Pearl obstetrics | gynaecology

Maximising the chances of an uncomplicated birth

Pain relief in labour

There are many things that you can do to hopefully enhance your chances of success when having a vaginal birth. Labour and birth can be tough. The best results occur when everything is optimised and you have trained for the event! Several of the methods below are not in common use, despite very good evidence that they are highly effective.

1. Having a trusted obstetrician

Confidence in the care-giver, by having continuity of care and a good relationship, is very important to reduce anxiety and encourage healthy labour.

2. Training for the labour

It has been traditional for women to go to birth classes and learn breathing exercises and other techniques to prepare for labour and birth. These techniques provide some help coping with contractions but they don’t actually help with the pushing.

The second stage of labour (the pushing stage) needs 2 things from your muscles:

1) A lot of physical exertion for 30-60 minutes.
2) Relaxing your pelvic floor at the right time as the baby’s head comes down, while still pushing.

The human body performs better in any activity when the person has trained and prepared.

You can prepare your body for birth using a new trainer called the EPI-NO. This helps the pelvic floor muscles get ready for stretching during birth and also trains the pushing muscles. When a woman prepares for birth using the EPI-NO, the following benefits have been seen in several research studies.

• Significant reductions in the rate of episiotomy & the rate of tears (reduced from 50% to 10-20%).
• Reductions in urinary incontinence, prolapse, problems with sex, and faecal incontinence (due to fewer third degree tears).
• Significantly reduced chance of forceps or vacuum delivery.
• The second stage of labour is significantly reduced in length putting less strain on you and your baby.
• Fewer painkillers are needed, during and after.
• Babies have better APGAR scores after birth and are less distressed. This improves bonding, breast feeding & reduces crying.
• Anxiety is reduced.
• Confidence in birth is much increased.

There are no downsides. 98% of women using the EPI-NO would recommend it.

We strongly recommend this birth trainer, which costs $179, and is bought online or from pharmacies.

3. Perineal massage

Regular, frequent massage with olive oil reduces tears during birth by about 4% but is not as good as the EPI-NO.

4. Being well rested

This is really important but is overlooked by just about everyone! Pregnant women have often had poor sleep leading up to their birth for multiple reasons. Read our guide to sleep and try to optimise this as much as possible. If you have young children, can someone else look after them if they wake during the night? Can someone else get them ready in the morning? Can you get a good afternoon nap after lunch? Don’t watch TV or surf the net after 8pm. Get the pets out the bedroom. If the other half snores send him to the spare room until after the birth! Go to bed and wake at the same time every day. Have a warm milky drink before bed. Have a tepid bath a couple of hours before bedtime. If hot, use air-con if you have it, fans if not. If you have heartburn try some antacids from the pharmacist, or even some over-the-counter Zantac – it’s safe in pregnancy. Try an antihistamine like Piriton at night for its drowsy effects – it’s safe in pregnancy.

5. Having a birth supporter

There is evidence that having the support of an additional trusted person in labour is important in birth and reduces anxiety & the length of the labour. A mum, sister, or a good friend (as well as your partner) can be a great help – as long as they don’t get stressed by it all!

6. Inducing labour

You will hear more opinions on induction than just about anything else in childbirth! Some are opposed to induction because they think it increases the chance of problems. The opposite is actually true; this is now supported by Level 1 evidence.

It is very clear that induction reduces the chance of emergency Caesarean section, having a bad third degree tear, baby getting distressed, and stillbirth. Yes, it’s “not natural”. For the evidence, go here.

• Chance of death of the baby is reduced by 2/3
• 50% reduction in meconium (“baby poo”) aspiration into the lungs
• 11% reduction in emergency Caesarean section
• 25% reduction in very large babies

The optimum time for induction to get these benefits is between 39-40 weeks of pregnancy. If you decide to have an induction, we go slow and mimic natural labour as much as possible, and allow plenty of rest during the process.

7. Upright positions in labour

In early labour, walking around helps reduce discomfort and encourages baby’s head to move down. In active labour, upright positions encourage good labour. Even if you have an epidural, stay upright as much as possible. Upright positions during pushing can also be helpful for many women.

8. Having some nourishment in labour

It’s important to keep your energy levels up. If it’s looking like you’ll need a Caesarean we’ll ask you to be nil by mouth. But if not, it’s important to keep eating – nothing too “heavy” but have easily digestible high energy food.

9. Having a special injection to relax the cervix and shorten the labour

This single injection of hyoscine is well proven, has been used in pregnancy for decades, has no downsides, and will shorten labour by 2-3 hours without increasing contractions or pain at all. The baby is completely unaffected.

10. A word on epidurals

An epidural does increase the chance of a longer labour and assisted delivery. It does not increase the risk of a Caesarean however, despite what many people think. The techniques listed above will help, but not entirely as some babies are more likely to remain “back-to-back” with an epidural.
A new technique for reducing forceps and vacuum delivery rates is where we turn the baby from back-to-back to the correct way with a hand. This is called a manual rotation. It is performed when you reach full dilatation, and only if baby is healthy and it is safe.

The steps involved are
• “Topping up” the epidural
• Scanning to check baby’s position
• Making a judgement that a vaginal birth is realistic, even if the baby is turned
• Placing a hand on baby’s head inside the vagina and a hand on the abdomen
• Whilst you push, turning the baby by rotating the head and shoulder to an anterior position
• Monitoring the baby while this is happening.
• It takes up to 3 contractions to do this.
• You then push the baby out yourself as normal

It is quite successful a lot of the time and reduces the length of the pushing stage and the chance of forceps or vacuum.

11. If it’s your first birth and you have an epidural

An oxytocin drip started when you’re fully dilated, even if you’re already contracting, reduces the forceps or vacuum rate significantly.

Dr. Mark Sillender. Consultant obstetrician & gynaecologist