Here at the Rotunda, we consider birth as a normal exciting life event and all the staff work together as a team to provide the care that you need to keep you and your baby well throughout your pregnancy, labour and birth.
DELIVERY SUITE ENVIRONMENT
The delivery suite rooms are designed to provide an environment that is relaxing, personal and calm. The birthing rooms are single occupancy rooms that contain many home comforts, for example, dimmed lighting, labouring mats and cub chairs. The delivery suite also has a five bedded room for women who require monitoring in the early stages of labour.
Staff caring for you
The team on the delivery suite consists of midwives who are the main care providers, doctors, care assistants and non-clinical support staff. Student midwives, care assistants and medical students are supervised by the midwives.
The obstetric doctors are always available if there are any concerns regarding you or your baby during labour. The doctors and midwives carry out ward rounds at regular intervals throughout the day. The anaesthetic team provides a 24-hour epidural service and provides anaesthetic support if surgery is needed. Paediatricians provide care for your baby at birth, if necessary and afterwards.
If you are attending for private care, the midwife will be in contact with the consultant during your labour to inform them of your progress and they will attend the birth. If you are attending for semi-private care, the midwife will be in contact with the doctors on duty, informing them of your progress. The registrar or consultant may attend the birth and may undertake any perineal suturing (stitches) that is required.
We think it is very important to help you to make choices that are right for you and your baby when you are in labour. The staff will keep you informed of your progress in labour and they will discuss various options of care available to you. The health and safety of you and your baby is always the most important consideration when care options and choices are discussed.
At the Rotunda, we support your right to choose a birth partner. Your birth partner might be the baby’s father, a close relative or friend. It’s your choice. However, we can only let one named birth partner stay with you during labour and birth. The midwives will advise and assist your birth partner to support and encourage you throughout your labour and the birth.
There is no right or wrong way to go into labour. Every woman does it differently and no two labours are the same. There are three stages to labour – throughout the first stage, your womb (uterus) will contract repeatedly causing your cervix (neck of the womb) to thin, shorten and dilate. The first stage ends when your cervix has fully dilated to 10 cms. During the second stage of labour, the baby is pushed down through the birth canal and is born. In the third stage, the placenta (afterbirth) is delivered and bleeding is controlled.
When you are admitted, you will be shown to your birthing room and a midwife and student will be assigned to support and care for you. The midwife will ask you about your pregnancy and labour so far and will carry out an assessment of you and your baby. They will review your healthcare record. If you like, you can change into more comfortable clothes. We recommend loose clothing, preferably made from cotton, as you may feel hot during labour.
As part of the assessment, the midwife will:
- take your temperature, pulse and blood pressure and also do a urine test;
- palpate (feel) your tummy to check the position of your baby and listen to the baby’s heartbeat;
- examine you internally (vaginal examination) to check how much your cervix has opened.
INDUCTION OF LABOUR
You may be admitted to the general prenatal ward for induction of labour. As your labour becomes established you will be transferred to a delivery suite room. Induction involves starting labour artificially. Labour may be induced if there is some risk to you or your baby’s health or if you are overdue. Induction of labour can take up to 24 hours: the longest part is getting the cervix to soften and open to about 2 cm. If your labour is induced, your contractions and your baby’s heartbeat will need to be continuously monitored.
There are four methods used to induce labour. Some women might need just one method, while others might need more. You will be given an information leaflet in the clinic once the decision is made to induce your labour and the doctor will tell you about the possible methods needed to induce your labour when you arrive in the hospital.
Prostin is a hormone used to soften and shorten the cervix, sometimes referred to as ‘ripening the cervix’. Before the prostin gel is inserted into your vagina, the midwife will carry out some assessments and observations on you and your baby, including monitoring of your baby’s heartbeat (CTG) for three minutes.
Once the prostin is inserted, you will be asked to stay in bed for one hour to help the gel to work. Continuous monitoring of the baby’s heartbeat will be undertaken for the first 30 minutes. After the hour you will be encouraged to walk about and to eat light food if you wish. At this stage, you might have pains like period pains. Some women may require a second or third prostin gel as part of the induction process.
Very occasionally, the prostin gel may cause your womb to contract too much and this in turn may affect the baby’s heartbeat. If this happens, you will be asked to lie on your left side and you may be given a drug to help your womb relax. Some women go into established labour following this method of induction.
The pessary, which is like a very small tampon is inserted into the vagina and is left there for 24 hours. During this time, a hormone like prostaglandin will be slowly released and this helps to ripen the cervix. After this time, the pessary is removed and the membranes are then ruptured.
Artificial rupture of the membranes (ARM)
This method of induction is to artificially break the membranes – the bag of water surrounding the baby. The doctor will carry out a vaginal examination and break the waters. This is a painless procedure for you and your baby and is like bursting a fluid-filled balloon. Once the waters break, fluid called ‘liquor’ will drain throughout your labour. Sometimes, this method of induction is enough to start labour.
This method of induction is by means of an oxytocin drip. This is explained in the next section – acceleration of labour.
ACCELERATION OF LABOUR
If your labour is slow, the doctor or midwife may recommend speeding up or accelerating your labour. Your labour can be speeded up by breaking your waters artificially (ARM) or by starting you on a drip with a hormone called oxytocin, once your waters are broken. This hormone will encourage contractions and the dose of oxytocin can be altered according to the length, strength and frequency of your pains. Once the drip is started, it usually continues until the birth of your baby.
If the oxytocin drip is used to speed up your labour, the frequency and length of your contractions and the baby’s heartbeat are monitored continuously. A known side effect of this drip is that the contractions can become too frequent or too long. This may affect your baby’s heart rate. If this happens, you will be asked to lie on your left side, the rate of the drip will be reduced or turned off and a senior member of staff will review you. The contractions return to normal very quickly once the drip is stopped. You can move about (unless you have an epidural) and use upright positions even if continuous monitoring is required.
FIRST STAGE OF LABOUR
During early labour some women find a warm bath helpful. Listening to soft music or going for a walk can also help. Simple, over-the-counter drugs like paracetamol can be taken, particularly if you have backache. Walking and using upright positions can improve your comfort too. In the early part of labour, you may have some light food.
Signs of true labour include:
- contractions occurring regularly;
- contractions getting longer, stronger and closer together.
The length of the first stage of labour can be different for every woman. If it is your first labour, the time from the start of labour to full dilation of the cervix (10 cm) is usually 6 – 12 hours. If it’s not your first labour, the time is usually shorter. The midwife will monitor the progress of your labour by continuously assessing the frequency and length of your contractions. They will check every few hours to see how your cervix is dilating, what way the baby is presenting and how the baby is moving down through the pelvis.
Generally, as labour progresses, your contractions will become more frequent, stronger and more painful. The bag of water (liquor) may still be present or may break at any time during this period.
Throughout your labour, the midwife provides emotional support, including reassurance and encouragement. They will tell you what is happening and help you to communicate your needs to other members of the team and help you to make choices that work for you. If you need any medical help to ensure your own safety and your baby’s safety, the midwife will explain the reasons for it.
Towards the end of the first stage of labour, you may feel like pushing during the contractions. The midwife will let you know when the cervix is fully dilated and when it is safe to push.
MONITORING YOUR BABY'S WELLBEING
The midwife will monitor your baby’s heartbeat throughout your labour. The midwife is watching for any changes in the heartbeat that may suggest your baby is becoming distressed or tired. The simplest method of monitoring is by using a pinard stethoscope. This is a trumpet-shaped stethoscope that helps the midwife to hear your baby’s heartbeat through your tummy. A doppler is a small hand-held ultrasound machine that looks like a microphone. It is placed on your tummy and allows you, your birth partner and midwife to listen to the baby’s heartbeat.
If there are any concerns about your baby’s heartbeat or if your pregnancy or labour falls into a ‘high risk’ category, continuous monitoring is recommended. This is done using a CTG machine. Two pads are placed on your tummy: one records the contractions and the other records the baby’s heartbeat. Sometimes it can be difficult to get a good printout of the heartbeat this way. The midwife might suggest putting a ‘clip’ on your baby’s head to improve the recording of your baby’s heartbeat. This involves securing a thin curved wire to the skin of your baby’s scalp during a vaginal examination. Some women are concerned that they can’t move around if they are attached to the CTG machine. The midwife will help you to find comfortable upright positions and there are pictures on the delivery room walls suggesting positions that you might find comfortable.
PAIN MANAGEMENT IN LABOUR
There are several ways of helping you cope with pain in labour. Relaxation and breathing techniques and walking are some of the self-help techniques. Some women find gentle massage, using warm water in the shower or bath helpful. It is difficult to know before labour what will work best for you. The midwife will be able to provide you with additional information to help you choose what suits you. Here are some facts about the main methods of pain management available in the Rotunda.
Natural methods of pain relief
Anti-burst gym ball
Sitting on a gym ball encourages a natural swaying and rotating motion of the pelvis and can help to move the baby down through the birth canal. Sitting on the ball can help to take pressure off your bottom. The way you sit on the ball is similar to a squat, which helps to open the pelvis and speeds up labour. Gentle moving on the ball reduces the pain of the contractions and it also means your partner can rub your back if you would like it massaged. If you are considering using a gym ball, please purchase an anti-burst one and make sure that it is inflated to the recommended level.
The sense of touch has been associated with the power of healing since the beginning of time. Touch has the power to soothe pain. Some women like a light, stroking massage or a long stroke massage, while others like firm, circular massage particularly if they are tense or are having back pain. Massage oils can be used and we recommend you talk about and practice the different types of massage with your birth partner before labour.
These relaxation techniques work by making you aware of your breathing patterns. Focusing on how you are breathing helps you to breathe slowly and deeply. It helps you to avoid holding your breath – holding your breath tenses up your muscles and reduces the level of oxygen. Some women develop techniques to help them concentrate on their breathing such as chanting a word or poem, or focusing on just one element of the breathing cycle.
Thinking about or imagining something pleasant can encourage relaxation and help women manage their pain in labour.
Aromatherapy is a way of accessing and applying the therapeutic benefits of plants by using oils called ‘essential oils’, which are extracted from plants, usually by distillation. They can be used in baths, compress, vaporisation, showers, inhalation and massage with specified essential oils and carrier oils such as sunflower.
Warm or cold pack
Warm or cold packs are simple ways of easing pain and helping you to relax in labour. You can buy heat and cold packs in your local pharmacy. An ice pack or heat pack on the lower back can help to ease backache.
Music can help you to relax and reduce stress and tension. It might also help you to focus on your breathing and take your mind off the contractions.
Gas and air (entonox)
This is a mixture of oxygen and another gas called nitrous oxide. You breathe it in through a mouthpiece when you have a contraction. It acts quickly and wears off quickly once you stop using it. While it won’t take the pain away completely, it makes the contractions easier to cope with. It doesn’t cause any harm to the baby and it can be used at any time during labour. It can also be used with the TENS machine.
TENS stands for ‘transcutaneous electrical nerve stimulation’. Four electrodes are placed on your back, which are connected to a small hand-held device that is battery operated. TENS has been used for back pain for many years. It works by stimulating the nerve near your womb and your body responds by producing natural ‘morphine like’ substances called endorphins. These are the body’s natural painkillers. The TENS machine helps to ease the pain for some women. There are no known side effects for either you or your baby and you can continue to move around while using it.
It is recommended that you start using the TENS machine as soon as your contractions become regular. As this often happens when you are at home, you may consider renting or buying one. If you start to use it at home, you can continue to use it throughout your labour. Some TENS machines are also available in the delivery suite.
Analgesia in labour
Pethidine is a drug that is injected into the muscle in your buttock (bottom). A second drug is given at the same time to stop you feeling sick. It takes about 20 minutes to work and the effects last between two and four hours. It works by easing the pain and it helps you to relax. Pethidine can make some women feel a bit light-headed and forgetful. The drug passes through the placenta to the baby so if it is given too close to birth, it may temporarily affect your baby’s breathing at birth and the initiation of breastfeeding.
An epidural is generally the most effective form of pain relief during labour. The word ‘epidural’ refers to a space in your back where pain messages from your womb and birth canal pass to the brain. An epidural involves injecting local anaesthetic and pain relieving drugs into this space to block the sensation of pain. If you decide you want an epidural, the anaesthetist will tell you how the procedure works and explain the advantages and possible side effects. You will need to sign a consent form before you can have an epidural.
It takes about 20 minutes to set up the epidural. You will need a drip in your arm to give you extra fluids so that your blood pressure does not fall. The midwife will help you into a sitting position or you can lie on your side. This makes it easier to get the epidural tube inserted. You will be asked to stay very still while the tube is being inserted.
The epidural can be very helpful for women who are having a long and painful labour. It takes the pain away for most women. Some of the disadvantages of having an epidural include having difficulty passing urine so a catheter (tube) is placed into your bladder to keep it empty. Your legs may feel heavy so you must stay in bed. Your baby’s heartbeat will be monitored continuously.
Some of the known side effects of an epidural are:
- the second stage of your labour may take longer;
- you are more likely to have an assisted birth with forceps or vacuum (but it doesn’t increase the chance of needing a caesarean section);
- you might have some backache for a few days after an epidural. (Long-term back pain after birth can happen with or without an epidural.);
- 1 in 100 people can develop severe headaches in the days following birth. This can be treated but it involves having another epidural procedure.
The risk of injury to the nerves in the epidural space is very small. This side effect is thought to occur 1 in 10,000 times. Numbness, tingling, or weakness in one or other leg can also rarely occur (1 in 2,000 times) following births where epidurals have not been used.
SECOND STAGE OF LABOUR
The second stage of labour starts when your cervix is 10 cm dilated. This will be confirmed by an internal (vaginal) examination. Up to an hour may pass before you will be asked to start active pushing. During this time, the baby’s head will come down through the birth canal. The urge to push is caused by the pressure of your baby’s head on your back passage. Sometimes, this feeling of pressure can make the bowels open.
Getting familiar with pushing may take some time, especially if it is your first baby. If you don’t have an epidural, find a position that is comfortable and effective for you. You may wish to stay on the bed supported with pillows or to kneel, squat, stand or sit. These positions can be adopted on the bed or on the floor.
As the baby’s head descends further through the birth canal, the contractions get stronger and so does the urge to push. If you have an epidural, you won’t really be aware of these sensations. Your midwife will advise and encourage you. This stage is hard work and it is important to rest and relax between the contractions. After each contraction the midwife will listen to your baby’s heart rate and will keep you informed of your progress. Your birth partner will also encourage you and may offer you sips of water and help support you in your chosen position.
As your baby’s head moves down to the vaginal opening, the baby’s head will become visible. At a certain stage, the midwife will tell you to either stop pushing, to push very gently or to pant (breathe in and out quickly through your mouth). This is important so that your baby’s head can be born slowly, giving the skin and muscles of the perineum time to stretch without tearing. (The perineum is the area between the vagina and the back passage.) Sometimes the skin won’t stretch enough and may tear or it may be necessary to perform an episiotomy, which is a cut in the skin to widen the opening. The perineum is numbed with a local anaesthetic before an episiotomy is done (unless you have an epidural).
After your baby’s head is born, the hard work is over. With one more contraction, your baby’s body will be born. After a few minutes, when the cord has stopped pulsating, the umbilical cord will be clamped and cut. Your baby will be dried and then placed on your chest and tummy for at least an hour of skin to skin contact.
Sometimes, some mucous needs to be cleared from the baby’s mouth and nose. If your baby needs oxygen or any other care immediately after birth, they will be placed on a radiant warmer, which is like an open cot with a heater overhead, in the birth room. As soon as possible, your baby will be returned to your arms and placed on your chest.
A caesarean section is an operation to allow the baby to be born without going through the birth canal. A caesarean section can be planned (elective) or unplanned (emergency). The baby is born through an incision or opening in your tummy just below the bikini line. The midwife will come with you to theatre and will care for your baby when it is born.
Usually your birth partner can come with you to the theatre for the baby’s birth. This will depend on how urgent your caesarean section is. Also, the obstetrician and anaesthetist must agree that it’s ok. If your partner can’t come with you, the midwife will stay with you throughout the operation; your birth partner will wait outside the theatre and will see your baby as soon as possible after birth.
If possible, the operation is performed under epidural or spinal anaesthetic. (A spinal anaesthetic is like an epidural but the drugs are injected into the fluid surrounding the lower spinal cord). A general anaesthetic (which puts you to sleep) is sometimes necessary in an emergency situation when the baby needs to be delivered very quickly and an epidural is not in place. If you have the caesarean section under epidural or spinal, you will be awake throughout the operation. You won’t feel any pain but you may feel some tugging as your baby is born. The operation takes about 30 – 40 minutes but the baby is usually born within the first ten minutes. A curtain or divider will prevent you and your partner from seeing the operation being performed. Once the baby is born and providing you and your baby are both well, the baby can be placed directly on your chest for skin to skin contact. If you are unable for skin to skin contact at this time, your partner will be given your baby to hold skin to skin.
Assisted vaginal delivery (ventouse or forceps delivery)
Some women need help to deliver their baby vaginally. This may be due to the baby’s position, because of exhaustion where the body is not able to push the baby out or if the baby is becoming distressed during birth. The midwife and doctor will explain the process to you. A ventouse (vacuum) is a shallow suction cup placed on the baby’s head. This suction helps to get the baby out quickly. Forceps are metal instruments, which look like a tongs. One part of the forceps is gently placed on each side of the baby’s head. You will be told to continue pushing during contractions while the doctor helps you using the ventouse or forceps. An episiotomy is more likely to be performed if you need an assisted vaginal delivery, in order to reduce the chance of you needing a lot of stitches.
THIRD STAGE OF LABOUR
The third stage of labour starts after the birth of your baby and ends once the placenta (afterbirth) is delivered and the bleeding is controlled. At the Rotunda, we recommend using an injection to help complete the third stage. The injection makes the womb contract which helps to separate the placenta. This reduces the risk of excessive bleeding.
Some women choose to deliver the placenta without the use of drugs. We can help you to do this if you:
- are not at risk of any complications of bleeding;
- had no drugs administered during labour;
- have discussed this option with your doctor or midwife during your pregnancy and in early labour.
Once the placenta is delivered, the womb normally stays contracted, which helps reduce the blood loss. On average, women will lose 100 – 200 mls of blood at birth. Your body has been preparing for this and you should not feel any side effects.
Sometimes, a detailed laboratory investigation on the placenta is recommended. This may identify certain factors that may relate to your pregnancy or the wellbeing of your baby. If your placenta is sent to the laboratory, the hospital will dispose of it once any tests are completed. If you have any specific requests relating to the placenta, please discuss them with your midwife or doctor.
IMMEDIATE CARE OF YOUR BABY AFTER BIRTH
Skin to skin contact
Immediately after birth, your baby will be dried and placed on your chest and tummy in direct contact with your skin and you will both be covered with a blanket. Skin to skin contact allows you to look closely at your baby and to touch them for the first time. Skin to skin contact also comforts your baby as they stay close to you. We recommend you put a hat on your baby’s head to help them keep warm. At the Rotunda, we aim to allow uninterrupted skin to skin contact for at least 60 minutes. If you are going to fall asleep during skin to skin contact or anytime your baby is lying prone (on their tummy) make sure there is somebody close by to check on your baby.
The timing of the first breastfeed depends on when your baby is ready to feed and it will usually start within 30 minutes of the birth. Your midwife will help you to latch your baby onto your breast and your baby can enjoy their first feed. Early feeding has been shown to help with the successful establishment of breastfeeding. These first precious moments are a very special time and allow you and your partner to welcome your new baby and to decide whom they look like!
Although the majority of babies cry at birth, some babies will need a little help to take their first breath. If the midwife or doctor has any concerns about the baby, a paediatrician will attend the birth. Babies who need help to breathe in the first few minutes usually recover quickly and can be placed skin-to-skin once they are crying and breathing themselves. Occasionally, babies may need ongoing care and observation by the midwife and paediatrician. In this case, your baby will remain under the radiant warmer in the birth room. Should your baby need to be admitted to the neonatal unit, the paediatrician will give you a detailed explanation of the reasons.
Identification and security
Identification bands will be put on your baby’s wrist and ankle. These bands will contain your details and those of your baby, including its sex. The details on the band will be checked with you before the bands are put on. It is important that the identification bands stay on your baby for as long as you are both in hospital. The midwife will also place a security tag on your baby’s ankle. The baby tag helps us to keep your baby safe while in hospital. If you notice that either the identity band or the security tag fall off your baby, please inform a member of staff immediately, so that the band or tag can be replaced.
The first question parents ask once the baby’s sex has been discovered is “what’s the weight”? The midwife will weigh your baby before transfer to the postnatal ward. The midwife will also carry out a physical examination of your baby including counting fingers and toes. This first physical examination will confirm that your baby appears to be healthy and well. The baby’s temperature will also be checked.
The Rotunda Hospital recommends that all newborn babies receive an injection of vitamin K following birth. Your midwife will discuss this with you during labour. Vitamin K is important for blood clotting and newborn babies don’t have any stores of the vitamin in their bodies. Babies make vitamin K as they start feeding and their gut matures over the first 3 – 6 months. The injection offers protection until your baby produces sufficient amounts of vitamin K.
IMMEDIATE CARE OF YOU AFTER BIRTH
Your beautiful newborn baby will seem to have the attention of everyone in the room, but you are also very important! Following the birth, the midwife or doctor will examine your vaginal area to see if you need any stitches. If you do, your perineum will be numbed with local anaesthetic (unless you have an epidural) and the stitches will be put in. Usually, one continuous stitch is used to repair the skin edges, which is more comfortable. The stitches dissolve over the next six weeks and do not need to be removed.
The midwife will also check your blood loss and will feel your tummy to make sure that your womb stays contracted. The midwife will check your temperature, pulse and blood pressure and will make sure you are comfortable and pain free.
Once you have finished feeding your baby, you will be offered a refreshing wash and you can change into some fresh nightclothes. If you’ve had an epidural, the midwife will remove the epidural tube from your back. The drip in your arm will be left in place until you have passed urine. You can try to pass urine before you are transferred to the postnatal ward. If you have a catheter in place, this may be removed.
You and your partner will then be given tea and toast, before you and your baby are transferred to the postnatal ward, which is usually within two hours of birth. Skin to skin contact can continue as you are transferred. The midwife will come with you to the ward, introduce you to the ward staff and give them a summary of your labour and birth details. The identification of your baby will be checked with you, your partner and the ward midwife.