Labour Instructions

These instructions apply to normal low-risk pregnancies and are meant to be a general guide. Included are detailed instructions as well as a one-page flow chart and tool for communication with the on-call OB. It is important for women to follow their OB’s instructions if they differ from the guide.

Women in special circumstances (TOLAC, preterm, twins, vaginal breech) should consult the condition-specific guidance, and pay particular attention to additional instructions provided by their OB.

What to Bring to the Hospital

In the third trimester, women should prepare a hospital bag packed with items that will be useful during labour and after delivery. While having the essentials is important, too much stuff just becomes cumbersome, as it will all need to be taken home, along with gifts brought in by relatives and friends.

The hospital does provide a “Starter Pack”, but it is quite spartan and only covers the bare essentials: some diapers, baby wipes, one pair of mesh underwear, sanitary pads, blue pads, and a peri-care bottle.

The following checklist can be used when assembling the hospital bag.

Induction of Labour

Sometimes, it is necessary to bring on labour before its natural onset. The two most common reasons are postdates pregnancies that are 10 days overdue, and when the water breaks but labour does not start spontaneously. Induction is also recommended in higher risk situations (eg. mothers over 40, insulin-treated diabetes, high blood pressure, fetal growth restriction).

The method of induction will depend on the reason for induction and the status of the cervix. When the cervix is ‘unfavourable’ (not yet dilated or thinned out), a prostaglandin medication called Cervidil is typically used. It is delivered on a shoestring-like device, which is inserted by a specialized RN at a scheduled hospital appointment. Multiple doses are sometimes needed, and re-assessments are done at 24-hour intervals, with the woman going home in between. In higher risk cases, women will stay in hospital on the antepartum unit during their induction. Induction can take a few days, and women are advised to rest as much as possible during the process.

In cases where Cervidil is not possible, induction may be started by placing a balloon (Foley catheter) into the cervix, and administering IV oxytocin.

When the cervix is already dilated, or if the water has broken, induction is usually done with IV oxytocin, which is administered in a labour room with one-on-one nursing and continuous fetal monitoring. The oxytocin dose is slowly increased until the desired contractions are achieved. Women do not leave the hospital until they have delivered.

Care in Labour

Women in active labour are admitted to Single Room Maternity (SRMC or Cedar/Holly) or LDR (in TACC), depending on their circumstances. All labour rooms are private. There is one-on-one nursing care with an RN specialized in OB. There are no limits on the number of support people, but labour is very taxing and having too many people around can add to the stress.

Women will generally be allowed to move freely. Hydration is important. Eating is usually permitted, but women should be aware that food is not digested in active labour, and will often come back up through vomiting. As such, it’s best to keep it light.

In low-risk situations, the baby’s heart rate will be listened to at regular intervals by the RN by intermittent auscultation (IA). In higher-risk cases, electronic fetal monitoring (EFM) will be initiated. Two belts will be placed on the maternal abdomen. One sensor measures the uterine contractions, and the other records the fetal heart rate. There are wireless sensors available when a woman wants to continue to ambulate.

The labour will be re-assessed at regular intervals by the OB Group team, and cervical checks may be done by the RN, the attending OB Group doctor, or the resident. When the labour is in its active phase, these checks are often done every 2-3 hours. For first time mothers, the cervix will usually dilate by at least one cm per hour in the active part of labour. Women who have given birth vaginally before will usually progress much faster.

When the labour is progressing slowly, or stops progressing altogether, measures such as artificial rupture of the membranes (breaking the water bag with a device similar to a crochet hook) or oxytocin may be recommended. Oxytocin is the naturally-occurring hormone that stimulates uterine contractions. Synthetic oxytocin can be administered through an IV to help to increase contractions. Women on oxytocin require continuous fetal monitoring by EFM. When the strength of uterine contractions is uncertain, an intra-uterine pressure catheter (IUPC) many be recommended. This is a plastic tube with a pressure sensor that is inserted into the uterus to measure the strength of contractions, and it can be helpful in ensuring that the proper dose of oxytocin is being administered.

Women who are GBS positive will receive antibiotics in labour. The IV can be capped between doses, and disconnected from the IV pole. It’s not unusual for women to develop a fever in labour and we have protocols for managing this. When women have a fever, the fetal heart rate will often increase and need to be watched closely.

When there are concerns about fetal well-being, as assessed by IA or EFM, an FECG may be recommended. This is a scalp electrode that attaches to the skin of the baby’s head, not unlike an acupuncture needle. It provides the most accurate picture of what is happening with the baby’s heart rate pattern. If the pattern is abnormal, and the team is concerned about the baby’s well-being, fetal scalp sampling (FSS) may be recommended to get a sense of the baby’s oxygen levels by assessing lactate levels in the blood. This is done with a small needle prick on the baby’s scalp. Normal lactate levels tell us that it’s safe for labour to continue.

When a woman reaches full dilatation (10cm), she will usually start pushing. Women with epidurals will lack the natural urge to push, and may need some coaching to learn how to push effectively. In some cases, when women are very numb from their epidural, an hour of rest (‘passive second stage’) will be recommended to allow the baby’s head to descend further before the onset of pushing. First time mothers usually push 1-2 hours; pushing is typically a bit longer when there is an epidural. Women who have had a prior vaginal delivery don’t typically push more than about 30 minutes. Women are encouraged to try various positions during pushing.

Progress is followed closely during pushing, and the OB team members will be called by the RN when delivery is near if they are not already present.

Pain Relief in Labour

Labour is likely to be the most painful thing a woman will experience in her lifetime. Fortunately, effective pain relief is readily available.

Natural means of pain relief include walking around, massage by a partner or doula, a hot shower or bath, and deep breath/vocalization. Additional measures such as a TENS machine or sterile water injections by the RN may be available.

Entonox (laughing gas) is readily available at the bedside, and women are free to try it at any time. It takes the edge off and helps to focus the breathing. Some women finds it makes them feel dizzy or unwell, and do not care for it. It wears off very quickly.

Morphine is a powerful opioid that is frequently used in early labour, and given by intramuscular injection, along with Gravol to prevent nausea. It makes the pain a lot more bearable, and allows women to drift off to sleep in between contractions. It is a powerful opioid, which crosses the placenta. If the baby is born soon after a dose, respiratory efforts may be depressed. Fortunately, there is an antidote for this. Morphine is avoided within 4 hours of delivery.

Fentanyl is also a strong opioid, but it is given intravenously in small incremental doses by the labour RN. Unlike morphine, it wears off very quickly, and can be given quite close to delivery. Once the maximum dose is reached, other pain relief options will need to be considered.

Epidural analgesia is the only means of pain relief that will take all of the pain away. The epidural is administered by an Anesthesiologist and our providers at BC Women’s are all specialists in obstetrical anesthesia. A needle is used to insert a small plastic tube (catheter) into the space outside a woman’s spinal cord in the lower back. Freezing is given through this tube and the woman’s lower body becomes numb. The insertion procedure takes about 15 minutes, and pain relief sets in after about 20 minutes. For women having their first vaginal delivery, it can be given at any point in active labour, even after full dilatation. Women who have given birth vaginally before should ask for the epidural early if don’t want to give birth without one. Otherwise, the birth can happen very rapidly before the epidural has had a chance to be inserted and take effect. The epidural stays in place and continues to provide pain relief until the baby is born.

The dose can be adjusted. In labour, the goal is for the lightest dose possible which relieves the pain while still allowing the woman to have some mobility. Having said this, it’s not an exact science, and many women will be too frozen to walk once an epidural is in place. Contractions can slow down after an epidural, and it’s not unusual for oxytocin to be required. Pushing also takes a bit longer, as women will lose their natural urge to push.

If an operative vaginal delivery or C-section is required, the epidural can be topped-up to relieve pain completely for these procedures.

Spontaneous Vaginal Delivery

This is the ultimate goal for women entering labour. When delivery is near, the OB team will be called by the RN, and all necessary equipment will be assembled. A second RN will come in to help. If there has been a concern over fetal well-being, the on-call Pediatrician will also be called to attend.

When delivery is about to happen (‘crowning’), women will be asked to stop pushing. When there is no epidural, this is not always easy and panting helps. Every effort will be made by the delivery team to control delivery of the head, and thus minimize tearing of the vagina and perineum. After the head is delivered, the shoulders and remainder of the body usually come very quickly. When they don’t, this could indicate that the shoulders might be stuck (shoulder dystocia) and the team will mobilize quickly to perform certain maneuvers to manage this.

The baby will be placed skin-to-skin on the mother’s chest, and stimulated to promote breathing. Delayed cord clamping for about 2 minutes is standard. If the baby is having difficulty adjusting, the RN may take him/her to the baby warmer for further attention, and the Pediatrician will be called if they are not already there.

The placenta will usually be delivered quite soon after the birth. If it has not come out within about 30 minutes, manual removal might be required. The uterus will then be massaged through the mother’s abdomen to promote its contraction and stop bleeding. This can be painful, but it takes only a few seconds. An injection of oxytocin will have been given during the birth to help this as well.

Women having their first vaginal delivery will usually have some tearing. This is typically a 2nd degree tear and is easy to repair. The tissues have a great blood supply and heal quickly. More severe tears extending into the anal tissues (3rd/4th degree) are fortunately rare. Women who’ve had babies vaginally before are more likely to have an intact perineum or minor 1st degree tear which does not need suturing.

Suturing will be done with freezing when a woman does not have an epidural. The repair is done in layers, using continuous (running) sutures, and they are not counted. The suture material dissolves on its own, and suture removal is never required. An ice pack is applied after the repair, and pain medications are given.

If the baby is healthy, bonding will take place over about an hour, and breastfeeding will be established. The on-call Pediatrician will then be called to complete a newborn exam, including birth weight and other measurements.

Women delivering on SRMC will remain in the same room for their entire hospital stay. Women delivering on LDR will be transferred to a postpartum ward a few hours after the birth.

Assisted Vaginal Delivery

Sometimes, despite the most valiant efforts, babies do not come out without some help. This is not uncommon. The main reasons for requiring assistance with vaginal delivery are prolonged second stage (pushing) and abnormal fetal heart rate. For women having their first baby, an assessment will generally be made if delivery does not appear imminent after about 2 hours of active pushing, and assistance may be offered at this point. Delivery may need to be expedited sooner if there are concerns regarding fetal well-being.

The options for assistance will depend on several factors, and may include manual rotation, episiotomy, vacuum-assisted delivery, forceps delivery, or C-section.

The OBs of BC Women’s are highly skilled in assisted vaginal delivery, but it is not always advisable, and the best approach will be recommended depending on the circumstances. In some instances, women may be presented options to choose from, after review of their associated risks and benefits.

Emergency C-Section

A C-section is deemed to be an ‘emergency’ C-section when it is unplanned. It is not always a dire emergency. The most common reason for an emergency C-section to be needed is actually when the labour stops progressing, despite interventions to help it along. This can happen in the first stage of labour, when the cervix fails to reach full dilatation (10cm). It can also happen in the second stage of labour (at full dilatation) when the baby’s head fails to descend sufficiently despite adequate maternal pushing, and the head is not low enough for assisted vaginal delivery, or if this is declined by the woman. Another common situation for an emergency C-section to be required is when there is maternal infection and/or a concern about fetal well-being as assessed by electronic fetal monitoring (EFM) and sometimes fetal scalp sampling.

The on-call OB will advise when a C-section is recommended. Sometimes, there will be an option to intervene, or perhaps persist a bit longer, and the pros/cons of both options will be presented. In those situations, it is helpful for the woman/couple to indicate their preference for trying as hard as possible for a vaginal birth vs. having a lower threshold to proceed to C-section. Wishes will be respected, as long as it’s safe to do so.

In an acute emergency (eg. fetal distress), there may not be much time for discussion, and a woman may be rushed to the OR very rapidly for a STAT C-section. Sometimes, a general anesthetic (woman is put to sleep) will be required. The on-site care team at BC Women’s is highly-trained to intervene quickly in such emergency situations, and it’s not unusual for a woman to be transferred to the OR, with a baby delivered by C-section in less than 10 minutes for immediate care by the pediatric team.

Fortunately, most emergency C-sections are not that urgent, and things will proceed more slowly. Typically, the entire procedure takes about an hour. The woman will be transferred from her labour room to the OR, and her partner will be asked to change into scrubs. Upon transfer to the actual Operating Room (OR), the surgical team will perform a surgical safety checklist to confirm things such as the patient identity and planned procedure, and discuss any special concerns. If there is a functioning epidural in place, the Anesthesiologist will top it up with stronger medications, giving a much stronger block for the C-section. If there is no epidural, or if it cannot be topped-up adequately, a spinal or general anesthetic may be required.

Once the epidural is topped-up or the spinal procedure is done, the woman is placed onto her back and a Foley catheter is inserted, to keep the bladder empty during the procedure. The catheter is typically removed on the day after the operation. The abdomen area is then cleansed with an antiseptic solution, and sterile surgical drapes are applied.

At this point, the woman’s support person, who has been impatiently waiting outside, will be brought in and asked to sit on a stool near the woman’s head. The operation will not be visible because of the drape, and watching is not encouraged other than the moment of the birth itself. This is because the role of the support person is not to be a spectator, but rather to provide comfort to their awake loved-one and be there to meet the newborn.

A ‘time-out’ will be called by the team, to do a final review of the procedure about to happen, and a pinch test will be done to ensure the epidural or spinal is fully effective. Please note that pressure sensations and touch are still felt, but there should be nothing sharp or painful.

In most cases, a bikini-line (Pfannenstiel) incision will be made horizontally above the hair line. Existing scars are usually removed and replaced with a fresh one. Delivery usually happens rather quickly, within 5-10 minutes of the start of the procedure. This step can take longer when there is a lot of scar tissue related to previous surgery. Women will feel intense pressure on their abdomen while the baby is being actively pushed out by the surgical assistant. When the baby is born, the support person may be invited to take some photographs. Video is never permitted. The support person must stay behind the blue drape, to avoid contaminating the sterile field.

If the baby is not needing immediate pediatric attention, 30 seconds of delayed cord clamping will take place. Delayed clamping is beneficial to the baby, but waiting more that 30 seconds can be hazardous for the mother, as there can be considerable brisk bleeding from the uterine incision until the placenta is removed and the uterus is closed.

If vigourous, the newborn will be handed to a nurse who will place him/her directly onto the mother’s chest while the procedure is being completed. Breastfeeding will generally not be possible, due to the limited exposure afforded by the draping. When women do not feel comfortable holding the baby, their partner can hold the newborn skin-to-skin.

A Pediatrician attends every C-section birth and is immediately available when resuscitation is required. When all is normal, they will defer their newborn assessment while the parents are bonding with the baby. When it’s time for them to weigh and examine the newborn, this will be done in the OR, with a camera up above so that the woman can watch on a monitor while her surgery is completed.

Suturing all of the layers takes about 30 minutes. When the surgery is done, the team will do a ‘sign out’ to review what took place, and any special considerations for the postpartum period.

In some situations, epidural or spinal anesthesia will not be possible, and the surgery will need to be done with general anesthesia (woman is asleep). In other cases, the epidural or spinal may stop working optimally, and a woman will need to be given general anesthesia part way through the procedure. In these instances, the support person will be asked to leave the OR and wait outside. The newborn will be brought to them after assessment by the Pediatrician.

Post-operatively, women spend 1-2 hours in the post-operative care unit (PACU) before being transferred to the postpartum ward. They will not be separated from their newborn unless admission to the NICU is required, and breastfeeding can begin in PACU. No visitors other than the support person are allowed in PACU.

Pediatrics

Newborns of OB Group patients will be assessed at birth by the on-call Pediatrician, whose team will then follow the baby daily until discharge. Upon discharge, copies of the baby’s hospital records will be provided and parents will be instructed to book a follow-up visit with their family doctor within one week of the birth. Women who don’t have a family doctor should look for one during the pregnancy. If they don’t have one at the time of delivery, the discharging Pediatrician will bridge care until one has been found.

If there are special problems that require on-going pediatric care, such care will be coordinated by the discharging Pediatrician.

Special Circumstances