Dr Martin Puzey, gynaecologist and obstetrician answers questions about birth from epidurals to false labour and more.
Forceps delivery, episiotomy and positions
Q: Under what circumstances does the mother have to have an enema?
A: In my opinion, there is no need to force the issue. Let the mother decide.
Q: What are the advantages of an episiotomy versus natural tearing and which will heal quicker?
A: If the birth is uncomplicated then I would suggest allowing the perineum to tear naturally. Only when there is a problem or need to have a forceps assisted delivery, would I institute an episiotomy.
Q: When is a forceps delivery used over a vacuum extraction?
A: Forceps are used when the mother needs to be assisted because there are insufficient forces to allow the baby to be delivered. A vacuum extraction is useful to assist the delivery such as when the head needs to be turned and the pushing reflex sets into motion.
Q: Regarding the various body positions for labour in hospital on your back seems to be the worst and most unnatural alternative. It is also the most painful because of the pressure of your uterus on your back and could be bad for the baby as it may reduce the amount of oxygen it receives. What alternatives are most hospitals equipped to provide?
A: I believe in empowering the woman to make her own decisions. So in this case, what ever the mother feels comfortable with. Use gravity to the best possible advantage.
False vs real labour
Q: What is false labour and how can a mother differentiate it from the real thing?
A: One of the major problems is differentiating between a latent and false labour.
The following are features of a false labour:
- It is usually felt less strongly
- It comes and goes irregularly
- It will not increase in intensity or frequency
- Lying down usually decreases the pain
- Foetus may decrease movements in labour
- A woman should definitely know when she is in labour and usually if there is any doubt in her mind, then she is not in true labour
The following are signs of true labour:
Q: At what stage should the mother contact her gynaecologist/midwife when in labour?
- A bloody ”show” together with contractions
- Leaking or a gush of amniotic fluid
- Contractions which become stronger and closer together
A: It is better to stay in a familiar and relaxing home environment for as long as possible. However, if at any time the mother starts to panic, there is no further benefit to her staying at home. If the mother’s waters break (as she starts to run the risk of an infection setting in) or if her contractions are strong and about 1-2minutes apart, she should get to the hospital immediately. It is normal to have a mucous “show ”or an increase in vaginal secretions near the end of pregnancy and this is not normally cause for undue concern.Q: How can a mother tell whether she has a urinary leak or her waters are breaking?
A: When the fore-waters break, she will normally feel a big gush. However, when the hind-waters break, it should only be sufficient to soak a sanitary pad. These waters smell sweet and a little alkaline.A mother should be careful not to confuse her waters breaking with bath/swim water, semen or urine. If any situation has taken place where the latter may be suspected, there should be no cause for concern.
Q: Very few people appear to have information on the use of the ambulatory epidural. What are the dangers associated with it and how is it different from the regular epidural? Should the anaesthetist be on hand at all times?
A: The ambulatory or walking epidural is applied in exactly the same spot on your lower spine as the regular epidural. However, the dosage of anaesthetic given is far less, allowing for more control of one’s motor nerves.The effect is that you are still able to walk around and do not need to make use of either a drip or a catheter. It is not an ideal solution when you are having a long hard labour, but is particularly effective if you have previously given birth. The anaesthetist should be available at all times.
Q: When does the mother know when to push? Does the anaesthetist time the effectiveness of the epidural so that she can feel enough to push?
A: The epidural block, unlike other regional anaesthesias is the only form of pain relief suitable for almost the entire labour. There are two types of administration: the constant infusion drip and the Bolus. The Bolus is usually administered as a single-dose block and cannot be “adjusted”.
Q: One of the most talked-about topics among modern mothers is Caesarean section. On the one hand midwives and many motherhood organisations seem to be quite against it. Some doctors, however, seem to be in favour of it it on an elective basis.
What is your take on this debate and why is there such a strong divergence of opinion? How do you manage this question with pregnant patients?
A: I feel that every birth is individual. Every labour and birth experience is unique and different in each woman. I try to give the patient an informed choice and support her in her decision. I always attempt to encourage the patient to go as “naturally as possible”. However, in many instances the patient has had a previous traumatic natural birth, or there are other fears that influence the decision making.
The decision to embark on an elective Caesarean section is certainly not taken lightly and the patient is fully counselled.
The Caesarean procedure has become extremely simple compared to 20years ago and there is prospective evidence that the mother and child are in no more danger than normal. Anaesthetics are safer and are done under a regional block. In a Caesarean section, the abdominal muscles are not cut, but pulled apart and there is no cutting of any muscular tissue. Thus there should be no more distortion of the abdominal muscle walls than with a normal delivery. I think that much of the "anti"opinion is based on old statistics and dogma in the management of C-section.
Q: Why then do so many medically-trained mothers go for an elective C-section?
A: There are potential issues with a normal delivery that they may be concerned about, like pelvic floor damage - leading to potential incontinence and vaginal laxity. It is something most people don’t talk about, but medical people might believe in the “risks of the modern C-section”.
Q: There is much Internet literature quoting higher risks for C-section versus natural birth. What is your opinion?
A: A lot of these statistics may be manipulation by people with an agenda. For instance, the data quoted above is usually from early studies. Techniques have improved dramatically since then.However, most importantly, if you want to compare apples with apples,it is impossible to take a sample of 10 000 normal pregnancies and 10000 C-sections (containing mothers needing emergency operations, having predisposing medical problems, or being whisked away from failed labour) and say “Gee! Look, the mortality rate is higher in C-sections”. That’s a pretty unfair comparison. My feeling is that a sampling comparing low risk elective C-sections and natural births(which is an impossible study) would show no real differences in mortality or morbidity.
The constant infusion mechanism enables the patient or doctor to be in control of the mother’s dosage, turning it up or down when necessary. However,trials comparing regular top-ups of epidural analgesia with top-ups on maternal demand showed that episodes of severe pain were reported by only 4% of women who received that regular top-up compared with over 30% of the women who have top-ups on demand. Also, the increased risk of instrumental deliveries associated with an epidural block may be reduced by careful timing of the top-up doses.
With a good and well-timed epidural, the mother will feel the urge to “bear down” and push.
Q: Does it affect your ability to emotionally bond with the child if your body has not been through the trauma of a labour and thus not really“prepared”.
A: In my opinion that is a completely unjustified belief.
Q: I’ve heard that you may be left with patches of numbness, particularly in your legs for many days following the delivery. What can be done to prevent this?
A: This may have a variety of causes such as malposition of the legs in the stirrups or “nerve damage” during the epidural. It will almost certainly resolve completely.