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This chapter describes procedures that may be performed during labour or delivery in a hospital or other properly equipped health facility. It also explains why these procedures may become necessary. Only trained medical or midwifery personnel in a well-equipped facility should perform these procedures.
Labour normally starts by itself about the 40th week of pregnancy. About 30 of every 100 babies are born before their due dates. About ten of every 100 babies are born more than ten days after their due dates. If labour has not started by itself after the 42nd week, however, it may be necessary to start labour artificially. If there are signs that the baby is not doing well (for example, the mother has not felt the baby move for 24 hours or more), it is definitely time for the mother to be taken to a hospital for evaluation. The baby's life may be at risk. Other possible reasons for starting labour artificially include pregnancy complications such as pre-eclampsia, diabetes, premature rupture of the membranes, or a previous pregnancy that has resulted in the birth of a dead baby around term.
Labour can be induced by giving the woman an enema which irritates the bowel and can cause the womb to start contracting. Sometimes a special drug called an oxytocin is given to cause the womb to contract. This drug is given in the form of a slow drip through a vein in the arm. It may take quite a long time for labour to start when these methods are used.
Labour can also be induced by artificial rupture of the membranes. With this procedure the bag of water surrounding the baby is punctured and the fluid is allowed to drain away. The effect is the same as when the membranes rupture by themselves; labour usually starts within a few hours. This procedure is usually no more uncomfortable than a vaginal exam.
Inducing labour may not be effective unless the cervix is "ripe" or ready for labour to start. Inducing labour works best if the cervix is already open a little bit, and the baby's head is low. If an attempt to start labour is unsuccessful, a Caesarean section may be necessary.
An episiotomy is a deliberate, clean cut made at the outside entrance of the vagina (see Figure 12.1). It is sometimes done when it appears that the delivery of the baby's head is likely to cause a tear in the opening of the vagina. It may also be done to speed the delivery of a distressed baby. Usually a pain-killing injection is given to the area before the cut is made. After the baby is born the cut is stitched up. The stitches may have to be removed after a few days. In many cases, when catgut is used, they dissolve by themselves and do not need to be removed. Women often feel very sore for a while around the episiotomy, but this usually disappears within a few weeks. Good hygiene is necessary to prevent an infection.
Figure 12.1: Episiotomy
An episiotomy is an incision or cut made at the entrance of the vagina during labour.
In women who have undergone female genital mutilation (female circumcision), the entrance to the vagina may be tightly closed and the surrounding tissues hardened by scarring. Normal delivery is impossible without further severe damage. A large episiotomy is often necessary to permit delivery through the vagina.
An obstetric forceps is an instrument that is specially designed to help pull the baby out of the vagina or birth canal. There are usually two reasons for forceps delivery. If the first stage of labour is very long, a woman may be too exhausted to make the final effort to push the baby out. Also, if the baby shows signs of distress it may become necessary to shorten the second stage of labour. A forceps delivery can be quite uncomfortable or painful. A local anaesthetic is usually injected into the nerves around the birth canal in order to lessen the pain. Occasionally, a general anaesthetic may be required.
Another procedure to pull the baby out is vacuum extraction. With this procedure a metal or plastic cup is applied to the baby's head and attached by means of a vacuum. By pulling on the cup, the baby is gradually pulled out of the birth canal.
After a forceps delivery or vacuum extraction, there may be marks made by the instrument on the face or head of the baby for a few days. These are nothing to worry about; they will soon disappear.
If the placenta fails to separate from the womb at the end of the second stage of labour, it may be necessary to remove it manually. A trained health worker can do this. The procedure involves using a catheter, then putting a sterile, gloved hand into the womb and gently separating the placenta from the womb. The placenta should then be checked to make sure it is complete, and that no pieces were left in the womb. An oxytocic drug is given to help make the womb contract. Antibiotics are also given to prevent an infection. The woman should be given iron tablets to prevent anaemia.
The procedure can be rather uncomfortable after the strain of childbirth. To avoid discomfort, an anaesthetic may be given, but it is not always necessary. If the placenta was retained in a past delivery it may happen again. Women who have had retained placenta before should have future deliveries in a clinic or hospital where a trained person can remove the placenta manually if necessary.
For the health and safety of both mother and baby, it is sometimes necessary to deliver the baby by an operation. There are two types of operations most commonly performed: Caesarean section and symphysiotomy.
Figure 12.2: Caesarean
Section
A Caesarean section is an operation in which the abdomen and womb are cut open and the baby and placenta are removed. The womb and abdomen are stitched up and left to heal.
"Classical" or Vertical Incision
If a previous Caesarean section was done with a vertical cut in the uterus, the woman should have a Caesarean section with all future deliveries.
Transverse Incision
If a previous Caesarean section was done with a transverse or horizontal cut in the lower part of the uterus, it may be possible for the woman to deliver normally. However, she should deliver in a hospital in case an operation is necessary.
CAESAREAN SECTION: A Caesarean section is a major operation in which the abdomen and womb are cut open and the baby and placenta are removed. The womb is not removed; it is stitched up and left to heal (see Figure 12.2). The operation has to be performed under general or local anaesthesia to make sure the woman does not feel anything. Such an operation should be performed only in a fully equipped hospital and by someone who has been well trained to perform the procedure. There are several reasons why a Caesarean section might become necessary:
· Prolonged labour - that is, labour that has lasted more than 12-18 hours without any sign that the baby is going to come out safely. This could be due to several reasons, but the most frequent cause of prolonged labour is when there is an obstruction (see Chapter 11).· Abnormal presentation (see Chapter 11).
· Heavy bleeding before delivery (see Chapter 9) or, occasionally, heavy bleeding during labour (see Chapter 11).
· Severe hypertension, pre-eclampsia, or full eclampsia (see Chapters 9 and 11).
· Signs that the baby is in distress, such as a slow or irregular heartbeat.
· A previous Caesarean section. Depending on the type of Caesarean section that was done and the reason it was done, it may be necessary to repeat the Caesarean section. It may be possible for the woman to have a normal delivery through the vagina if the baby is a normal size and is lying head-down, if the woman had only one previous Caesarean section, and if the scar was in the lower part of the womb. Even if a normal delivery is being attempted, it should take place in a hospital in case another Caesarean section becomes necessary.
· Previous pregnancies that have ended in a stillbirth, or diabetes or severe heart disease in the woman.
The risk of dying from a Caesarean section is higher than for a normal delivery, largely because of an increased risk of infection. A Caesarean section should be carried out only if it is really necessary.
SYMPHYSIOTOMY: When labour is obstructed, a symphysiotomy is sometimes performed. In this operation, a small cut is made at the top of the pubic bone so that the bones around the birth canal can be opened a little more to allow the baby to pass through. The operation is performed with anaesthesia.
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Summary: Some Obstetric Operations and Procedures Sometimes during labour it is necessary to perform procedures which will facilitate delivery. These should only be performed by properly trained personnel using appropriate equipment. | |
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CIRCUMSTANCES |
PROCEDURE |
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No labour after 42 weeks Slow heartbeat in the baby, or other signs that the baby might be in trouble Pre-eclampsia or diabetes Early rupture of membranes when the baby is near term |
INDUCTION OF LABOUR: Methods include: giving an enema artificial rupture of membranes |
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Scar tissue in the vagina due to genital mutilation Signs of distress in the baby |
EPISIOTOMY: A cut is made at the entrance to the vagina to enlarge the opening for delivery. It is sewn up after delivery. Drugs are used to stop the pain. |
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Exhaustion on the part of the mother Signs of distress in the baby |
FORCEPS OR VACUUM EXTRACTION: The baby is pulled out of the birth canal using forceps or a vacuum. |
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Failure of the placenta to separate from the womb after the baby is born |
MANUAL REMOVAL OF PLACENTA: A doctor or trained midwife uses his or her hand to separate the placenta from the womb. |
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Prolonged labour Obstructed labour Heavy bleeding Hypertension/pre-eclampsia/eclampsia Previous Caesarean section (depending on the type of scar) Transverse lie near the due date Fistula during a previous delivery |
CAESAREAN SECTION: The abdomen and womb are cut open and the baby is removed. The abdomen and womb are then stitched closed. Sometimes when labour is obstructed, a symphisiotomy is performed. |
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