Thursday, September 23, 2010

8.35 Birthing the Best Baby

Physician's Notebooks 8 - See  Homepage

35. Birthing - Update 08 April 2018

The labor of birthing should give good oxygen to the soon-to-be-born from the air the laboring pregnant mother breathes. The oxygen travels in her blood to her placenta and then through umbilical cord veins into her fetus's blood. Labor and delivery must not block this. Ideally, the mother in labor should have a pulse oximeter on her finger tip with a reading 96% or higher  and, if less than 96% she should breathe 100% oxygen during labor & delivery.

Length of labor should not be longer than 24 hours because long labors lead to low oxygen to the fetus. Ultrasound fetal heart monitoring should be done continuously during labor and if fetal distress noted and birth cannot be hastened, cesarean section is best. (Assumes a top western hospital setting)

Traumatic birth (vacuum extraction, difficult forceps delivery, breech or other abnormal presenting birth, or forceful manual delivery) should be avoided in favor of cesarean section (CS) under ideal hospital birthing conditions. (Exception is with fetal distress at end of labor with birth imminent, a fast low forceps delivery is OK)

I write under the ‘best possible care’ assumption. My focus in discussing best birthing is: Leave nothing to chance. My ideal birthing woman is monitoring her pregnancy and labor (with professional assistance) and making assisted decision in the cool leisure obtained by data rather than under emergency.

Predicting fetal size and state of maturity: Assuming accurate first day Last Menstrual Period, the best time for birth is 38 to 42 weeks. Earlier birth gives a weak newborn with high risk of birth trauma to brain and other body part; later birth gives a too large newborn or stillborn, or poor placenta, low oxygenated baby that may die in labor or shortly after. Worst effect of premature or post-mature birth is brain cell damage leading to defect and retardation, or, in less obvious case, lowered IQ.

Two decisions relate to birth: Whether to go for vaginal delivery or for cesarean section (CS)? I assume immediate access to world-class CS and top neonatal care hospital care. Then, CS becomes best to avoid the lack of oxygen, the newborn brain trauma and the vaginal birth damage of complicated labor or delivery. Labor may be allowed with history of previous normal delivery; with normal size and head presentation baby; and if mother is younger than 35 and has no medical complication before or during pregnancy. If these are not normal, the best course may very well be elective CS at best time and date after fetal maturity has been confirmed clinically and by test.

Conduct of normal labor: The time for best birth starts at the pregnancy 38th week. The first sign of impending labor is ‘lightening’, or descent of the pregnant uterus in abdomen, which occurs within 4 weeks before labor. Next is increasing frequency and strength of irregular uterine contractions of pregnancy, sometime called ‘false labor’, which are felt as tightening or hardening of uterus by hand on abdomen. To know whether or not pain is true or false labor, one times the onset of 3 consecutive contractions. If they are regular and predictable (eg, every 9 to 10 minutes in early phase of labor), it is true labor. This is important because one judgment of abnormal labor is based on duration, ie, labor should not be allowed to go more than 24 hours. But this judgment hinges on when one clocks the start of true labor.
   Passage of small plug of bloody mucus (“the bloody show”) from vagina is warning of imminent labor. (It is sometimes seen after labor begins) The breaking of the bag of water (BOW), noted as gush of watery fluid from vagina (sometimes a leaky dripping that needs to be tested before BOW breaking can be diagnosed) is a more imminent sign of labor.
   In the ideal case, the pregnant mother should be monitoring fetal heart with hand-held ultrasound. The normal FH ranges from 120 to 160/min and may go as low as 100 at end of a uterine contraction. Outside that range is a sign of fetal distress. A laboring woman should have access to 100% oxygen and should breathe it if any sign of fetal distress (brown colored amniotic fluid passage and abnormally active fetal movement) or an oxygen in blood less than 96%.
   Once you determine you are in labor, or if waters break without labor, go to hospital.

Management of normal labor: (Addressed to the laboring woman) You should be up and about during most of it since gravity and walking help the fetus move down the birth canal and lying in bed makes contractions more painful and lowers maternal blood supply to the placenta and fetus. Do not pant or breathe fast. It may cause excessive alkalinity in blood that can harm the fetus and interfere with labor. Just breathe at normal rate and depth. Eat lightly; drink water. Try not to be excited. The attitude to practice is quiet concentration on doing a good labor and birthing a good new person. Feel quietly humble in order to balance the arrogance most of us express in daily life.
   Expect pain but tolerable. You will be surprised how much control you can exert over the labor & delivery staff by just acting calm with good manners and no foul or shouted words. First, walk in with a smile rather than be wheeled in. Be a good actress by showing no fear. Show you care about the other women in labor and, if you can, try to comfort them. The simplest way is not to scream or shout. Once the staff notes your attitude they will admire you and help.
   In many labor suites a newly admitted laboring woman has pubic hair shave and gets an enema. It improves the hygiene of birth. A hospital gown is better than your own getting ruined by blood and secretion. An IntraVenous needle will be put in arm vein but that is no reason to get stuck in bed – be up and around with your IV on a rolling pole unless instructed to be in bed. Fetal monitor may be attached to abdomen because the more continuously the fetus is monitored the better the chance of healthy birth.
   Show your freedom from pain's control by not reacting to it, not doubling up, and no obscenity or screaming as so many laboring women have been shown to do by the negative role model they have observed in movie or the behavior of others. The way to refer to your pain is “Hey, I’m getting a good pain right now,” and rubbing abdomen vigorously while smiling. This will affect others to help you get what you want.
   As labor comes towards the end, the pain comes on at shorter interval – 5, 4, 3 minutes –, continues longer and is more powerful. It starts in low back, spreads around to front and at peak the uterus feels rock hard and rises up in belly.
   If the BOW (bag of waters) have not yet broken, then when it breaks and gushes out the vagina, it may mean the birthing will be soon. Midwives prick open the BOW late in labor to check on fetal distress (brown fluid) and speed time to birth.
   Labor from first regular contraction to delivery should not be more than 24 hours. But earlier interruption may be needed to get out the distressed soon-born. As the birthing approaches, the laboring soon-new-mother will start feeling rectal pressure. She may no longer feel like walking about. The labor’s end and birthing may be best in an assisted sitting position although in hospital this is today rarely done and the birthing is usually in the supine position with knees up and apart. The soon-mother will feel the vagina being stretched by the soon-born crowning head. At this time, in hospital, she will have been assisted onto the birthing delivery table.
   If all is going well, best to push out a newborn without tranquilizing or pain medications. Here the pre-birthing discussion with midwife or obstetrician and whoever may give anesthesia is important in assuring that everyone involved knows everyone else’s wishes during labor without being fanatical. If there is a reasonable explanation for need for medication or anesthesia and assurance that the soon-born’s oxygenation will be OK, the soon-mother should accept the judgment of her professional assistants. At all times she should be humble.
   The key to good vaginal delivery at its final moment is good pushing according to prepared knowledge and instruction. This comes natural to most laboring women when the soon-born head is far down in birth canal causing pressure on rectum. It is like you do with a controlled, time-limited straining to expel a big bowel movement of feces. You take a breath, hold it, and give good push to the build up of the end-labor uterine contraction.
   If all goes well, a natural, spontaneous vaginal birth with the new mother awake, alert and doing the work is best. Pure oxygen by nasal catheter should keep highest possible oxygen level in maternal and fetal blood at this crucial point of birthing.
   To use skillful obstetric forceps to speed a delivery in event of sudden fetal distress when the soon-born head is distending the vulva-vagina is good because it gets the baby out into air where it can get oxygen best. But the use of forceps just to demonstrate skill or to speed a normal delivery or the use of forceps for any reason when baby’s head is high and up out of vagina is a No-No in my book. If fetal distress intervenes and low forceps is judged not applicable, immediate CS, if available under safe, modern conditions, should be done. Of course, the obstetrician should be world-class in forceps application and knowledge of its use. But vacuum extraction, meaning the application of suction cup to soon-born scalp and pulling is another of my No-No's because of the high incidence of scalp and brain hemorrhage even in expert hands.
   These questions should be discussed and settled without going to undue length with your obstetrician well before labor and birth. Nothing should be left to chance and emergency decision. Then once you have done that, you must have faith and confidence in your obstetrician or midwife and the anesthetist.
   Stillbirth and birth injury because of a big baby will rise sharply after 42 weeks, or with diabetic or pre diabetics, so if labor cannot easily or safely be induced at that time, an elective CS should be planned.
   These are the principles behind a good birth. Find world-class obstetrician and hospital and keep good communication with your prenatal and birthing personnel and a humble open mind that you will fill with good knowledge and then hope for the best birth.
   The above is the ideal case and is to be striven for by preparations. In less than ideal case, use the principles here humbly to make for the best birthing. Never be fanatic or stubbornly negative about the birthing conditions.
 END OF CHAPTER. To read next now, click 8.36 Conceiving a Boy or Girl? Choice?

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