Your birth experience

As your maternity clinic physicians, our goal is to support you during your birth so that you can have an empowering and positive birth experience, while also ensuring the best possible health for yourself and your baby.

As partners in care, there are many things that we can do together to help you have the best possible birth experience.  Thinking about some of the topics below before your birth will help you to prepare.

Birth Plans: You do not need to have a written birth plan. Every birth is unique, and the reality is that birth is very difficult to predict or to make a set plan for.  At Peace Arch Maternity we generally do as little intervention as needed but as much as needed to ensure a healthy outcome for you and your baby.

Research has shown that women have the best birth experiences when they feel like they are part of a team, feel a sense of control, know their pain will be well controlled, and that the expectations they have about their birth are met.  For this reason, we do encourage you to think about your birth “preferences” – that is, how you hope your labour might go and how you might like to proceed given different scenarios in your labour.  Please discuss your birth preference with your nurses and doctor during your birth and with your maternity clinic doctor at any of your prenatal appointments.

During your birth you will be part of a team that will work to support you.  Your birth team includes the people you want with you during your birth and your health care team. You can choose whoever you want to be with you during your birth.  Some women choose to have only their partner with them while others also include their mom, sisters, friends, and a doula.  You will have one of our experienced labour nurses with you the whole way through your entire labour process.  The nurses at Peace Arch will help support you through labour and delivery and help assist you with postpartum issues such as breastfeeding. If you have a more complicated birth we may also involve our specialist colleagues who are available 24/7 to assist.  These specialists include anesthetists, obstetricians, and pediatricians.

We will do whatever we can to help you have control over your birth as much as possible. For example, choosing the position that feels right to push in and choosing how you want to cope through your contractions.  You will always be involved in decision making about your birth. If we think you need a medical intervention like oxytocin we will discuss why and give you the opportunity to ask questions and give your own input. It is very rare in labour that an emergency arises where we do not have the time to fully discuss a decision that needs to be made.  If this occurs, we will always talk and debrief about what happened after the birth.

Lastly, an important part of a good labour experience is having pain that is well controlled or that is within the realm of what you can handle.  Labour and delivery are not pain free.  And that is ok.  We will help you cope first with natural means.  But if the pain of your labour becomes too much for you, we will also help you to get the pain relief that you need. And again, all of these suggestions are options and your choice. Plan to let yourself go with the flow of the labour and to be proud of yourself whatever happens.  Even more important is to remind yourself that you are strong, that you can do this, and remain positive and optimistic, and then you will be able to handle whatever comes in your birth.  Believe in yourself!!

Coping Strategies in Labour

This section contains the following resources:

• Labour Support
• Preparation for Labour and Delivery
• Early Labour
• Comfort Measures for Early Labour
• Active Labour
• Comfort Measures for Active Labour
• Transition

Congratulations on nearing the end of your pregnancy and the start of a whole new life! Before that happens though, you will need to experience labour. The word “labour” can bring up many emotions, including “excitement”, “fear” and “joy”, as well as the idea of “pain”.

Here at Peace Arch Hospital we would like to help you prepare for your labour to reduce the fear, and help you manage your pain which allows you to focus on your joy and excitement.

Throughout this booklet we will explore the different stages of labour and the pain management options to help you manage each stage, as well as the risks and benefits of each option.

Labour Support

Having a labour support person to help you manage your labour is very important. It has been shown that the presence of a supportive companion can improve the outcome of birth by decreasing the need for pain medications and reducing the need for other interventions. Most women choose to have their partner with them during labour. We encourage you to bring another supportive person besides your partner, who will provide support for both you and your partner. Some women choose to bring mothers, :friends, or even a professional support person called a “Doula.”

Preparation for Labour and Delivery

Reading this booklet is a good start, however there is a lot more to learn. Just as having a labour support person is important, so is having the information you might need to help you manage your labour. Baby’s Best Chance is a book available from your Doctor, Midwife or Public Health Unit. It is a great reference which is also available online. It is also highly recommended that you attend prenatal classes.

Early Labour

Early labour is just what this stage of labour is; the beginning of labour. This is the period of time when you may start to notice contractions. The contractions may range from 5-20 minutes apart and last 30 seconds or less. It is during this early phase of labour that your cervix will start to thin out or “efface” and open or “dilate” to 3 cm. If this is your first pregnancy, it is important to know that your cervix usually thins out first and then dilation begins. Early labour usually lasts about 7-8 hours but for some women this stage may last longer.

Comfort Measures for Early Labour

Most women experience this part of labour at home. The best thing to do in early labour is to continue with your day to day routine. Go for a walk, read a book or watch a movie. Ensure you have everything ready to go to the hospital. Lastly, review all of those coping methods you have decided to try during your labour. Call the maternity unit when you have regular contractions that are 5 minutes apart and 45 – 6o+ seconds long. Also call if your water breaks, you notice a decrease in your baby’s movements, you experience vaginal bleeding or you have any other questions while managing your labour at home. The nurses will help you decide whether or not you should come to the hospital at this time. The phone number to call is: 604-535-4500 Local 757273.

Active Labour

Active labour is the stage of labour where your cervix is dilating from 3 to 10 cm. Owing this phase your contractions will be coming every 3 – 5 minutes, lasting about 60 seconds. At this point you should come to the hospital. Please call first so that we know to expect you. It is in this stage of labour where both your labour coach and your comfort measures become very important.

Comfort Measures for Active Labour

• 1

  Patterned Breathing

  Patterned breathing is an important skill to practice before going into labour. In the active phase of labour the most common form of breathing is called “slow breathing.” You take a slow breath in though your nose, then breathe out through pursed lips (like you are breathing out through a straw). This is done slowly, at about half of your normal rate.

  Benefits	Risks
  Focuses your attention on breathing	None
  Makes sure you and baby are getting enough oxygen
  Patterned breathing helps you to stay relaxed and decreases pain

• 2

  Music

  Music can be used during labour.

  Benefits	Risks
  Calming, peaceful music helps you stay relaxed	None
  Focuses your attention on the music instead of the contractions

• 3

  Focal Point

  A focal point is something that you look at or focus on during a contraction. A focal point can be a picture, a person or simply a spot in the room. A focal point is usually used with patterned breathing.

  Benefits	Risks
  Focus is on something other than the contractions	None

• 4

  Visualization

  Visualization is picturing something or somewhere that is pleasant to you. Some women picture their favourite place; for example a beach. Other women picture an activity or a special memory. This is done throughout the contraction.

  Benefits	Risks
  Attention is focused on the visualization exercise	None

• 5

  Warm Water

  Having a shower or warm bath during labour is extremely helpful. All rooms at the hospital have showers and all but one room have a bath. Try different positions (see # 8) while in the tub or simply spend the time soaking. The showers at the hospital have attachments that come off the wall and can be used to provide a water “massage” on your back or tummy during contractions. Some women like to direct strong jets of water while others like to direct the water in circular patterns. Try both methods.

  Benefits	Risks
  The warm water helps you to relax.	None
  Baths during active labour can help your labour progress
  How you direct the water with a shower attachment can become a focal point for you

• 6

  Warm Packs

  Some women like to have warmth applied to their back or abdomen to help relieve labour pains. We do not have warm packs at the hospital. If you think this is something you might like, please bring your own from home. Please note, electric heating pads are not allowed.

  Benefits	Risks
  The warmth increases relaxation	None

• 7

  Cold Packs

  Some women like cold packs applied instead of heat for comfort. Women apply cold packs to their foreheads, the back of their neck or their low back.

  Benefits	Risks
  Reduces pain and muscle spasms	None

  (Alternating warm and cold packs is also beneficial for some women)

• 8

  Touch

  Some women like massage of their neck, shoulders, thighs, feet & hands or stroking of their face or tummy. Squeezing & releasing, steady pressure or light rhythmic stroking are different methods to try.

  Benefits	Risks
  Reduces pain and muscle spasms	None

• 9

  Positions

  There are many positions that can be helpful during labour. Positioning is very useful in the case where the baby is lying with his/her back against your back (called back labour). Some of these positions include:

  • Kneeling/Hands and Knees
  • Leaning forward
  • Using a birthing ball
  • Sitting on the toilet
  • Squatting
  • Walking
  • Side lying
  • Rocking/Moving hips side to side

  Benefits	Risks
  Uses gravity to help move baby into a better position for delivery	None

  See Baby’s Best Chance for pictures of different positions.

• 10

  Sterile Water Injections

  Sterile Water Injections is a technique used to block low back pain messages to provide relief during the first stage of labour. Tiny amounts of sterile water are injected just below the skin in four locations over the lower back. Sterile Water Injections last 45 minutes to 2 hours.

  Benefits	Risks
  Sterile Water Injections can begin acting quickly- about 2 minutes	Intense stinging that lasts about 30 seconds can occur with each injection
  Sterile Water Injections can provide relief for low back pain in labour	Sterile Water Injections do not take the pain away but can reduce the pain
  Sterile Water Injections can be repeated in one hour
  No side effects for baby

• 11

  Medications

  There are several different medications that may be used to help with pain management in labour. These medications include:

  • Nitrous Oxide (Entonox)
  • Morphine
  • Fentanyl
  • Epidural

  Each medication has its own risks and benefits.

  Nitrous Oxide (Entonox)

  Entonox is also known as “laughing gas.” Entonox is breathed through a mask which is held to the face and inhaled from the start of the contraction through until the end of the contraction.

  Benefits	Risks
  The woman holds the mask to her face so she can breathe in the amount she requires	Some women complain of nausea
  Entonox can help with patterned breathing	Some women complain of feeling dizzy and light-headed
  No side effects for baby	Some women develop a headache
  	Entonox does not take the pain away but will reduce the pain

  Morphine

  Morphine is a narcotic pain medication. Morphine may be given in either early or active labour. Morphine is given by an injection (shot) into a muscle. The medication starts to work in 10-30 minutes and lasts 4-5 hours. Morphine is often given with Gravol. Gravol helps reduce nausea and makes the morphine work better. Morphine makes most women feel sleepy and/or relaxed.

  Benefits	Risks
  Morphine helps you to relax, whether enough to help you sleep or for labour to progress	If morphine is given too close to the time of delivery (within 2 hours) it may affect the baby’s ability to start breathing
  Morphine helps to reduce the pain of labour	The effect of the Morphine may temporarily affect breast feeding in some cases
  	Morphine may make you nauseated
  	Morphine does not completely take the pain of labour away

  Fentanyl

  Fentanyl is a narcotic pain medication. Fentanyl is given in the active stage of labour. Fentanyl is given through an IV (a needle into a vein). Fentanyl works within 3-5 minutes and works for 30-60 minutes. Fentanyl may be given as a single dose or through an IV drip.

  Benefits	Risks
  Fentanyl acts quickly	If Fentanyl is given too close to the time of delivery (within 10-20 minutes) it may affect the baby’s breathing
  Fentanyl helps to decrease the pain of labour	Fentanyl effects don’t last a long time
  	Fentanyl may affect breast feeding in some cases

  Epidural

  An epidural is the injection of local anaesthetic and/or narcotic pain medication through a tiny tube (epidural catheter) placed into the epidural space. An epidural catheter is placed in the back between the spinal bones and into the “epidural space.” This epidural space surrounds the spinal cord. An epidural works by numbing the nerves and blocking the pain signals from the waist down.

  An epidural is often used once you are in active labour or at least 3-4 cm dilated. An epidural is a medical intervention that should be decided on by you and your caregiver as the most appropriate management decision for what is happening in your labour. Epidurals are inserted by anaesthesiologists so if the decision is for you to receive one your caregiver must consult the anaesthesiologist on call for this service. Before getting an epidural it is usually expected that you will have already tried other labour coping strategies first, including other medications. Prior to receiving an epidural you must have an IV inserted and once it is in place you will be restricted to bed. You may also be connected to a monitor to monitor your baby’s heart rate. Additionally, with an epidural if you are unable to empty your bladder, a tube (catheter) may need to be inserted into your bladder.

  An anaesthesiologist provides many services throughout the hospital. At Peace Arch Hospital, like many community hospitals in Fraser Health, there is only one anaesthesiologist on call for the entire hospital. What this means is that epidurals are not available “on demand” and if you require an epidural, it may take some time before you can be seen by the anaesthesiologist if they are attending another patient or involved in an emergency. If an epidural is felt to be appropriate, all efforts will be made to get one for you.

  Benefits	Common Risks	Rare Risks
  In most cases an epidural provides effective pain relief	Backache	Injection of the epidural solution into a vein, which would cause seizures
  You can be awake, without the side effects of being drowsy, as with other medications	Spinal Headache	Injection of the epidural solution into the spinal space, which would cause the freezing to go up too high, which would cause breathing problems.
  	Fentanyl may affect breast feeding in some cases	Permanent nerve damage

Transition

Transition is the stage in labour from 8 to 10 cm. This point in labour can be very hard. It is common to feel shaky, nauseated and like you “just can’t do it anymore!” This is all normal during transition. The pain management techniques used in transition are the same as we’ve already
mentioned, although at this point it may be too late for some medications because of their effect on the baby. Positioning, breathing, music,
visualization, heat, cold, using a focal point and Entonox are all possible during this time. Usually whatever helped you manage until this point will be what you continue to use until you reach 1 Ocm (fully dilated).

Once you reach 1 Ocm, it will be time for you to push. The length of time it takes to push & deliver your baby varies anywhere from a few minutes to a few hours. Once you feel the urge and start to push know that you will soon meet your baby, just what all this hard work has been for!

What to expect during your birth

Finally you are in early labour! You are nervous and excited and wondering what might happen.  The first thing to remember is that every birth is different and nobody’s birth follows a set or predictable pattern despite what every book and website might say.  This is the joy of birth.  Let yourself go with the natural flow of your own birth.  Your body was designed for this.  As your health care team, we will help you through this natural process.  If there are parts of your birth that are not proceeding within the large normal range that we expect to see, we will talk with you about ways we can help your birth progress in a normal way.  We will talk with you about what you expect in your birth and what you hope might happen and will work with you towards these goals adjusting always to the realities of your own birth process.

During the first part of labour your contractions may be irregular.  They might come every 5-20 minutes, vary in how painful they are and how long they last.  These irregular early labour contractions might last many hours or even occur on and off for days.  Initially you will be able to easily breathe through your contractions and can continue on with most of your normal activities.  During early labour the best place for you and your baby to be is in the comfort of your own home.  You should keep drinking water and eating small amounts.  You should rest if you feel like it and walk around and change positions if you have the energy to help your labour progress. Start practicing your breathing, relaxation exercises, and positive thinking.  A shower, bath, back rub, calming music, or anything that can distract you can help you cope in early labour.

Please call the maternity ward to let us know you are in early labour and especially call if this is your second (or more) baby, you are bleeding, your baby isn’t moving well, you think your water may have broken, if your pain is severe,  or if you feel anything abnormal may be occurring in your labour.

Eventually, your contractions will become so intense you will be pretty sure you are in true or “active” labour.  At this stage of your labour, your contractions will often be lasting 60-90 seconds, very strong or painful, and happening every 3-5 minutes, and you will be working very hard through them and perhaps wanting pain medicine.  We will usually ask you to come in to the maternity ward at this stage if you are not already there!

When you arrive at Peace Arch Hospital, check in at the registration desk on the main floor of the hospital near the main entrance or, at night time, check in at the emergency front desk on the main floor before coming upstairs.

When you arrive on the maternity ward a maternity nurse and the maternity clinic doctor will ask you questions, listen to your baby’s heartbeat, check your cervix to see how dilated it is, review how your labour is going,  and will make a plan with you about the next stage of your birth.  Sometimes we will find that you are still in early labour and you may need to go home again, to return later when you labour becomes stronger.

Once we determine that you are in active labour we will move you and your birth team to one of our private birthing rooms.  You will stay in this room during your birth and with your newborn until it is time to go home.   Our recently renovated private birthing rooms are spacious, and contain a large bath tub and shower, TV, fridge, and a bed for your partner to sleep on.  There is also a large fridge, microwave, and water dispenser in the family room on the maternity ward.  We do have some shared postpartum rooms but these are rarely used.

The experience of labour pain is not predictable and we will work with you to help you cope.  During the contractions use the pain relief strategies you thought about before labour to help you get through each contraction.  Your labour nurse will be by your side through every contraction and will guide you and teach you many different ways of coping with the contractions during your birth.

See the following section on “Coping strategies in labour”.

During active labour we will encourage you to drink fluids and to eat if you desire, to keep walking or moving around, and to try the shower or bath for pain relief.  In most labours we use intermittent auscultation of your baby’s heart rate to ensure your baby is doing well.  In more complicated labours or if you have an epidural or need oxytocin we will need to listen to your baby’s heart beat continuously using a small monitor attached to your tummy.  This will limit your ability to move around the room but you will still be able to change positions on the delivery bed and to sit on a birthing ball or rocking chair next to the bed.  We will only start an IV in you if you need one such as for fluid hydration or to give you medicines.

If your labour is not progressing at a normal rate, your chance of complications or C-section may go up.  To avoid this, we may suggest using medicines to improve the progress of your labour.  This may include using oxytocin or getting an epidural.  For a first baby, active labour (when your cervix dilates from 4-10 cm dilated) usually lasts around 4-10 hours.

Once your cervix is fully (10 cm) dilated you will start to feel an urge to push. We will teach you different ways to push and will encourage you to push however feels natural for you.  With a second or more baby this stage of your labour may take only a few minutes but with a first baby most women push for 45 minutes to 2 tours before the baby is born and occasionally it may take 3 hours or longer.

As your baby is being born we will ask you to stop pushing and to puff or breathe your baby out to help prevent tearing.  We very rarely perform episiotomies.

As soon as your baby is born, we place your baby on your chest.  We dry and rub your baby to help your baby start to take its first breaths.  Do not be alarmed if your baby is a bit bluish in the first few minutes.  This is normal.  Once your baby is dry, we will put him or her right onto your skin against your breast and will encourage as much “skin to skin” time as possible.  We ask your partner if they would like to cut the umbilical cord and do delayed cord clamping following most births.  While your baby is in your arms, we will listen to your baby’s heart and give it a checkup.  We will encourage you to start breastfeeding.  We may need to briefly take your baby to the baby warmer in your room to give it a checkup, to weigh it, and to give it a vitamin k shot and to put antibiotic ointment in his or her eyes.  If your baby needs extra help to breath when it is born, we may quickly take your baby to the newborn resuscitation bed in your room and as soon as your baby is breathing well will give your baby back to you.  Our goal is for you to be separated from your baby as little as possible. Your baby will stay with you or your partner in the room at all times and will usually not be taken out of your sight during your stay.  If we do need to take your baby out of the room, we will explain this to you.

We encourage all moms to breastfeed their baby and our nurses have extensive training in breastfeeding education.  For mom’s who are unable to breastfeed or choose not to do so, we will make sure you are comfortable with formula feeding before you go home.

Could I be diverted to another hospital for my birth?

It is rare for patients to be diverted to another hospital, however, baby births are unpredictable and we do have times when there are many deliveries in one day and the ward becomes too full.  This situation is rare, occurs at every hospital, and results in patients being diverted to another site.  You may also be diverted to another hospital if you are in labour and are less than 36 weeks GA, have a serious pregnancy complication for which delivery at a large tertiary hospital would be preferred, of if your new born baby needs a higher level of care (due to infection, prematurity, blood sugar issues, etc.). We do have pediatricians and staff trained to help with sick babies but do not have an NICU to support longer new born admissions or ongoing care of more complication new born health problems.

Complications in your birth

The reality is that complications and emergencies happen during some births. Your maternity clinic physicians, nurses, and specialists are very well trained and experienced at dealing with these situations and will attempt to involve you in discussions and decision making while also providing the urgent care you or your newborn need to ensure the best health outcome for you both.

Occasionally we may need to use a vacuum or forceps to delivery your baby.  Times we use vacuum or forceps include if you are too tired to push your baby the last part of the way out or if your baby’s heart beat pattern suggests your baby is distressed.  We will discuss the risks and benefits and how the procedure is done at the time.

About 1 in 3 babies in BC is born by cesarean section.  Sometimes we plan a C-section before labour even begins such as for a baby that is in a breech presentation.  For most women it is very disappointing to realize they need a C-section.  We will only recommend a C-section if we strongly believe it is needed to ensure the health of you or your baby. We will discuss the risks and benefits of having a C-section versus continuing with your labour and you will be the person who gives the final permission for your C-section.

Some times that a C-section are needed include:
If your labour is very slow or stops.  This is often due to a baby being too big to fit through your pelvis or birth canal or if baby is not positioned properly to fit through easily.
If you develop an infection in your uterus (chorioamnionitis).  This can happen if your water is broken for a long time.
If your baby’s heart rate pattern suggests baby is distressed or not coping with labour.

For your C-section, we will bring you down to the operating room on the second floor of Peace Arch Hospital.  Your partner will be with you during your C-section sitting at your side.  You will have a spinal anesthetic or your epidural will be topped up. It is extremely rare that a women needs to be put to sleep during a C-section.  You will usually be completely awake during the C-section but will be numb from the waist down. Your obstetrician and family doctor will explain the C-section procedure to you more at the time.

After your C-section, your baby will go with your partner back to the maternity ward while you are in the operating recovery room.  Your partner will be with your baby at all times and will be encouraged to have skin to skin time with your baby.  As soon as possible, you will return to the maternity ward where you can start breastfeeding your baby.  We will not offer your baby formula.  In rare circumstances if your baby’s blood sugar level is too low and you are not able to breast feed yet, we may recommend a formula feed.  We will discuss this with your partner or you if this is suggested.

If you have an emergency delivery or other labour complication, you may find yourself grieving and upset about this after your birth. Please talk with your care providers about how you are feeling.  We can review your entire birth with you and talk about any questions or issues you have about it and offer support to help you recover emotionally and physically from your birth.

Membrane Sweeping

This rather common but poorly understood intervention is used to hopefully accelerate the start of spontaneous labour in the late, third trimester.  It essentially means the insertion of a fingertip into the cervical opening and rotating the finger in hopes to gently separate the fetal membranes from the lower uterine segment.  The goal of this intervention is to help avoid a prolonged pregnancy (pregnancy beyond the 41st week) and the subsequent need for an induction of labour (that usually requires the use of a ripening agent placed intra-vaginally called cervidil, or an intra-venous medication called oxytocin).  It is a safe and relatively natural approach to help to shorten the interval of time to spontaneous labour and is an option for most women after 38 weeks of pregnancy.

Labour Induction

Induction of labour means starting your labour contractions with medical procedures, rather than waiting for labour to occur naturally.  Your doctor may discuss induction with you if any of the following conditions are present:

• You have high blood pressure
• You have ruptured membranes without labour
• You have a medical condition such as type one diabetes
• Your baby’s growth is less than expected
• You are at least 10 days past your due date
• You are at your due date and more than 39 years old

There are a number of different ways that labour can be induced.  You and your doctor will decide together whether induction is appropriate for you, when it should be done, and what method of induction will be used.

Some ways labour may be induced include using cervidil or prostin gel inserted into the vagina, using oxytocin, breaking your water, or using a foley catheter inserted into your cervix.