# Childbirth --- **Childbirth** is when a [[pregnancy|pregnant]] person actually gives birth to their baby. 90% of pregnancies are uncomplicated, and their care "high touch, low tech", with a lot of monitoring and checking in to make sure things go according to plan. For complicated pregnancies, although modern medicine has decreased the rate of maternal death, it can still be dangerous. More than 50% of all maternal deaths occur within 24 hours after delivery. The three main reason people die in childbirth are: - bleeding disorders - most significant cause of maternal death worldwide - [[uterine involution|uterine atony]] - retained placenta - [[coagulation]] - uterine inversion - trauma - hypertensive disorders - [[preeclampsia|eclampsia]] - infection - [[prenatal care]] comes during pregnancy - [[postpartum care]] comes after childbirth ## Physiologic Birth **Physiologic birth** is the spontaneous vaginal delivery of a baby following [[labor]] which has not been modified by medical interventions. There are many health benefits to physiologic birth, such a: - less postpartum pain - quicker physical recovery from the birth - increased sense of self-esteem - enhanced bonding with baby - reduced chance of postpartum depression - a calmer, more settled baby - easier breastfeeding - easier time transitioning to breathing air for baby - more effective gut colonization - reduced risk of genital tract trauma - reduced risk of postpartum hemorrhage There are certainly situations where medical interventions are necessary for the health of mother and child, but initiating interventions without proper indications can lead to [[cascade iatrogenesis|further and further]] unnecessary medical interventions. Medical interventions include: - [[amniotic sac|AROM]] - other things - [[caesarian section]] ## Hormones of Childbirth A lot of [[hormone|hormones]] go into inducing and completing childbirth. - [[Estrogen]] from the [[placenta]] induces [[oxytocin]] receptors on the [[uterus]] - Oxytocin from both the fetus and mother's [[pituitary gland]] stimulates the [[uterus]] to contract and stimulates the [[placenta]] to produces [[prostaglandins]]. - The prostaglandins stimulates the uterus to contract even more. This creates a rare example of a [[homeostasis|positive feedback]] loop which produces more oxytocin and more contractions. ![[birth hormones.png]] ## Fetal Presentation & Attitude & Position **Fetal presentation** refers to which part of the baby is down, or "presenting" to the world. **Cephalic** or head-down presentation is the most common and the safest presentation. You can think of it as how the baby's spine is in relation to the parent's spine. Oblique is at a diagonal, and pretty rare...less than 5% of babies are in oblique positions. ![[fetal presentation.png]] Babies in cephalic presentations have an additional feature called **fetal attitude**, which reflects how flexed (chin tucked) or extended (chin up) their neck is. ![[fetal attitude.png]] ![[fetal position.png]] **Malpresentation** Anything other than cephalic or headfirst Breech presentation 3-4% • Face, brow presentations more rare Breech presentations are associated with: - Multifetal gestation - Preterm birth - Fetal and maternal anomalies - Polyhydramnios - Oligohydramnios - Certain genetic disorders - Neuromuscular disorders - Abnormal amniotic fluid volume (both increased and decreased) Breech Presentation • External cephalic version (ECV) may be tried to turn the fetus from a breech to a vertex presentation • Risks associated with vaginal birth from a breech presentation include: • Prolapse of the umbilical cord • Trapping of the after-coming fetal head • Trauma resulting from extension of the fetal head or nuchal position of the arms • Descent may be slow because the breech is not as effective a dilating wedge as is the fetal head - increased risk of [[placental abruption]] we can spin the baby around, but a lot of times they spin back around - have to be ready for a c-section, and this can kick off labor as well. In the United States, cesarean section is almost always performed when babies are in a breech presentation • External cephalic version Turning a fetus from malpresentation to a vertex presentation for birth Success rate is around 65%, risk for caesarean birth is reduced by 50% Should be offered and performed whenever possible It is one strategy to safely lower the primary cesarean birth rate Contraindications to ECV include the following: •Uterine anomalies - Third-trimester bleeding - Multiple gestation - Oligohydramnios - Evidence of uteroplacental insufficiency - A nuchal cord (identified by ultrasound) - Previous cesarean birth or other significant uterine surgery - Obvious CPD Most successful in multiparous person with a normal BMI, a nonanterior placenta and abundant amount of amniotic fluid and whose fetus is not yet engaged in the pelvis • ECV is accomplished manually, usually at 36 to 37 weeks • Should be performed in a hospital equipped to provide emergency surgery in case of fetal distress • Before ECV is attempted • Obtain informed consent • Ultrasound to confirm the breech presentation, detect multiple gestation, oligohydramnios, or fetal abnormalities and measure fetal dimensions • Perform NST to confirm fetal well-being • Give Rhogam if Rh negative • Give terbutaline to relax the uterus and facilitate the maneuvers ECV is sometimes performed under regional anesthesia • Maintain continuous EFM throughout procedure • Monitor especially for bradycardia and variable decelerations • After the procedure, monitor vital signs, uterine activity, FHR and vaginal bleeding for at least 1 hour Are they RH neg? they get rhogam ## Cardinal Movements of Birth Engagement - at zero station Descent - pushed down with strong contractions Flexion - head pushed down, chin to chest Internal Rotation - starts to look over it's shoulder - the bi-parietal diameter (the line between the parietal bones) aligns to the widest part Extension - there's a curve of Karis (upward curve of the coxyx) and the baby's head looks up - this is "crowning" or expulsion External Rotation (Restitution) - they stop looking over their shoulder - now the shoulders are the widest part Expulsion ## Operative Vaginal Birth • Vaginal births that are assisted with either forceps or a vacuum extractor to apply direct traction on the fetal skull/scalp • Indications and prerequisites for the use of both instruments are identical • The decision to use forceps or a vacuum extractor is based on the experience and personal preference of the physician performing the procedure **Forceps** • Instrument with two curved blades used to assist in the birth of the fetal head • Indications: Urgent need to shorten the second stage • Use decreasing, replaced by vacuum extraction or cesarean birth • For a forceps-assisted birth to be successful: • The cervix must be fully dilated to prevent lacerations and hemorrhage • The bladder should be empty • The presenting part must be engaged • Membranes must be ruptured • Size of the pelvis adequate for the estimated fetal size Medical management • Both blades are positioned by the physician, and the handles are locked Traction is applied during contractions • The person may or may not be instructed to push during contractions • If a decrease in the FHR occurs, the forceps are removed and reapplied Nursing interventions After birth, asses for vaginal or cervical lacerations, urinary retention, and hematoma formation in the pelvic soft tissues • Assess infant for bruising, abrasions, facial palsy, and subdural hematoma at blade sites • Inform newborn caregivers that forceps were used **vacuum** extraction Causes less trauma than the forceps, but they don't always stick. baby's head is all wet and sometimes the cup won't stay. you get two tries, after that you risk causing more damage than the forceps • Vacuum extraction involves the attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head • Generally not used before 34 weeks • Indications same as for forceps • Prerequisites for use include informed consent, a completely dilated cervix, ruptured membranes, engaged head, vertex presentation, no suspicion of CPD, experienced operator, and adequate anesthesia • Advantages compared with forceps: ease with which the vacuum can be placed and less need for anesthesia Medical management • The vacuum cup is applied to the fetal head by the physician • The patient is encouraged to push as traction is applied by the physician • The vacuum cup is released and removed after birth of the head • If vacuum extraction is not successful, a cesarean birth is performed • Risks to the newborn include cephalohematoma, scalp lacerations, and subdural hematoma • Parental risks include perineal, vaginal, or cervical lacerations and soft-tissue hematomas Nursing interventions • The nurse provides education and support and documents procedure • The FHR should be assessed frequently during the procedure • Inform neonatal caregivers that birth was vacuum-assisted Observe newborn for signs of trauma and infection at the application site and for cerebral irritation (e.g., seizures, lethargy, increased irritability or poor feeding) • The newborn can be at risk for hyperbilirubinemia and neonatal jaundice as bruising resolves • The parents need to be reassured that the caput succedaneum usually disappears in 3 to 5 days [[cesarean section]] ## Problems With Childbirth - [[preeclampsia]] - problems with the umbilical chord - [[cord prolapse]] - [[umbilical cord|nuchal cord]] - [[placenta|placenta previa]] - [[shoulder dystocia]] ___