Giving birth can sometimes require medical intervention or help. Intervention procedures can include induction, augmentation, episiotomy, forceps or vacuum delivery and caesarean section. Some or all intervention procedures may not be necessary for the birth of your baby, but intervention can also make birth safer for a mother and her baby.
The onset of natural labour is triggered by the hormone oxytocin, which prompts the uterus to contract. These contractions also soften and widen the cervix (neck of the womb), so that the baby can exit the uterus through the vagina. The opening of the cervix is known as the first stage of labour. Pushing the baby out of the vagina is the second stage, and the delivery of the placenta is the third and last stage.
A normal, problem-free labour is every pregnant woman's wish, but medical intervention is needed to help the birth of the baby in around one third of cases. Some of the techniques used include induction, augmentation, episiotomy, forceps delivery, vacuum delivery and caesarean section.
The method chosen depends on a number of factors including:
- The condition of your baby
- Your condition
- The progress of labour
- Dilatation of the cervix
- How far down in your pelvis the baby has gone
- The position of the baby's head
- Your comfort and choices.
There are some concerns that medical intervention rates in Australia are too high, which suggests that procedures are sometimes being used when they are not necessary. For example, intervention rates in private hospitals are higher than in public hospitals. On the other hand, mortality rates in Australia for both mothers and their babies are exceptionally low, thanks to medical intervention techniques.
If you are pregnant, you should discuss your concerns with your doctor and consider making a 'birth plan', which outlines your preferences.
Types of medical intervention
Intervention procedures can include induction, augmentation, episiotomy, forceps delivery, vacuum delivery and caesarean section.
Induction means to bring about labour before it spontaneously occurs. You might be induced if your doctor believes that your or your baby's health is likely to benefit. Around 20 per cent of labours are induced.
You may be induced if you are pregnant with more than one baby, if you have gestational diabetes or maternal high blood pressure, if you are well past your due date (at more than 41 weeks), or if the baby’s growth has slowed down. Induction may also be used if your labour has not started within 24 to 72 hours after your membranes have ruptured (your water has broken).
When an induction is required your doctor should assess if your cervix is ready for labour (ripe and soft). This is done by vaginal examination. If the cervix is 'unripe', prostaglandin may be inserted into the vagina either in gel or pessary form. This reduces the likelihood of a 'failed induction' and prolonged labour.
Some methods of inducing labour include:
- Sweeping of the membranes – involves a vaginal examination and the circular movement of two fingers to separate the membranes from the inside of your cervix. This method may reduce the need for other forms of induction, but can cause discomfort during the procedure and some bleeding afterwards.
- Vaginal prostaglandin gel – application of a hormonal gel to the cervix to encourage it to soften and open. It can take between 6 and 18 hours for the gel to take effect and trigger labour. Dilators inserted into the cervix may also be used.
- Amniotomy – artificial rupture of the membranes, or breaking the waters. The membrane holding the baby and the amniotic fluid is punctured with a slender instrument inserted into the vagina and through the opened cervix. Labour usually begins around 12 hours after the procedure. This method may be used to induce labour if there are specific reasons for not using prostaglandins.
- Oxytocin – this hormone is produced by the mother's pituitary gland and prompts the uterine contractions during labour. A synthesised version of the hormone is given via an intravenous drip to stimulate contractions. Oxytocin is often administered where membranes have been ruptured and labour has not started.
Methods of ‘ripening the cervix’ and inducing labour that are not recommended include the use of:
- Castor oil
- Homoeopathic therapy (such as caulophyllum)
- Herbal supplements
- Sexual intercourse
- Hot baths.
If your labour is artificially induced it is essential that your wellbeing, your contractions and your baby's wellbeing are monitored closely and carefully.
Contractions of the uterus during labour generally take about 40 to 60 seconds, spaced two to five minutes apart. Sometimes labour begins naturally but the contractions aren't effective. A labour that's progressing slowly can be augmented, which means certain techniques are used to speed it along. These techniques include:
- Amniotomy – breaking the waters
- Oxytocin – this hormone is administered via an intravenous drip to stimulate uterine contractions.
The area between the vagina and anus is called the perineum. Once the baby's head starts to crown (appear) the perineum will tear if it can't stretch enough. These naturally occurring tears can be difficult to stitch and may not heal very well. In around three or four per cent of cases, the vagina tears right through to the anus.
An episiotomy is an intentional cut of the perineum, using a pair of scissors. This clean cut is much easier to control and repair, tends to heal better than a tear, and is less traumatic to the underlying muscle and tissue.
If the baby is in the vagina, but can't seem to progress any further, forceps may be used. These are large curved tongs that are gently inserted into the vagina and cupped around the baby's head. An anaesthetic may be used for the mother.
Similar to the use of forceps, a vacuum delivery aims to help the baby out of the vagina. A giant suction cup is placed on the baby's head. An anaesthetic may be used for the mother.
A caesarean section (or c-section) is the delivery of the baby through an incision in the mother's abdomen and uterus. This operation can be planned well before the birth, or may need to be performed as an emergency during labour.
A caesarean section is usually performed under regional (spinal or epidural) anaesthesia. However, sometimes general anaesthesia is required.
Around one in four Australian babies is delivered by caesarean section, and the risks are relatively low compared to other types of major surgery. A caesarean section is needed if a vaginal birth isn't possible. Some of the reasons for this may include:
- Head size – the baby's head is larger than the mother's pelvic opening
- Breech presentation – the baby is positioned to be born bottom or feet first, rather than head first
- Transverse presentation – the baby is lying sideways
- Placenta previa – the cervix is blocked by the placenta
- Placental insufficiency – the placenta is no longer providing the baby with enough oxygen
- Multiple births – in some cases, multiple babies are delivered by c-section
- Dangerous maternal conditions – such as pre-eclampsia or hypertension
- Fetal distress – the baby may not be receiving enough food or oxygen
- Prolapsed umbilical cord – the cord nourishing the baby has been pushed through the cervix into the vagina
- Last resort – when the baby can't be delivered any other way.
There is some concern about the rising caesarean section rates, particularly for women giving birth for the first time. For this reason all maternity hospitals in Victoria are required to report to the Department of Health on their caesarean rates for first-time, low-risk mothers.
Breech presentation and medical intervention
A breech presentation or a 'breech baby' is one with its bottom down and its head up towards the top of the uterus. A baby that is in the breech position at six or seven months will, in most cases, turn in the last couple of months. If it does not, your baby may be born vaginally, but it is more common for a breech baby to be born by caesarean section, particularly in a first pregnancy.
Another option is to try external cephalic version (ECV), which involves a doctor trained in the technique gently turning the baby using hands on the outside of your abdomen. This has been shown to successfully turn the baby from a breech to a head presentation in 50 per cent of cases.
Discuss breech birth alternatives with your doctor or midwife.
Improving the odds for a normal labour and avoiding medical intervention
There are certain things you can do during pregnancy to improve your chances of having a normal labour:
- Avoid smoking
- Avoid alcohol (or drink moderately only on occasion)
- Avoid 'social' drugs
- Avoid taking any medications, unless prescribed by your doctor
- Have regular medical checkups
- Go to antenatal classes
- Exercise gently and regularly throughout your pregnancy
- Eat a well-balanced diet
- Discuss any concerns or unusual symptoms immediately with your doctor.
Where to get help
- Your doctor
Things to remember
- Medical intervention is needed in around one out of every three births.
- Procedures can include induction, augmentation, episiotomy, forceps delivery, vacuum delivery and caesarean section.
- If you are pregnant, discuss your concerns and preferences about medical intervention with your doctor.
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North East Valley Division of General Practice
Fact sheet currently being reviewed.
Last reviewed: October 2011
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