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.