Labor and Breastfeeding Notes

Labor and Breastfeeding

Placental Stage

  • Critical stage post-labor due to risks of hemorrhaging and infection if the placenta is not fully delivered.

Preparing for Labor: Relaxin

  • Before dilation, the body releases relaxin, a hormone that loosens the ligaments in the pelvic region.
  • Relaxin prevents hip fractures or pelvic cracks during natural childbirth by allowing the bones to shift slightly.
  • Dislocated pelvis during childbirth is a painful and serious condition, often inadequately treated.
  • Relaxin release increases during the third trimester, especially in the last month.
  • Narrow or small pelvis can prevent pregnancy or necessitate a cesarean section.
  • Historically, "birthing hips" referred to women with a wider pelvis, naturally suited for pregnancy and delivery.

Dilation Stage

  • Initiated when the fetus becomes too large and pushes against the cervix.
  • Head-first delivery (ideal) causes the head to push on the cervix.
  • Any part of the fetus pushing on the cervix can initiate dilation.
  • The pressure sends a nerve impulse to the hypothalamus, which releases oxytocin.
  • Oxytocin causes the uterus to contract, pushing the fetus against the cervix, creating a positive feedback loop.
  • Contractions become closer and more intense until the cervix dilates from the size of a Cheerio to the size of a bagel.
  • Full dilation is about 10 centimeters, or five fingers.
  • Dilation can last from 2 to 20 hours or longer, and the process varies among women.
  • Cervical mucus plug prevents bacteria and infection during pregnancy; dislodging it often signals the start of labor.
  • Amniotic sac pops, releasing amniotic fluid; amount varies among women.
  • Excessive amniotic fluid can cause breathing difficulties for the mother.

Hormones and Contractions

  • Oxytocin acts on the uterus, causing contractions.
  • Prostaglandins, released by the placenta, work with oxytocin to speed up dilation.
  • Cervical mucus plug prevents infection by blocking openings.
  • Amniotic sac rupture leads to the release of amniotic fluid.

Vaginal Canal Dilation

  • The relaxin hormone loosens the vaginal canal, allowing some expansion, but less than the cervix.

Contractions

  • Contractions become more intense due to the positive feedback loop of oxytocin and the effect of prostaglandins.

Expulsion Stage

  • Follows full dilation (10 centimeters).
  • Medical term for when the baby's head is visible through the cervix, the term is crowning.
  • Characterized by forceful contractions that push the baby through the cervix and birth canal.

Pain Management: Epidurals

  • Certain medications like morphine are unsafe as they slow down the labor process.
  • Epidural anesthesia involves injecting into the spine to block sensory pain receptors, reducing pain from the waist down.
  • Epidurals can be used for lower abdominal surgeries, such as colon surgery.
  • Risks of epidurals include back pain, paralysis, or loss of feeling in the feet.
  • Alberta statistics indicate that 1 in 100 women experience long-term issues from epidurals.
  • Anesthesia has advanced significantly, but epidural procedures carry potential risks.

Forceps and Vacuum Assistance

  • Forceps: Rarely used due to the risk of crushing the skull and causing brain damage.
  • Vacuum: A vacuum hose is attached to the baby's head, and the baby is delivered with suction assistance.
  • Vacuum-assisted births can cause a bruise on the baby's head.

Episiotomy

  • Episiotomy: A controlled cut made in the perineum to enlarge the vaginal opening.
  • Used when the baby needs to be delivered quickly or if there's a risk of severe tearing.
  • Less common now but was standard practice until the late 1970s.

Hospital Practices

  • Past practices (1960s-1970s) included routine enemas, shaving of the pelvic region, and episiotomies.
  • Current practices have changed, with enemas and episiotomies no longer being routine.
  • Pain management has improved, but early methods like knocking women out during dilation are no longer used.

Placental Stage

  • Involves delivery of the placenta and remaining umbilical cord.
  • Delayed cord cutting allows for additional nutrients and oxygen transfer to the baby.
  • Placenta should be delivered within 10-15 minutes, up to half an hour.
  • The expelled placenta is referred to as the afterbirth.
  • Failure to deliver the placenta fully can lead to hemorrhaging and infection.

Placenta Examination

  • The placenta is inspected to ensure all parts are intact.
  • Amniotic sac is examined.
  • The mother is at risk if parts of the placenta remain and could lead to issues like postpartum hemorrhage and infections.

Water Births

  • Water births are practiced in some cultures.
  • A sterile environment is essential to prevent infection.
  • Water births are believed to promote relaxation, facilitating easier labor.

Cesarean Section

  • Reasons for cesarean sections include:
    • Large baby size.
    • High blood pressure in the mother.
    • Small pelvis.
    • STI transmission.
    • Breech or transverse baby position.
    • Umbilical cord issues.
  • The main umbilical cord issues might include cases where the umbilical cord is wrapped around the neck of the fetus.

Cesarean Section Procedure

  • Involves cutting through the abdominal wall and uterus.
  • The baby is delivered, and the umbilical cord is clamped and cut.
  • Oxytocin and prophylactic antibiotics are administered to the mother.
  • The uterus is externalized for easy visualization and repair.
  • Major abdominal surgery with a significant healing process.
  • Multiple cesarean sections can increase risk.

Patient Advocacy

  • All patients have the right to ask about procedures, alternatives, and seek second opinions.
  • Pre-surgical clinics provide opportunities to ask questions and receive education.

Positive Feedback Loops

  • Oxytocin and prostaglandin are positive feedback loops.

Breastfeeding

  • Prolactin is needed for breast milk letdown but can be negatively impacted during pregnancy.
  • Progesterone and estrogen suppress prolactin production during pregnancy.
  • Lactation during pregnancy is possible if the mother was already lactating.
  • High-risk pregnancies may require stopping breastfeeding to conserve energy and prevent early labor.

Breastfeeding Process

  • Progesterone and estrogen levels decrease after delivery, allowing prolactin to be produced.
  • Breastfeeding is not instantaneous and requires training and support.
  • Nerve stimulation from the baby triggers the hypothalamus to release milk.
  • Pavlovian response: The body associates the baby's cry with hunger, leading to milk letdown.
  • Involuntary process affected by stress, hormones, and structural issues.
  • Nipple cream can moisturize nipples to prevent cracking and infections.
  • Breast milk production varies among women.
  • Breastfeeding in impoverished countries may be the only source of nutrition for the child.
  • Cesarean sections may delay breast milk production due to shock to the system and energy diversion for recovery.

Teratogens

  • Teratogens: Substances exposed to during pregnancy that cause structural abnormalities, especially during the embryo stage.
  • In Alberta, 2-3% of children are born with birth defects due to teratogen exposure.
  • Impact lessens as exposure occurs later in pregnancy.
    • Examples:
      • Cigarettes: Lead to low birth rates, premature miscarriage, and ectopic pregnancy.
      • Alcohol: Causes fetal alcohol syndrome, with the highest risk between weeks 7 and 12 of pregnancy.
      • Cocaine.
      • Accutane.