Introduction
Hi , I’m Caroline and this is my colleague Jackie, we are women’s health obstetric physios at The James Cook University Hospital, and normally we run a ‘preparation for labour course’ for ladies and their birthing partners.
It is normally a two to three hour course held on an evening or an afternoon and would include a tour of the labour wards as well as a practical session of labour positions using beanbags and birthing balls, but due to the current situation, we have decided to put together a concise version of the course as an online video.
There is also a link for a ‘virtual tour’ of the labour wards at James Cook as well as preparation for labour leaflets that are linked to this video that provide a great summary of all the labour information we are going to discuss and it would be really useful if you could download and print them. Alternatively, you could ring James Cook switch board and ask for extension 53741, and leave a message to request a labour pack and we will send out the information in the post.
I am going to start by briefly explaining the anatomy of the pelvis and the hormonal changes that occur during pregnancy, that prepare your body for labour. There is an extended online version of this, on the South Tees Hospitals website, called ‘the back and pelvis advice session’ which might be useful to watch as well, if you haven’t already.
So this is your pelvis, with your big pelvic bones round the side and joining together at your pubic bones at the front. In the middle of your pubic bones is this cartilage, which is normally 4mm wide, when you’re not pregnant and this is normally a really strong joint in the body when you are not pregnant. However, when you are pregnant, your hormones are softening your ligaments.
Your ligaments are like strong elastic bands that surround every joint and your hormones are starting to soften the ligaments, so you are now
not as strong in the joints in the pelvis. So the front pubic bones are not as strong so you are more vulnerable at the front and you need to really be careful what you do with your legs. So your hips are here, and your legs are here, coming out of the pelvis. So please be careful that you are not doing big wide movements, in and out a car, standing on one leg getting dressed, shaving in the shower or pushing anything out of the way with your foot. You really need to look after the pubic bones in here. If you are getting aches and pains, the golden rule is to keep your legs together as much as you can and be more
lady-like, so ideally get dressed sitting down.
So if we look at the back of the pelvis, where the pelvic bones come round the back, your spine comes down and joins your sacrum with your coccyx. So your sacrum is a triangular bone with your coccyx at the bottom, and there is a lot of junction on here, so pelvic bones come together, meet the sacrum bone, form your dimples. So at the base of your spine are your dimples there. Now, this sacrum does sit perfectly in the middle of your pelvis, but it does gently rock up, down, side to side, so that’s normal. Then you have
your big ligaments which hold everything in place, but while you are pregnant, they have softened, so again you are not as strong around your pelvic area and your sacrum area, whilst you are pregnant, with your pregnancy hormones, so this bone does rock a little bit more in every direction while you are pregnant.
You need to be really aware and really careful of your back area and this back band here, especially as you are growing a bump at the front. So you need to be really careful if you are leaning forward that it’s gently opening those back joints a little bit more, and if you are leaning forward and twisting, to hoover, mop, do some housework, you are twisting one side a little bit more than the other. So make sure you are as symmetrical as you can, do light duties as much as you can, so light housework and really look after your
posture.
Pregnancy hormones
In the last few weeks of pregnancy your hormones are preparing your pelvis for labour by softening the ligaments at the front of your pelvis and in the lower back region. Be mindful of this whilst doing daily tasks, avoiding extra stress and strain on your back and pelvis by doing light duties only and changing your posture regularly. Start to use the gym ball as an alternative to sitting on the sofa and gently massage the lower back muscles as they may start to ache.
Your hospital bag for labour should be packed and ready from about 36 weeks. Involve your birthing partner in this process, so that they know what is in the bag. Remember nappies, cottonwool or waterwipes, newborn (0-3mth) vests and babygrows as well as muslin cloths and scratch mittens. (Remember pre-made milk cartons and bottles if not breast feeding) Changes of clothes for yourself, toiletries, breast pads, nipple cream, sanitary pads and plenty of spare underwear.
Other top tips: hair bobble, lip balm, handheld fan, energy bars and juice cartons. (Look online NHS for more extensive lists).
Early signs
As labour approaches you may experience loose stools, as baby positions deeper into the
pelvis putting pressure on the bowels, as well as high levels of hormones. You may also notice a mucus plug discharge, called the ‘show’ and this is a thick whitish colour or may have a pink tinge from spots of blood, but it is not necessary to inform the hospital of the ‘show’ unless it is a bleed (or a greenish colour discharge) then phone the advice line.
If your ‘waters’ break or you are leaking amniotic fluid (clear and odourless) you must phone the hospital and seek advice. Otherwise early signs of labour may be felt as
waves of discomfort in your lower back /tummy area, similar to that of ‘period’ type discomfort/pain.
Plan to stay at home
During the early stages of labour, the best place to be, is at home. It is important
to stay calm and create a relaxing environment at home eg dim lights, play soothing music etc to keep producing the right hormones and keep labour progressing.
Make sure you have paracetamol pain relief at home (and can progress to co-codamol) but record your dosage intake, especially noting the paracetamol content.
You could also hire a TENS machine, which could be used at home. It is an electrical unit that sends an electrical signal to your nerves to stimulate your natural endorphins and help take the edge off the pain signals. Please watch the TENS information link to find out more.
Other alternative pain relief options at home include: a warm bath (max 37°), gentle heat pack, back massage, aromatherapy, deepfreeze gel and a gym ball / birthing ball The ball is one of the best tools we would recommend in pregnancy and labour, so you can buy it in most of the shops now but the only thing is to make sure it is a 65cm ball and it says ‘anti-burst’ on the box.
Make sure you have the right pump to go with the stopper and get someone else to blow the ball up. When you sit on it, make sure your knees and hips are level and your knees are roughly shoulder width apart. You can gently rock forwards and back, and using your pelvis to glide forward and back, side to side, by rotating your hips, whatever feels comfortable, just don’t bounce on it.
So, we look back at the hormonal changes in the pelvis, with the softening and stretching of the ligaments in the front pubic area as well as the lower back dimple / sacrum area, it will help us to understand why the best positions in labour are to try and be upright and forward, to allow the body to naturally progress. I am going to hand over to Jackie, who is going to demonstrate possible labour positions to try at home as well as similar positions to adopt in hospital in the labour wards:
Preparing for labour video – Positions for labour
There are 3 (main) principles to remember when choosing what position to be in during your labour.
- Firstly – being upright
- Secondly – being in a forward leaning position
- Thirdly – keep changing your position and move around regularly.
These help to get the baby into an optimal (good) position ready for birth, as well as minimising strain on your body (as Caroline has already pointed out).
(Use of diagram of pelvis to illustrate)
Being upright ensures maximum use of gravity to assist the muscles of the uterus which have a squeezing effect on the baby as they contract. This allows the gradual widening of the cervix (the opening of the uterus) during labour. If you are laid on your back, gravity is not aiding labour as much, and you may also feel more discomfort in your lower back.
At home, during the early part of your labour, you will probably find it easier to move around and change positions as the contractions may be mild and quite far apart, but as the contractions become stronger and closer together, you may need to find more supported/resting positions, but still try to remember the principles of upright and
forward.
The ‘Fit for Birth’ leaflet, which you will find a link to in this section, has plenty of ideas of different positions you can try. There is no ‘right’ way, just find a position that is most comfortable for you, sticking to the principles. Here are some pictures of examples of comfortable positions you may like to try at home:
Photo 1 – Kneeling on the floor and resting your upper body on the sofa
Photo 2 – Kneeling on the sofa and resting over the arm on pillows or cushions………….
Photo 3 – and sitting the wrong way round on a dining chair, supported by pillows – maybe also watch the TV in this position as a good distraction.
When you come into hospital, it is important that you and your birthing partner settle into your labour room and make it feel as homely and comfortable as possible. Feel free to dim the lights, use battery candles and play soothing music on your phone. Have a look around your room, such as this one, and see what equipment there is for helping you find good positions for your labour.
Ask for a ball, beanbag or birthing stool if you would like one but there isn’t one in your room. As Caroline has mentioned, the use of a gym ball can be especially useful in labour (as well as throughout pregnancy and in general). Obviously, if you have one at home, you can use it from early in labour.
You are upright, well supported and can move with a gentle rocking of the pelvis with little effort….
(Demonstrates on ball)
Other good positions with the ball involve leaning forwards over it, either in kneeling or sitting. You can also do the same thing using a beanbag for support. A birthing stool can also be used to sit on and lean on to the bed over the beanbag.
The ‘Cube’ is a useful piece of equipment to help get you into a comfortable and upright/forward position in labour. Information about this can be found on the internet. Your position, along with gentle movement and relaxed breathing, can help you to cope with your contractions in labour.
Active labour
Time the length of your contractions (discomfort/pain) and the gap of time between
your contractions. You will notice the contractions becoming stronger and longer (30 to 40 seconds) and the gap between them becoming shorter. Try stay active during this first stage of labour by walking or adopting upright and forward positions eg sitting on a ball and resting forward onto a table, or kneeling on the floor /sofa and resting forward.
Keep breathing through the discomfort or pain and make sure you don’t hold your breath. Listen to relaxing music and take slow deep breaths, concentrating on expanding your ribcage and tuning out/ignoring the pain, by remaining calm and staying positive.
Ring the hospital
If you are high dependency please ring the advice line as advised by your consultant or midwife, otherwise if you are low dependency it is a good time to phone the advice-line when your contractions are about five minutes apart, to discuss whether it is advisable for you to come into hospital or stay at home a bit longer (until you are experiencing 3 contractions in a 10 minute period). It is best if you make the phone call, so the midwife can ask you direct questions and assess your breathing.
Arriving at hospital
After phoning the advice-line and being advised to come into hospital, bring your hand-held antenatal notes with you, and arrive through the maternity / women and children’s entrance and head towards the maternity assessment unit (MAU). After an internal examination, monitoring your contractions, as well as baby’s heart rate, it will be decided if you are in ‘established first stage of labour’ and whether you are still ‘low’ or ‘high’ dependency for labour, and then taken round to the appropriate labour ward.
When you are in your labour room, it is important that you and your birthing partner ‘settle in’ and make it feel homely and comfortable. Feel free to dim the lights, use battery candles, run yourself a bath and play soothing music on your phone.
Ask for a birthing ball, beanbag and possibly a birthing stool, and the midwife will assist you in re-arranging the pillows and bed height to allow you to find comfortable active birthing positions. The midwife will be popping in periodically to monitor you and baby, as well as offer different forms of pain relief, but if you feel your ‘waters’ break at any point, please let the midwife know.
In tune with midwife
During this important second stage of labour, the midwife will stay with you and guide you through step by step, to help you push baby out. It is better to be in a more upright position during the pushing stage, as this will allow gravity to help both you and baby. Try remain calm and breathe slowly and deeply. The midwife will guide you to use a long breath out, to push or bear down and work with your uterus during contractions, so listen carefully and stay tuned to your midwife’s instructions.
The painful contractions will only last for about a minute long, then they will cease and relax, until the next one. Each contraction is bringing you closer to meeting your baby, so focus on that and stay positive. As the head starts to crown, you may feel a burning/stinging sensation, which is your body’s signal to push slowly and gently, as your midwife guides you through delivering your baby.
Only the placenta left
Once your baby is born, the third stage of labour is to deliver the placenta. The
midwife will usually wait a minute for baby to receive all the nutrients and blood from the placenta, then when it stops pulsating, the midwife will clamp and cut the cord.
The placenta can be ‘actively managed’ by having an injection to speed up this stage and reduce bleeding or it can be an ‘unaided’ delivery whereby your body does this process naturally. (Please discuss these options at your ‘birth plan’ appointment and make sure your request is documented in your notes.)
You may be asked to help push the placenta out or the midwife may press on your tummy to draw it out, although the placenta is soft and will deliver without discomfort.
New bonding
The best part is when you get to hold and cuddle your newborn baby and enjoy ‘skin to
skin’ bonding time. This precious time of mum and baby being wrapped up together, helps to regulate baby’s heartbeat, temperature and breathing.
It also encourages the baby’s natural urge to feed (breast or bottle) and helps you release hormones related to breast-feeding and to emotionally bond with your baby. It is also possible for your birthing partner to experience ‘skin to skin’ bonding time as well.