At some stage during your pregnancy it is worthwhile discussing your delivery planning and expectations about birth. Open channels of communication about your dreams and concerns are key to your sense of satisfaction about the events surrounding the birth of your child. You are encouraged to bring up this topic when you feel ready, otherwise it is discussed as a matter of routine as you progress toward your due date.
Vaginal birth after caesarean section (VBAC)
VBAC is supported by obstetric guidelines around the developed world provided it meets patient-based, institution-based and practitioner-based safety requirements. Decisions around whether or not to try for a VBAC can be highly emotive. A reasonable plan for one patient may be very different to another a the circumstances and risks can differ substantially. For this reason it is important to seek the advice of a practitioner that has seen the risks play out during pregnancy and labour, and knows how to deal with potentially life-threatening complications of a VBAC.
As a general approach, provided the risks are considered acceptable, every chance should be given to help you achieve a natural vaginal birth under the careful and watchful guardianship of your practitioner
Education and support including breastfeeding after delivery
Your midwife is invaluable in helping you to establish good breastfeeding habits after delivery. This will usually start with encouragement of skin-to-skin contact and breastfeeding as soon as possible after birth. Even at caesarean section it is possible to achieve this with the help of your midwife and other theatre staff. Occasionally your paediatrician may need to keep a very close eye on your baby in the nursery after delivery. However every effort is made to allow you a first contact as soon as possible after your delivery.
A strong focus on breastfeeding is currently adopted as there are evidence-based benefits to breast-feeding your child for at least 6 months. Breastfeeding reduces your child’s risk of developing metabolic and weight issues later in life, and there is early research showing breastfeeding can “reverse” these risks for babies that were “programmed” for metabolic impairment during the pregnancy. These are amazing benefits, however sometimes it feels like there is a lot of pressure around this issue after the birth. Again, open channels of communication with the team including your midwife, lactation consultants, obstetrician and paediatrician are key to working through these issues. Your voice is most important in this process and everyone is there to support you. It is worth remembering that breastfeeding is a partnership between you and baby, and it is not always the best thing for you both especially where the difficulties outweigh the benefits.
Analgesia in labour
There are some effective options for analgesia in labour that are supported by good evidence.
The epidural provides hands-down the best possible pain relief you can be offered in labour. Unfortunately, however, epidurals are not risk-free, they affect your mobility in labour, and can increase the duration of pushing and the risk of instrumental deliveries. They do not increase the risk of a caesarean section, and this detail is well supported by good evidence. The specific risks of an epidural should be discussed with you prior to labour so that you are not making decisions for the first time under the duress of labour.
Entonox or nitrous oxide (laughing gas) can provide some mild pain relief in labour. For some it is also a great distraction from labour. However many people experience intolerable effects including dizziness, nausea and sometimes vomiting. It is an option certainly worth considering for pain relief in labour where an epidural is considered undesirable.
Warm water immersion, or a warm shower, may provide good pain relief in labour. It is also relaxing. So where it is possible, is considered safe and does not pose a danger to yourself, baby or staff, it is a great option to consider.
Other than those above, there are no known reputable alternative sources of pain relief in labour. Some people have had good experience with morphine or pethidine, however overall it has not been shown to work well for the majority of people and is poorly supported by the evidence.
Analgesia at Caesarean Section
Caesarean sections require very effective and reliable pain relief. Spinal or epidural aneasthesia provide a regional nerve blockade so that your sensation is impaired below your waist thereby allowing your obstetrician painless access to deliver you child.
A spinal anaesthetic is introduced via a very fine needle through your lower spinal vertebrae and into the fluid bathing your spinal cord. The effect is very fast and effective. Conversely an epidural is introduced via a larger catheter, but stops short of entering the spinal canal, and relies on the diffusion of anaesthetic across tissue membranes to enter the spinal fluid that bathes the sensory nerves of your spinal cord. Occassionally your anaesthetist will combine these two methods to get a faster and more complete acting regional block, but also the benefit of an epidural catheter placement that can deliver anaesthetic following your operation. Each method has its benefits, limitations and risks and should be canvassed with the anaesthetist.
Sometimes a general anaesthetic will be required to provide adequate analgesia for a caesarean section where a spinal or epidural cannot be sited or where it is considered the safest means given the circumstances. In this situation you will be put to sleep and kept safe under the watchful eye of your anaesthetist while your baby is delivered. You are asleep for a short time and woken soon after your wound is closed and dressed. Recovery after a general anaesthetic can take some time as you may feel a bit drowsy, but generally after a few hours you are back to normal.