Childbirth

Childbirth
Other names	Labour and delivery, partus, giving birth, parturition, birth, confinement maternal deaths a year[5]

Childbirth, also known as labour, parturition and delivery, is the completion of

The most common childbirth method worldwide is vaginal delivery.

Vaginal delivery is generally recommended as a first option. Cesarean section can lead to increased risk of complications and a significantly slower recovery. There are also many natural benefits of a vaginal delivery in both mother and baby. Various methods may help with pain, such as

It is best practice to limit the amount of interventions that occur during labour and delivery such as an elective cesarean section, however in some cases a scheduled cesarean section must be planned for a successful delivery and recovery of the mother. An emergency cesarean section may be recommended if unexpected complications occur or little to no progression through the birthing canal is observed in a vaginal delivery.

Each year, complications from pregnancy and childbirth result in about 500,000

Signs and symptoms

The most prominent sign of labour is strong repetitive

Another prominent sign of labour is the

Labour Pain

There is currently no definitive scientific explanation for why labour hurts. According to studies, during pregancy, the myometrium (the muscle part of the uterus) is greatly denervated.^[27] Stretch receptors in the uterus disappear during pregnancy, and stretch receptors in the cervix disappear at the onset of labour.^[28] Consequently, the reason for labour pain has only been theorized, not ascertained. One theory is that the pain results from the buildup of chemicals released during physical exertion. The second leading theory is that the pain results from the vasoconstriction of uterine blood vessels in the myometrium; each contraction squeezes the blood vessels, reducing blood flow and causing some hypoxia.

Psychological

During the later stages of gestation there is an increase in abundance of oxytocin, a hormone that is known to evoke feelings of contentment, reductions in anxiety, and feelings of calmness and security around the mate.^[29] Oxytocin is further released during labour when the fetus stimulates the cervix and vagina, and it is believed that it plays a major role in the bonding of a mother to her infant and in the establishment of maternal behaviour. Studies show that the father of the child also has an increase in oxytocin levels following contact with the infant and parents with higher oxytocin levels showed more responsiveness and synchrony in their interactions with their infant. The act of nursing a child also causes a release of oxytocin to help the baby get milk more easily from the nipple.^[30][31]

Vaginal birth

Station refers to the relationship of the fetal presenting part to the level of the ischial spines. When the presenting part is at the ischial spines the station is 0 (synonymous with engagement). If the presenting fetal part is above the spines, the distance is measured and described as minus stations, which range from −1 to −4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations ( +1 to +4 cm). At +3 and +4 the presenting part is at the perineum and can be seen.^[32]

The fetal head may temporarily change shape (becoming more elongated or cone shaped) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.^[33]

Cervical ripening is the physical and chemical changes in the cervix to prepare it for the stretching that will take place as the fetus moves out of the uterus and into the birth canal. A scoring system called a

Vaginal delivery involves four stages of labour: the

Onset of labour

Definitions of the onset of labour include:

• Regular uterine contractions at least every six minutes with evidence of change in cervical dilation or cervical effacement between consecutive digital examinations.^[35]
• Regular contractions occurring less than 10 minutes apart and progressive cervical dilation or cervical effacement.^[36]
• At least three painful regular uterine contractions during a 10-minute period, each lasting more than 45 seconds.^[37]

Many women are known to experience what has been termed the "nesting instinct". Women report a spurt of energy shortly before going into labour.^[38] Common signs that labour is about to begin may include what is known as lightening, which is the process of the baby moving down from the rib cage with the head of the baby engaging deep in the pelvis. The pregnant woman may then find breathing easier, since her lungs have more room for expansion, but pressure on her bladder may cause more frequent need to void (urinate). Lightening may occur a few weeks or a few hours before labour begins, or even not until labour has begun.^[38] Some women also experience an increase in vaginal discharge several days before labour begins when the "mucus plug", a thick plug of mucus that blocks the opening to the uterus, is pushed out into the vagina. The mucus plug may become dislodged days before labour begins or not until the start of labour.^[38]

While inside the uterus the baby is enclosed in a fluid-filled membrane called the amniotic sac. Shortly before, at the beginning of, or during labour the sac ruptures. Once the sac ruptures, termed "the water breaks", the baby is at risk for infection and the mother's medical team will assess the need to induce labour if it has not started within the time they believe to be safe for the infant.^[38]

Stages of labour

First stage

The first stage of labour is divided into latent and active phases, where the latent phase is sometimes included in the definition of labour,^[39] and sometimes not.^[40]

The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions.^[41] In contrast, Braxton Hicks contractions, which are contractions that may start around 26 weeks gestation and are sometimes called "false labour", are infrequent, irregular, and involve only mild cramping.^[42] Braxton Hicks contractions are the uterine muscles preparing to deliver the infant.

Cervical effacement, which is the thinning and stretching of the cervix, and cervical dilation occur during the closing weeks of pregnancy. Effacement is usually complete or near-complete and dilation is about 5 cm by the end of the latent phase.^[43] The degree of cervical effacement and dilation may be felt during a vaginal examination.

The active phase of labour has geographically differing definitions. The World Health Organization describes the active first stage as "a period of time characterised by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours”.^[44] In the US, the definition of active labour was changed from 3 to 4 cm, to 5 cm of cervical dilation for multiparous women, mothers who had given birth previously, and at 6 cm for nulliparous women, those who had not given birth before.^[45] This was done in an effort to increase the rates of vaginal delivery.^[46]

Health care providers may assess the mother's progress in labour by performing a cervical exam to evaluate the cervical dilation, effacement, and station. These factors form the

.

During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, uterine muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion.^[47] The presenting fetal part then is permitted to descend. Full dilation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.

A standard duration of the latent first stage has not been established and can vary widely from one woman to another. However, the duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in the first labour("primiparae"), and usually does not extend beyond 10 hours in subsequent labours ("multiparae").^[48]

Dystocia of labour, also called "dysfunctional labour" or "failure to progress", is difficult labour or abnormally slow progress of labour, involving progressive cervical dilatation or lack of descent of the fetus. Friedman's Curve, developed in 1955, was for many years used to determine labour dystocia. However, more recent medical research suggests that the Friedman curve may not be currently^[when?] applicable.^[49][50]

Second stage: fetal expulsion

The expulsion stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, a sensation of pelvic pressure is experienced, and, with it, an urge to begin pushing. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the

. The appearance of the fetal head at the vaginal opening is termed crowning. At this point, the mother will feel an intense burning or stinging sensation.

When the

".

Complete expulsion of the baby signals the successful completion of the second stage of labour. Some babies, especially preterm infants, are born covered with a waxy or cheese-like white substance called

vernix

. It is thought to have some protective roles during fetal development and for a few hours after birth.

The second stage varies from one woman to another. In first labours, birth is usually completed within three hours whereas in subsequent labours, birth is usually completed within two hours.[51] Second-stage labours longer than three hours are associated with declining rates of spontaneous vaginal delivery and increasing rates of infection, perineal tears, and obstetric haemorrhage, as well as the need for intensive care of the neonate.^[52]

Third stage: placental expulsion

The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage. Placental expulsion begins as a physiological separation from the wall of the uterus. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10–12 minutes dependent on whether active or expectant management is employed.^[53] In as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta.^[54]

Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance. Active management is the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, followed by performance of uterine massage every 15 minutes for two hours.^[55] In a joint statement, World Health Organization, the International Federation of Gynaecology and Obstetrics and the International Confederation of Midwives recommend active management of the third stage of labour in all vaginal deliveries to help to prevent postpartum haemorrhage.^[56][57][58]

Delaying the clamping of the

Fourth stage: postpartum

Further information:

Puerperal disorder

The fourth stage of labour is the period beginning immediately after childbirth, and extends for about six weeks. The terms

Following the birth, if the mother had an

At one time babies born in hospitals were removed from their mothers shortly after birth and brought to the mother only at feeding times.[67] Mothers were told that their newborns would be safer in the nursery and that the separation would offer the mothers more time to rest. As attitudes began to change, some hospitals offered a "rooming in" option wherein after a period of routine hospital procedures and observation, the infant could be allowed to share the mother's room. As of 2020, rooming-in has increasingly become standard practice in maternity wards.^[68]

Early skin-to-skin contact

As of 2014, early postpartum SSC is endorsed by all major organisations that are responsible for the well-being of infants, including the American Academy of Pediatrics.^[18] The World Health Organization (WHO) states that "the process of childbirth is not finished until the baby has safely transferred from placental to mammary nutrition." It is advised that the newborn be placed skin-to-skin with the mother following vaginal birth, or as soon as the mother is alert and responsive after a Caesarean section, postponing any routine procedures for at least one to two hours. The baby's father or other support person may also choose to hold the baby SSC until the mother recovers from the anaesthetic.^[72]

The WHO suggests that any initial observations of the infant can be done while the infant remains close to the mother, saying that even a brief separation before the baby has had its first feed can disturb the bonding process. They further advise frequent skin-to-skin contact as much as possible during the first days after delivery, especially if it were interrupted for some reason after the delivery.^[19][20]

La Leche League advises women to have a delivery team which includes a support person who will advocate to assure that:

• The mother and her baby are not separated unnecessarily
• The baby will receive only her milk
• The baby will receive no supplementation without a medical reason
• All testing, bathing or other procedures are done in the parent's room^[73]

It has long been known that a mother's level of the hormone oxytocin elevates in a mother when she interacts with her infant. In 2019, a large review of the effects of oxytocin found that the oxytocin level in fathers that engage in SSC is increased as well. Two studies found that "when the infant is clothed only in a diaper and placed in between the mother or father's breasts, chest-to-chest [elevated paternal oxytocin levels were] shown to reduce stress and anxiety in parents after interaction."^[74]

Discharge

For births that occur in hospitals the WHO recommends a hospital stay of at least 24 hours following an uncomplicated vaginal delivery and 96 hours for a Cesarean section. Looking at length of stay (in 2016) for an uncomplicated delivery around the world shows an average of less than 1 day in Egypt to 6 days in (pre-war) Ukraine. Averages for Australia are 2.8 days and 1.5 days in the UK.^[75] While this number is low, two-thirds of women in the UK have midwife-assisted births and in some cases the mother may choose a hospital setting for birth to be closer to the wide range of assistance available for an emergency situation. However, women with midwife care may leave the hospital shortly after birth and her midwife will continue her care at her home.^[76] In the U.S. the average length of stay has gradually dropped from 4.1 days in 1970 to a current stay of 2 days. The CDC attributed the drop to the rise in health care costs, saying people could not afford to stay in the hospital any longer. To keep it from dropping any lower, in 1996 congress passed the Newborns' and Mothers' Health Protection Act that requires insurers to cover at least 48 hours for uncomplicated delivery.^[75]

Labour induction and caesarean section

In many cases and with increasing frequency, childbirth is achieved through

Caesarean section is the removal of the

Labour induction

The 2012 rate of labour induction in the United States was 23.3%, and had more than doubled from 1990 to 2010.[81]^[82] By 2022 it had climbed to 32%.^[83] The

(ACOG) guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks (full term) of gestation for optimal health of the newborn when considering elective induction of labour. Per these guidelines, indications for induction may include:

• Abruptio placentae
• Chorioamnionitis
• Fetal compromise such as isoimmunisation leading to
  haemolytic disease of the newborn or oligohydramnios
• Fetal demise
• Gestational hypertension
• Maternal conditions such as gestational diabetes or chronic kidney disease
• Preeclampsia or eclampsia
• Premature rupture of membranes
• Post-term pregnancy

Induction is also considered for logistical reasons, such as the distance from hospital or psychosocial conditions, but in these instances gestational age confirmation must be done, and the maturity of the fetal lung must be confirmed by testing. The ACOG also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including

Cesarean section

The WHO recommends a C-section rate of between 10 and 15% because C-sections rates higher than 10% are not associated with a decrease in morbidity and mortality.[85] In 2018, a group of medical professionals called the rates of increase around the world "alarming". In a Lancet report, C-sections were found to have more than tripled from about 6% of all births to 21%. In a statement by the maternal and child health organisation, the March of Dimes, the increase is largely due to an increase of elective C-sections rather than when it is really necessary or indicated.^[86]

Looking at the C-section rates between 1976 and 1996, one large study done in the U.S. found that the proportion of pregnancies delivered by C section increased from 6.7% in 1976 to 14.2% in 1996, with maternal choice the most frequent reason given.^[87] By 2018 the rate had climbed to one-third of all births.^[88]

Management

Obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. Supportive care during labour may involve emotional support, comfort measures, and information and advocacy which may promote the physical process of labour as well as women's feelings of control and competence, thus reducing the need for obstetric intervention. The continuous support may be provided either by hospital staff such as nurses or midwives, doulas, or by companions of the woman's choice from her social network. There is increasing evidence to show that the participation of the child's father in the birth leads to a better birth and also post-birth outcomes, providing the father does not exhibit excessive anxiety.^[90]

Continuous labour support may help women to give birth spontaneously, that is, without caesarean or vacuum or forceps, with slightly shorter labours, and to have more positive feelings regarding their experience of giving birth. Continuous labour support may also reduce women's use of pain medication during labour and reduce the risk of babies having low five-minute Apgar scores.^[91]

Preparation

Eating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes,

At one time shaving of the

Forceps or vacuum assisted delivery

An assisted delivery is used in about 1 in 8 births, and may be needed if either mother or infant appears to be at risk during a vaginal delivery. The methods used are termed

Pain control

Non-pharmaceutical

Some women prefer to avoid analgesic medication during childbirth. Psychological preparation may be beneficial. Relaxation techniques, immersion in water, massage, and acupuncture may provide pain relief. Acupuncture and relaxation were found to decrease the number of caesarean sections required.^[100] Immersion in water has been found to relieve pain during the first stage of labour, reduce the need for anaesthesia, and shorten the duration of labour.^[101] Additionally, water birth is associated with a decreased risk of postpartum hemorrhaging, low Apgar scores, neonatal infections, requirement for neonatal resuscitation, and neonatal admission to intensive care. However, there is a higher chance of cord avulsion.^[102]

Most women like to have someone to support them during labour and birth; such as a midwife, nurse, or doula; or a lay person such as the father of the baby, a family member, or a close friend. Studies have found that continuous support during labour and delivery reduce the need for medication and a caesarean or operative vaginal delivery, and result in an improved Apgar score for the infant.^[103][104]

Pharmaceutical

Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled

Popular medical pain control in hospitals include the regional anaesthetics

Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus.[110] Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.^[108]

Augmentation

Augmentation is the process of stimulating the uterus to increase the intensity and duration of contractions after labour has begun. Several methods of augmentation are commonly been used to treat slow progress of labour (dystocia) when uterine contractions are assessed to be too weak.

Episiotomy

For years an episiotomy was thought to help prevent more extensive vaginal tears and heal better than a natural tear. Perineal tears can occur at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. Once common, they are now recognised as generally not needed.^[15] When needed, the midwife or obstetrician makes a surgical cut in the perineum to prevent severe tears that can be difficult to repair. A 2017 Cochrane review compared episiotomy as needed (restrictive) with routine episiotomy to determine the possible benefits and harms for mother and baby. The review found that restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth.^[113]

Multiple births

In cases of a head first-presenting first twin, twins can often be delivered vaginally. In some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e.g.

• Both twins born vaginally – this can occur both presented head first or where one comes head first and the other is breech and/or helped by a forceps/ventouse delivery
• One twin born vaginally and the other by caesarean section.
• If the twins are joined at any part of the body – called conjoined twins, delivery is mostly by caesarean section.

Fetal monitoring

For external

") can be used. A method of external (noninvasive) fetal Monitoring with a cardiotocograph can either be intermittent or continuous.[115] The World Health Organization (WHO) advises that for healthy women undergoing spontaneous labour continuous cardiotocography is not recommended for assessment of fetal well-being. The WHO states: "In countries and settings where continuous CTG is used defensively to protect against litigation, all stakeholders should be made aware that this practice is not evidence-based and does not improve birth outcomes."^[116]

A mother's water has to break before internal (invasive) monitoring can be used. More invasive monitoring can involve a

]

Complications

There was a 44% decline in the maternal death rate between 1990 and 2015. However, 830 women died every day in 2015 from causes related to pregnancy or childbirth and for every woman who dies, 20 or 30 encounter injuries, infections or disabilities. Most of these deaths and injuries are preventable.^[117][118]

Maternal mortality and adverse health consequences

In 2008, noting that each year more than 100,000 women die of complications of pregnancy and childbirth and at least seven million experience serious health problems while 50 million more have adverse health consequences after childbirth, the World Health Organization (WHO) has urged midwife training to strengthen maternal and newborn health services. To support the upgrading of midwifery skills the WHO established a midwife training program, Action for Safe Motherhood.^[5]

The rising maternal death rate in the US is of concern. In 1990 the US ranked 12th of the 14 developed countries that were analysed. However, since that time the rates of every country have steadily continued to improve while the US rate has spiked dramatically. While every other developed nation of the 14 analysed in 1990 shows a 2017 death rate of less than 10 deaths per every 100,000 live births, the US rate has risen to 26.4. By comparison, the United Kingdom ranks second highest at 9.2 and Finland is the safest at 3.8.^[119]

In 2022, the WHO reported that the US had the highest maternal death rate of any developed nation while other nations continued to experience declines. The death rate of black women has also continued to climb with a 2020 CDC report showing the maternal death rate at 55.3 deaths per 100,000 live births – 2.9 times the rate for white women.^[120] In 2023, a study reported that deaths among Native American women were even higher, at 3.5 times the rate for White women. The report attributed the high rate in part to the fact that Native American women are cared for under a poorly funded Federal Health Care System that is so stretched that the average monthly visit lasts only from three to seven minutes. Such a short visit allows neither time for performing an adequate health assessment nor time for the patient to discuss any problems she may be experiencing.^[121]

Infant mortality

Compared to other developed nations, the United States also has high infant mortality rates. The Trust for America's Health reports that as of 2011, about one-third of American births have some complications; many are directly related to the mother's health including increasing rates of obesity, type 2 diabetes, and physical inactivity. The U.S. Centers for Disease Control and Prevention (CDC) has led an initiative to improve woman's health previous to conception in an effort to improve both neonatal and maternal death rates.^[122]

Looking at 168 countries around the world, a 2015 Save the Children's report found that each day about 8,000 newborns die during the first month of life. Worldwide, more than 1 million babies die during their first day even though simple measures such as antibiotics, hand-held breathing masks and other simple interventions could prevent the deaths of 70% of infants. The United States had the highest first-day infant death rate of all the industrialised nations in the world. In the US, each year about 11,300 newborns die within 24 hours of their birth, 50% more first-day deaths than all other industrialised countries combined.^[123]

Labour and delivery complications

Obstructed labour

The second stage of labour may be delayed or lengthy due to poor or uncoordinated uterine action, an abnormal uterine position such as breech or shoulder dystocia, and cephalopelvic disproportion (a small pelvis or large infant). Prolonged labour may result in maternal exhaustion, fetal distress, and other complications including obstetric fistula.^[124]

Eclampsia

Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. Pre-eclampsia is a disorder of pregnancy in which there is high blood pressure and either large amounts of protein in the urine or other organ dysfunction. Pre-eclampsia is routinely screened for during prenatal care. Onset may be before, during, or rarely, after delivery. Around 1% of women with eclampsia die.^{[medical citation needed]}

Maternal complications

A puerperal disorder or postpartum disorder is a complication which presents primarily during the puerperium, or postpartum period. The postpartum period can be divided into three distinct stages; the initial or acute phase, six to 12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem.^[125][126] Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women.^[127]

Postpartum bleeding

According to the WHO, haemorrhage is the leading cause of maternal death worldwide accounting for approximately 27.1% of maternal deaths.^[128] Within maternal deaths due to haemorrhage, two-thirds are caused by postpartum haemorrhage.^[128] The causes of postpartum haemorrhage can be separated into four main categories: Tone, Trauma, Tissue, and Thrombin. Tone represents uterine atony, the failure of the uterus to contract adequately following delivery. Trauma includes lacerations or uterine rupture. Tissue includes conditions that can lead to a retained placenta. Thrombin, which is a molecule used in the human body's blood clotting system, represents all coagulopathies.^[129]

Postpartum infections

Postpartum infections, also historically known as childbed fever and medically as puerperal fever, are any bacterial infections of the reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than 38.0 °C (100.4 °F), chills, lower abdominal pain, and possibly bad-smelling vaginal discharge. The infection usually occurs after the first 24 hours and within the first ten days following delivery. Infection remains a major cause of maternal deaths and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of childbed fever and his work saved many lives.^[130]

Psychological complications

Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface. Abnormal and persistent fear of childbirth is known as tokophobia. The prevalence of fear of childbirth around the world ranges between 4–25%, with 3–7% of pregnant women having clinical fear of childbirth.^[131][132] Although pain may be seen as a self-evident and indisputable fact, in reality pain is only one sensation of childbirth. There are many other sensations such as bliss, joy and satisfaction which can be more powerful than pain. Previous studies have indicated that negative expectations can actually increase sensitivity to pain through the process of nocebo hyperalgesia. While positive expectations can reduce pain through placebo analgesia.^[133]

Most new mothers may experience mild feelings of unhappiness and worry after giving birth. Babies require a lot of care, so it is normal for mothers to be worried about, or tired from, providing that care. The feelings, often termed the

Postpartum depression is different from the "baby blues". With postpartum depression, feelings of sadness and anxiety can be extreme and might interfere with a woman's ability to care for herself or her family. Because of the severity of the symptoms, postpartum depression usually requires treatment. The condition, which occurs in nearly 15% of births, may begin shortly before or any time after childbirth, but commonly begins between a week and a month after delivery.^[134]

Causes include issues such as an emergency C-section, preterm labour, inadequate care during labour, lack of social support following childbirth, and others. Examples of symptoms include

Postpartum psychosis is a rare psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions set in, beginning suddenly in the first two weeks after childbirth. The symptoms vary and can change quickly.^[139] It usually requires hospitalisation. The most severe symptoms last from two to 12 weeks, and recovery takes six months to a year.^[139]

Fetal complications

Five causes make up about 80% of newborn deaths globally: prematurity, low-birth-weight, infections, lack of oxygen at birth, and trauma during birth.^[21]

Stillbirth

Stillbirth is typically defined as fetal death at or after 20 to 28 weeks of pregnancy.^[140][141] It results in a baby born without signs of life.^[141]

Worldwide prevention of most stillbirths is possible with improved health systems.

Worldwide in 2019 there were about 2 million stillbirths that occurred after 28 weeks of pregnancy, this equates to 1 in 72 total births or one every 16 seconds.[145] Still births are more common in South Asia and Sub-Saharan Africa.^[141] Stillbirth rates have declined, though more slowly since the 2000s.^[146]

Preterm birth

Preterm birth is the birth of an infant at fewer than 37 weeks

If a pregnant woman enters preterm labour, delivery can be delayed by giving medications called

Post-term birth

The term postterm pregnancy is used to describe a condition in which a woman has not yet delivered her baby after 42 weeks of

Neonatal infection

birth asphyxia and birth trauma which have their own maps/data.^[155]

  no data

  less than 150

  150–300

  300–450

  450–600

  600–750

  750–900

  900–1050

  1050–1200

  1200–1350

  1350–1500

  1500–1850

  more than 1850

Newborns are prone to infection in the first month of life. The

Untreated

Perinatal asphyxia

Mechanical fetal injury

Risk factors for fetal birth injury include

History

Role of males

Historically, women have been attended and supported by other women during labour and birth. Midwife training in European cities began in the 1400s, but rural women were usually assisted by female family or friends.^[161] However, it was not simply a ladies' social bonding event as some historians have portrayed – fear and pain often filled the atmosphere, as death during childbirth was a common occurrence.^[162] In the United States before the 1950s, a father would not be in the birthing room. It did not matter if it was a home birth; the father would be waiting downstairs or in another room in the home. If it was in a hospital, then the father would wait in the waiting room.^[163] Fathers were only permitted in the room if the life of the mother or baby was severely at-risk. In 1522, a German physician was sentenced to death for sneaking into a delivery room dressed as a woman.^[161]

The majority of guidebooks related to pregnancy and childbirth were written by men who had never been involved in the birthing process.^{[according to whom?]} A Greek physician, Soranus of Ephesus, wrote a book about obstetrics and gynaecology in the second century, which was referenced for the next thousand years. The book contained endless home remedies for pregnancy and childbirth, many of which would be considered heinous by modern women and medical professionals.^[161]

Both preterm and full term infants benefit from skin to skin contact, sometimes called

Hospitals

Historically, most women gave birth at home without emergency medical care available. In the early days of hospitalisation for childbirth, a 17th-century maternity ward in Paris was incredibly congested, with up to five pregnant women sharing one bed. At this hospital, one in five women died during the birthing process.[161] At the onset of the Industrial Revolution, giving birth at home became more difficult due to congested living spaces and dirty living conditions. That drove urban and lower-class women to newly available hospitals, while wealthy and middle-class women continued to labour at home.^[164] Consequently, wealthier women experienced lower maternal mortality rates than those of a lower social class.^[165] Throughout the 1900s, there was an increasing availability of hospitals, and more women began going into the hospital for labour and delivery.^[166] In the United States, 5% of women gave birth in hospitals in 1900. By 1930, 50% of all women and 75% of urban-dwelling women delivered in hospitals.^[161] By 1960, this number increased to 96%.^[162] By the 1970s, home birth rates fell to approximately 1%.^[167] In the United States, the middle classes were especially receptive to the medicalisation of childbirth, which promised a safer and less painful labour.^[166]

Accompanied by the shift from home to hospital was the shift from midwife to physician. Male physicians began to replace female midwives in Europe and the United States in the 1700s. The rise in status and popularity of this new position was accompanied by a drop in status for midwives. By the 1800s, affluent families were primarily calling male doctors to assist with their deliveries, and female midwives were seen as a resource for women who could not afford better care. That completely removed women from assisting in labour, as only men were eligible to become doctors at the time. Additionally, it privatised the birthing process as family members and friends were often banned from the delivery room.^{[citation needed]}

There was opposition to the change from both progressive feminists and religious conservatives. The feminists were concerned about job security for a role that had traditionally been held by women. The conservatives argued that it was immoral for a woman to be exposed in such a way in front of a man. For that reason, many male obstetricians performed deliveries in dark rooms or with their patient fully covered with a drape.^{[citation needed]}

Baby Friendly Hospitals

In 1991 the WHO launched a global program, the Baby Friendly Hospital Initiative (BFHI), that encourages birthing centers and hospitals to institute procedures that encourage mother/baby bonding and breastfeeding. The Johns Hopkins Hospital describes the process of receiving the Baby Friendly designation:

It involves changing long-standing policies, protocols and behaviors. The Baby-Friendly Hospital Initiative includes a very rigorous credentialing process that includes a two-day site visit, where assessors evaluate policies, community partnerships and education plans, as well as interview patients, physicians and staff members.^[168]

Every major health organisation, such as the CDC, supports the BFHI. As of 2019, 28% of hospitals in the US have been accredited by the WHO.^[168][169]

Medication

The use of pain medication in labour has been a controversial issue for hundreds of years. A Scottish woman was burned at the stake in 1591 for requesting pain relief in the delivery of twins. Medication became more acceptable in 1852, when Queen Victoria used chloroform as pain relief during labour. The use of morphine and scopolamine, also known as "twilight sleep", was first used in Germany and popularised by German physicians Bernard Kronig and Karl Gauss. This concoction offered minor pain relief but mostly allowed women to completely forget the entire delivery process. Under twilight sleep, mothers were often blindfolded and restrained as they experienced the immense pain of childbirth. The cocktail came with severe side effects, such as decreased uterine contractions and altered mental state. Additionally, babies delivered with the use of childbirth drugs often experienced temporarily-ceased breathing. The feminist movement in the United States openly and actively supported the use of twilight sleep, which was introduced to the country in 1914. Some physicians, many of whom had been using painkillers for the past fifty years, including opium, cocaine, and quinine, embraced the new drug. Others were hesitant.^[161]

Caesarean sections

There are many conflicting stories of the first successful

Natural childbirth

The reemergence of "natural childbirth" began in Europe and was adopted by some in the US as early as the late 1940s. Early supporters believed that the drugs used during deliveries interfered with "happy childbirth" and could negatively impact the newborn's "emotional wellbeing". By the 1970s, the call for natural childbirth was spread nationwide, in conjunction with the second-wave of the feminist movement.^[161] While it is still most common for American women to deliver in the hospital, supporters of natural birth still widely exist, especially in the UK where midwife-assisted home births have gained popularity.^[167]

Epidemiology

The United Nations Population Fund estimated that 303,000 women died of pregnancy or childbirth related causes in 2015.^[171] These causes range from severe bleeding to obstructed labour,^[172] for which there are highly effective interventions. As women have gained access to family planning and skilled birth attendants with backup emergency obstetric care, the global maternal mortality ratio has fallen from 385 maternal deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015, and it was reported in 2017 that many countries had halved their maternal death rates in the last 10 years.^[171]

Outcomes for mothers in childbirth were especially poor before

Home births facilitated by trained midwives produced the best outcomes from 1880 to 1930 in the US and Europe, whereas physician-facilitated hospital births produced the worst. The change in trend of maternal mortality can be attributed with the widespread use of antibiotics along with the progression of medical technology, more extensive physician training, and less medical interference with normal deliveries.[165]

Since the US began recording childbirth statistics in 1915, the US has had historically poor maternal mortality rates in comparison to other developed countries. Britain started recording maternal mortality data from 1880 onward.

Society and culture

Distress levels vary widely during pregnancy as well as during labour and delivery. They appear to be influenced by fear and anxiety levels, experience with prior childbirth, cultural ideas of childbirth pain, mobility during labour, and the support received during labour.^[173][174]

Louvre museum

.

Personal expectations, the amount of support from caregivers, quality of the caregiver-patient relationship, and involvement in decision-making are more important in the mother's overall satisfaction with the birthing experience than are other factors such as age, socioeconomic status, ethnicity, preparation, physical environment, pain, immobility, or medical interventions.^[175]

Costs

According to a 2013 analysis commissioned by The New York Times and performed by Truven Healthcare Analytics, the cost of childbirth varies dramatically by country. In the United States the average amount actually paid by insurance companies or other payers in 2012 averaged $9,775 for an uncomplicated conventional delivery and $15,041 for a caesarean birth.^[176] A 2013 study found varying costs by facility for childbirth expenses in California, varying from $3,296 to $37,227 for a vaginal birth and from $8,312 to $70,908 for a caesarean birth.^[177]

Reporting on costs in 2023, Forbes gave an average cost of $18,865 ($14,768 for vaginal and $26,280 for cesarean) which included pregnancy, delivery and postpartum care. However, many factors determined the costs, including where the woman lived, the type of birth, and whether or not they had insurance. Even with insurance, average out of the pocket expenses for a vaginal delivery were $2,655 and $3,214 for a cesarean birth. Variables which determined charges included length of hospital stay, which averaged 48 hours for vaginal birth and 96 hours for a cesarean. There could be charges for any complications before or after the birth, for example an induced labour costs more than a spontaneous birth. Babies that had a difficult birth may need special tests and monitoring, adding to the costs of childbirth.^[178]

Beginning in 2014, the National Institute for Health and Care Excellence began recommending that many women give birth at home under the care of a midwife rather than an obstetrician, citing lower expenses and better healthcare outcomes.^[179][180] The median cost associated with home birth was estimated to be about $1,500 vs. about $2,500 in hospital.^[181]

Location

Childbirth routinely occurs in hospitals in many

In rural and

The

.

Facilities

Facilities for childbirth include:

• A labour ward, also called a delivery ward or labour and delivery, is generally a
  postpartum
  rest and observation of mothers in normal as well as complicated cases.
• A maternity hospital is a hospital that specialises in caring for women while they are pregnant and during childbirth and provide care for newborn babies,
• A birthing center generally presents a simulated home-like environment. Birthing centers may be located on hospital grounds or "free standing" (that is, not affiliated with a hospital).
• A home birth is usually accomplished with the assist of a midwife. Some women choose to give birth at home without any professionals present, termed an unassisted childbirth.

Associated occupations

Different categories of birth attendants may provide support and care during pregnancy and childbirth, although there are important differences across categories based on professional training and skills, practice regulations, and the nature of care delivered. Many of these occupations are highly professionalised, but other roles exist on a less formal basis.

"Childbirth educators" are instructors who aim to teach pregnant women and their partners about the nature of pregnancy, labour signs and stages, techniques for giving birth, breastfeeding and newborn baby care. Training for this role can be found in hospital settings or through independent certifying organisations. Each organisation teaches its own curriculum and each emphasises different techniques. The Lamaze technique is one well-known example.

Doulas are assistants who support mothers during pregnancy, labour, birth, and postpartum. They are not medical attendants; rather, they provide emotional support and non-medical pain relief for women during labour. Like childbirth educators and other unlicensed assistive personnel, certification to become a doula is not compulsory, thus, anyone can call themself a doula or a childbirth educator.^{[citation needed]}

Confinement nannies are individuals who are employed to provide assistance and stay with the mothers at their home after childbirth. They are usually experienced mothers who took courses on how to take care of mothers and newborn babies.^{[citation needed]}

Midwives are autonomous practitioners who provide basic and emergency health care before, during and after pregnancy and childbirth, generally to women with low-risk pregnancies. Midwives are trained to assist during labour and birth, either through direct-entry or nurse-midwifery education programs. Jurisdictions where midwifery is a regulated profession will typically have a registering and disciplinary body for quality control, such as the American Midwifery Certification Board in the United States,^[184] the College of Midwives of British Columbia in Canada^[185][186] or the Nursing and Midwifery Council in the United Kingdom.^[187][188]

In the past, midwifery played a crucial role in childbirth throughout most indigenous societies. Although western civilisations attempted to assimilate their birthing technologies into certain indigenous societies, like Turtle Island, and get rid of the midwifery, the National Aboriginal Council of Midwives brought back the cultural ideas and midwifery that were once associated with indigenous birthing.^[189]

In jurisdictions where midwifery is not a regulated profession, traditional birth attendants, also known as traditional or lay midwives, may assist women during childbirth, although they do not typically receive formal health care education and training.

specialists are obstetrician/gynecologists subspecialised in managing and treating high-risk pregnancy and delivery.

.

nursing training

.

Paramedics are healthcare providers that are able to provide emergency care to both the mother and infant during and after delivery using a wide range of medications and tools on an ambulance. They are capable of delivering babies but can do very little for infants that become "stuck" and are unable to be delivered vaginally.

.

Non-western communities

Cultural values, assumptions, and practices of pregnancy and childbirth vary across cultures. For example, some Maya women who work in agricultural fields of some rural communities will usually continue to work in a similar function to how they normally would throughout pregnancy, in some cases working until labour begins.^[190]

Comfort and proximity to extended family and social support systems may be a childbirth priority of many communities in developing countries, such as the Chillihuani in Peru and the Mayan town of San Pedro La Laguna.^[190][191] Home births can help women in these cultures feel more comfortable as they are in their own home with their family around them helping out in different ways.^[190] Traditionally, it has been rare in these cultures for the mother to lie down during childbirth, opting instead for standing, kneeling, or walking around prior to and during birthing.^[191][190]

Some communities rely heavily on religion for their birthing practices. It is believed that if certain acts are carried out, then it will allow the child for a healthier and happier future. One example of this is the belief in the Chillihuani that if a knife or scissors are used for cutting the umbilical cord, it will cause for the child to go through clothes very quickly. To prevent this, a jagged ceramic tile is used to cut the umbilical cord.^[191] In Mayan societies, ceremonial gifts are presented to the mother throughout pregnancy and childbirth to help her into the beginning of her child's life.^[190]

Ceremonies and customs can vary greatly between countries. See;

Collecting stem cells

It is currently possible to collect two types of

Placentophagy

Some animal mothers are known to eat their afterbirth, called placentophagy. In some cultures the placenta may be consumed as a nutritional boost, but it may also be seen as a special part of birth and eaten by the newborn's family ceremonially.^[193] In the developed world the placenta may be eaten believing that it reduces postpartum bleeding, increases milk supply, provides micronutrients such as iron, and improves mood and boosts energy. The CDC advises against this practice, saying it has not been shown to promote health but has been shown to possibly transmit disease organisms that were passed from the placenta into the mother's breastmilk and then infecting the baby.^[194]

See also

References

External links

• Spontaneous Vaginal Delivery, Video by Merck Manual Professional Edition
• Maternal Morbidity/Mortality in the Media Archived 27 July 2022 at the Wayback Machine