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  5. Labor, Delivery, and Postpartum Issues

Some women prefer to avoid analgesic medication during childbirth. Psychological preparation may be beneficial. Relaxation techniques, immersion in water, massage, and acupuncture may provide pain relief. Acupuncture and relaxation were found to decrease the number of caesarean sections required. Most women like to have someone to support them during labour and birth; such as a midwife, nurse, or doula ; or a lay person such as the father of the baby, a family member, or a close friend.

Studies have found that continuous support during labor and delivery reduce the need for medication and a caesarean or operative vaginal delivery, and result in an improved Apgar score for the infant [87] [88].

Best Practice in Labour and Delivery

Different measures for pain control have varying degrees of success and side effects to the woman and her baby. Popular medical pain control in hospitals include the regional anesthetics epidurals EDA , and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention particularly instrument delivery , and increases in cost.

Augmentation is the process of stimulating the uterus to increase the intensity and duration of contractions after labour has begun. Several methods of augmentation are commonly been used to treat slow progress of labour dystocia when uterine contractions are assessed to be too weak. Oxytocin is the most common method used to increase the rate of vaginal delivery. The WHO does not recommend the use of antispasmodic agents for prevention of delay in labour.

Perineal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. While making a cut to the opening of the vagina, known as an episiotomy is common, it is generally not needed.

A Cochrane review compared episiotomy as needed restrictive with routine episiotomy to determine the possible benefits and harms for mother and baby. The review found that restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Obstetric forceps or ventouse may be used to facilitate childbirth. In cases of a head first-presenting first twin, twins can often be delivered vaginally.

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In some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e. Obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. Supportive care during labour may involve emotional support, comfort measures, and information and advocacy which may promote the physical process of labour as well as women's feelings of control and competence, thus reducing the need for obstetric intervention. The continuous support may be provided either by hospital staff such as nurses or midwives, doulas , or by companions of the woman's choice from her social network.

There is increasing evidence to show that the participation of the child's father in the birth leads to better birth and also post-birth outcomes, providing the father does not exhibit excessive anxiety. Continuous labour support may help women to give birth spontaneously, i. Continuous labour support may also reduce women's use of pain medication during labour and reduce the risk of babies having low five-minure Agpar scores. For monitoring of the fetus during childbirth, a simple pinard stethoscope or doppler fetal monitor " doptone " can be used.

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A method of external noninvasive fetal monitoring EFM during childbirth is cardiotocography , using a cardiotocograph that consists of two sensors: The heart cardio sensor is an ultrasonic sensor , similar to a Doppler fetal monitor , that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound. The pressure-sensitive contraction transducer, called a tocodynamometer toco has a flat area that is fixated to the skin by a band around the belly. The pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction.

The WHO states: "In countries and settings where continuous CTG is used defensively to protect against litigation, all stakeholders should be made aware that this practice is not evidence-based and does not improve birth outcomes. A mother's water has to break before internal invasive monitoring can be used. It can also involve fetal scalp pH testing. Per figures retrieved in , since there has been a 44 per cent decline in the maternal death rate. However, according to figures women die every day from causes related to pregnancy or childbirth and for every woman who dies, 20 or 30 encounter injuries, infections or disabilities.

Most of these deaths and injuries are preventable. In , noting that each year more than , women die of complications of pregnancy and childbirth and at least seven million experience serious health problems while 50 million more have adverse health consequences after childbirth, the World Health Organization WHO has urged midwife training to strengthen maternal and newborn health services. To support the upgrading of midwifery skills the WHO established a midwife training program, Action for Safe Motherhood.

The rising maternal death rate in the US is of concern.

In the US ranked 12th of the 14 developed countries that were analyzed. However, since that time the rates of every country have steadily continued to improve while the US rate has spiked dramatically. While every other developed nation of the 14 analyzed in shows a death rate of less than 10 deaths per every , live births, the US rate has risen to By comparison, the United Kingdom ranks second highest at 9.

Compared to other developed nations, the United States also has high infant mortality rates. The Trust for America's Health reports that as of , about one-third of American births have some complications; many are directly related to the mother's health including increasing rates of obesity, type 2 diabetes, and physical inactivity. The U. Centers for Disease Control and Prevention CDC has led an initiative to improve woman's health previous to conception in an effort to improve both neonatal and maternal death rates.

The second stage of labour may be delayed or lengthy due to poor or uncoordinated uterine action, an abnormal uterine position such as breech or shoulder dystocia , and cephalopelvic disproportion a small pelvis or large infant. Prolonged labour may result in maternal exhaustion, fetal distress, and other complications including obstetric fistula. Eclampsia is the onset of seizures convulsions in a woman with pre-eclampsia. Pre-eclampsia is a disorder of pregnancy in which there is high blood pressure and either large amounts of protein in the urine or other organ dysfunction.

Pre-eclampsia is routinely screened for during prenatal care. Onset may be before, during, or rarely, after delivery. Around one percent of women with eclampsia die. A puerperal disorder or postpartum disorder is a complication which presents primarily during the puerperium, or postpartum period. The postpartum period can be divided into three distinct stages; the initial or acute phase, six to 12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months.

Postpartum bleeding is the leading cause of death of birthing mothers in the world, especially in the developing world. Globally it occurs about 8. Uterine atony, the inability of the uterus to contract, is the most common cause of postpartum bleeding. Following delivery of the placenta, the uterus is left with a large area of open blood vessels which must be constricted to avoid blood loss. Retained placental tissue and infection may contribute to uterine atony.

Heavy blood loss leads to hypovolemic shock , insufficient perfusion of vital organs and death if not rapidly treated. Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than The infection usually occurs after the first 24 hours and within the first ten days following delivery.

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Infection remains a major cause of maternal deaths and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of childbed fever and his work saved many lives. Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface. Abnormal and persistent fear of childbirth is known as tokophobia. Most new mothers may experience mild feelings of unhappiness and worry after giving birth.

The feelings, often termed the "baby blues" , affect up to 80 percent of mothers. They are somewhat mild, last a week or two, and usually go away on their own. Because of the severity of the symptoms, postpartum depression usually requires treatment.

The condition, which occurs in nearly 15 percent of births, may begin shortly before or any time after childbirth, but commonly begins between a week and a month after delivery. Childbirth-related posttraumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. Examples of symptoms include intrusive symptoms , flashback s and nightmare s, as well as symptoms of avoidance including amnesia for the whole or parts of the event , problems in developing a mother-child attachment , and others similar to those commonly experienced in posttraumatic stress disorder PTSD.

Many women who are experiencing symptoms of PTSD after childbirth are misdiagnosed with postpartum depression or adjustment disorders. These diagnoses can lead to inadequate treatment. Postpartum psychosis is a rare psychiatric emergency in which symptoms of high mood and racing thoughts mania , depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions set in, beginning suddenly in the first two weeks after childbirth.

» Labour and Delivery / Maternal Newborn Unit

The symptoms vary and can change quickly. The most severe symptoms last from two to 12 weeks, and recovery takes six months to a year. Five causes make up about 80 percent of newborn deaths. They include prematurity and low-birth-weight, infections, lack of oxygen at birth, and trauma during birth.

Preterm birth is the birth of an infant at fewer than 37 weeks gestational age. It is estimated that one in 10 babies are born prematurely.

Premature birth is the leading cause of death in children under five years of age though many that survive experience disabilities including learning defects and visual and hearing problems. Causes for early birth may be unknown or may be related to certain chronic conditions such as diabetes, infections, and other known causes. The World Health Organization has developed guidelines with recommendations to improve the chances of survival and health outcomes for preterm infants. Newborns are prone to infection in the first month of life.

Labor, Delivery, and Postpartum Issues

The organism S. The baby contracts the infection from the mother during labor. In it was estimated that about one in newborn babies have GBS bacterial infections within the first week of life, usually evident as respiratory disease, general sepsis , or meningitis. Untreated sexually transmitted infections STIs are associated with congenital and infections in newborn babies, particularly in the areas where rates of infection remain high.