. We provide easy free parking. We're easily accessible from Joondalup, Hillarys, Stirling, Currambine, Ocean Reef, Beldon, Connolly, Edgewater, Wanneroo, Burns Beach, Sorrento, Padbury, Marmion, Watermans Bay, North Beach, Karrinyup, Gwelup, Carine, Balcatta, Westminster, Mirrabooka, Malaga, Hamersley, Koondoola, Girrawheen, Marangaroo, Greenwood, Warwick, Madeley, Darch, Wangara, Kallaroo, Craigie, Heathridge, Woodvale, Scarborough, Doubleview, Innaloo, Osbourne Park, Wembley Downs, Tuart Hill, Trigg, North Beach. The Western suburbs (Cottesloe, Claremont, City Beach, Floreat, Swanbourne) are all within easy reach.