Care During Labour & Birth

I'm in late pregnancy, is there an emergency phone number or 24-hour drop-in support service available to me?

Yes, in all units. Most units provided some detail to us. This information is typically given out at the antenatal clinics also.

If I think I'm in labour, is there a labour assessment or triage room in my local maternity unit?

Assessments take place either in dedicated assessment units/admission rooms or on antenatal or labour wards. We asked whether birth partners were welcome to stay during the assessment; not all units gave us that detail but 15 indicated that one birth partner was welcome to stay during the assessment.

I am being advised to have an induction. What is involved?

At this point you will have thoroughly discussed reasons for induction with your caregiver. These might be medical reasons or simply being a certain number of days (with the number depending on the local hospital policy) past your due date. See also "For what medical reasons might an induction be recommended?" and "What happens if I go over due?".

In the survey on late pregnancy care, we also asked about routine induction when a woman is past her due date. In some cases, we received different answers in this section about the timing of these routine inductions. Nine units did not specify dates here. Dates specified were 40 weeks +14 days (two units), 40 weeks + 12 (one unit), 40 weeks +10 to +12 (two units), 40 weeks + 10 (one unit) and 40 weeks +7 to +10 (one unit). If a woman and her baby are both healthy and well, postponing induction until 40 weeks +14 days is a safe option. Most units can offer additional monitoring (to confirm that all is well) when a woman wishes to wait for labour to start spontaneously, if that goes longer than the local policy. This also applies if a woman wishes to wait longer than 40 weeks +14 days.

If you are being offered induction by your caregiver, it might be helpful to know how ready your body is for labour. This is assessed using the Bishop Score; a high score indicates a higher degree of readiness and a lower score indicates the cervix is not yet ready. Women with a low Bishop Score (6 or lower) may choose to defer induction until their body is more ready. Women with a high Bishop Score (10+) may also choose to defer induction, as they are likely to go into labour naturally in the following couple of days.

If you agree to induction, the first step depends on the readiness of your cervix. If necessary, you will be offered a prostaglandin (artificial form of the hormone) tampon, gel or pessary (vaginal tablet) to be inserted vaginally with the purpose of softening the cervix for induction. The gels or pessaries may be repeated 6-hourly up to three times in total, whereas the Propess tampon can be left in for 24 hours. (Propess is becoming more common.) In some cases artificial prostaglandin is enough to start labour. If it hasn't started labour, you will be offered ARM (artificial rupture of membranes), which involves releasing the amniotic fluid with a special instrument. You will be encouraged to walk around. In some cases, prostaglandin is not necessary, and ARM can be offered first if the cervix is ready (soft enough and open enough).

If labour doesn't commence or is slow, you will be offered Syntocinon (artificial form of the hormone oxytocin) which is given intravenously via a drip.

In some cases, induction does not work (labour does not start at all or is very slow) and a caesarean birth is then deemed necessary.

Different levels of details were provided by the maternity units nationwide.

What happens if my waters release naturally?

Most likely you will have been told in the antenatal clinic to phone the hospital. You might be advised to go to your maternity unit for assessment, especially if you have no contractions.

If you have contractions but are assessed as not being in established labour, you have the option to go home if your waters are clear (straw-coloured). If you live very far away, you may discuss staying at the hospital or decide to stay somewhere locally where you can relax. If you are already in established labour you will be admitted to the unit. Some units specified speeding up labour after 24 hours if a woman was not yet in established labour after the waters released, and others specified the use of antibiotics typically after 18 hours of the waters releasing.

If you have no contractions and your waters are clear, you have the option to go home and return within a certain period of time for induction of labour (typically 24 hours) and antibiotics (typically 18 hours). Women are given information on how to check that they and their baby are well during this time.

Some women opt to defer induction for a day or two if they would prefer to have more time for labour to start spontaneously. Additional monitoring is advised to detect any signs of infection and to confirm that both mother and baby are well. A plan can be agreed between the mother and her caregivers. The responses from some units seemed to indicate more willingness to accommodate a woman’s preference to defer induction than others – click on Show All below to compare answers.

Whether or not a woman is having contractions, it is the guideline in some units to admit women once they arrive at that unit with waters released. Even in these units, women have the option to go home if that is their preference, but they will need to make that preference clear to their caregivers.

I think I'm in labour. What happens when I go to my maternity unit?

Research shows that staying at home for as long as you feel comfortable and confident can reduce the likelihood of interventions.

When you go to your maternity unit you will be assessed, which involves being offered some or all of the following: abdominal palpation (externally feeling the position of the baby), listening to the baby's heart, vaginal examination to see if the cervix is dilating, blood pressure check and urine test.

Some women opt not to have some or all of these procedures and we asked the hospitals what happens in those cases. The responses varied from respecting all choices made following informed discussion to involving senior clinicians to justify the procedures. Most mentioned explanations and discussion of risks. (Some specified induction of labour which might mean there was a misinterpretation of our question.)

The 2012 National Clinical Guidelines on monitoring of the baby’s heart in labour state that “the current evidence base does not support the use of the admission CTG in low risk pregnancies and is, therefore, not recommended as a routine.” The admission trace is still in use in many units, although some had plans (at the time of our survey) to phase it out for low-risk women. Research has shown that intermittent monitoring is safest for low-risk mothers and babies. It also has the advantage of not restricting the mother’s ability to move in labour.

If you are assessed as not yet being in established labour, most units give the choice of returning home unless there are medical reasons or you live too far from the unit. It is the guideline in several units to admit women, often to the antenatal ward where women can walk around and wait for labour to be established. Even in these units, women have the option to go home if that is their preference, but they will need to make that preference clear to their caregivers.

If you are assessed as being in established labour, you are admitted to the labour ward.

If I had a medical condition in this pregnancy, how would it affect my labour and birth?

We asked about the implications for labour due to diabetes/gestational diabetes, Group B Strep (GBS) and pre-eclampsia. Not all units answered for each one. Responses varied from unit to unit which shows that for any condition there are a range of appropriate options. It also means that it is worth asking your caregiver about all the options available to you. Then, if you have a strong preference for some aspect of care that is usually not offered at your unit, it may still be possible.

Group B Strep is a transient infection and at any time 15 to 20% of pregnant women have it. It is usually harmless. Babies can pick it up during the birth process; most will not suffer any ill-effects, some will be sick and a tiny percentage will be extremely sick or could even die. Even though a positive test in this pregnancy does not mean that the infection will definitely be present at the time of birth, most units’ care plans still include IV antibiotics during labour or if a woman’s waters release. A fast, new test is available in some units that can be used to test a woman’s GBS status in labour or if her waters have released to determine if antibiotics are required. This will help avoid unnecessary use of antibiotics in the future if it is adopted nationwide.

If my pregnancy involved assisted conception, would this affect my labour and birth?

We asked about the implications for labour for assisted conception pregnancies. Not all units answered this question. Responses varied very widely from ‘not relevant’ to ‘deemed low risk’ to ‘high-risk pregnancy’. Obstetrician-led care and individualised care plans were frequently mentioned, but some units specified that it would not affect the woman’s care.

If I’m over a certain age or obese, would this affect my labour and birth?

We asked about the implications for labour for older mothers and obese mothers. Not all units answered these questions. Responses varied very widely from ‘not relevant’ to ‘high-risk pregnancy’. Obstetrician-led care and individualised care plans were frequently mentioned but two units specified that it would not affect the woman’s care during labour. Three units mentioned induction of labour might be offered to older mothers. Two units mentioned anaesthetic review before labour for obese mothers.

My baby is predicted to be small/big. How will this affect my labour and birth?

We asked about the implications for labour where babies are diagnosed as either small or big. Not all units answered these questions. For babies diagnosed as small, answers frequently specified obstetrician-led care and induction of labour. For babies diagnosed as big, answers varied more widely and included obstetrician-led care, induction of labour, individualised care plans, and three units mentioned management of shoulder dystocia.

It is important to note that scans to estimate a baby’s size in late pregnancy are not very reliable. As many as 50% of them can significantly under- or over-estimate a baby’s size. In fact, research has consistently shown that if the care provider’s perception is that the baby is big, this perception introduces more complications than an undiagnosed big baby. This is because caregivers are likely to suggest interventions like induction and artificially speeding up labour, if the baby is perceived as big, both of which may have negative knock-on effects. Whereas, many undiagnosed big babies are born without the need for a caesarean birth, without any ill effects.

Upright positions and staying mobile during labour and birth are helpful in all cases but can also help prevent shoulder dystocia.

This is a very good (but long and detailed) article with lots of research-based information about this topic.

If my baby was still breech at full term, how would this affect my labour and birth?

See also our question in Late Pregnancy, "I'm in late pregnancy and my baby is breech. What usually happens?". Not all units answered this question but the majority that did said that singleton babies in the breech position are born by planned caesarean birth. One unit stated that second- or subsequent-time mothers sometimes have vaginal breech births and that if a second twin is breech (with the first twin head down), a vaginal birth is planned. Another unit mentioned offering the option of vaginal birth for mothers who have had a baby before.

Our breech statistics from the hospitals show that the majority of these babies are born by caesarean but a small percentage are born vaginally.

If my baby was in the OP position (back-to-back), how would this affect my labour and birth?

Of the units that answered this question, several indicated that it would not affect care. Others mentioned good positions, staying mobile and using birthing aids like the peanut ball.

What if I showed signs of premature labour?

Not all units answered this question. Answers typically included obstetric-led care, continuous fetal monitoring, paediatric involvement and alerting the special care unit. In some cases, a woman would be transferred to a hospital with a neonatal intensive care unit if she was less than 32 weeks pregnant.

If we already know that my baby has medical or congenital issues, how will this affect our care during labour and birth?

Generally, this will depend on the condition or issue that the baby has. Answers included individualised care plans, obstetric-led care, paediatric involvement, alerting special care unit and sensitive treatment of parents.

If we already know that my baby will be stillborn, how will this affect our care during labour and birth?

Several units did not answer this question. Answers included individualised care plans, induction of labour, private room and bereavement support.

Under what circumstances would a woman's care be transferred to a larger hospital in late pregnancy or in labour?

In cases where a maternity unit cannot provide the required care for a woman or her unborn baby, she can be transferred to a larger hospital for specialist or complex care. Examples are extreme prematurity and complex medical conditions in either mother or baby.

Where will I spend early labour if I'm admitted?

In labour, staying at home for as long as you feel comfortable and confident is a good idea as you will have all the comforts of home around you, including your own shower/bath.

Early labour rooms vary across the units, from home-from-home style, to single rooms, to twin rooms, to up to 6-bedded rooms. Very few rooms have en-suite facilities. Women only have access to communal toilet and shower facilities and sometimes baths on the ward. Birth partners generally stay, but in some units they cannot stay overnight if labour is not yet established or if it is the early stages of an induction process.

As labour progresses and becomes established, women move into birthing rooms which are predominantly single rooms. Some units have twin birthing rooms which they generally used for only one woman at a time but can be used for two if necessary.

In contrast, the two midwifery-led units have rooms that women stay in from early labour, through established labour and birth, to the end of the postnatal stay. These rooms have en-suite facilities and pools as well as other birthing aids. Partners and other family members are welcome to stay.

What is my maternity unit's policy on eating and drinking in EARLY labour?

Research says it is not evidence-based to restrict what a low-risk woman eats or drinks in early labour. Policies vary from unit to unit and many have relaxed their policies since our last survey. Despite the research, not all units support a woman eating whatever she wants but all support her eating a ‘light diet’ at least. Some units also answered ‘yes’ to the more restrictive ‘fluids only’ but did not specify what the criteria were.

At different stages of my labour and birth, how many midwives will be with me?

From our survey, in early labour the midwife-to-women ratio varies from 1 midwife:2/3 women to 1 midwife:11 women. The exceptions are the two midwifery-led units where the ratios are 1:1.

In established labour when a woman moves into a birthing room the ratio is almost always (18 units) 1 midwife to 1 woman or sometimes 1 midwife plus a student midwife. Two units reported their ratio as 1:1/2 where a qualified midwife might go between two women (and one unit stated that each woman would have a student midwife assigned). Only one unit specified their ratio could vary from 1 midwife:1-3 women.

In the majority of units when the baby is close to being born an additional midwife supports the first midwife. In the remaining units, the ratio stays at 1:1.

We asked the units about differences in staffing levels at weekends and at night and whether that affected midwife-to-women ratios. About half didn’t answer; of those that did, the majority said ratios stayed the same. Some mentioned being able to draw on additional midwives from other areas if necessary.

What is my unit's policy on the number of birth partners in labour?

See also the FAQ below about doulas.

The two midwifery-led units have no restrictions on number of birth partners at any stage of labour and birth.

Only 5 units routinely support women in having more than one birth partner with them during early labour. However during established labour, this reduces to just 4 units, and at birth this is only 3 units.

11 units stated they will consider a maternal request for more birth partners/supporters than the policy states. This usually has to be discussed in advance and sometimes particular procedures have to be followed. In some instances the request would only be considered if there were special circumstances. In response to this question, 4 units specified that birth partners can alternate but that only one can be present at any time. 4 other units do not support more than one birth partner other than in very exceptional circumstances.

All units stated that birth partners/supporters can operate a relay system where only one of them is with the mother at any time. This usually has to be discussed in advance and some units have a more formal request process than other units.

Birth partners/supporters for women:

Does my unit welcome birth plans?

All units stated they welcomed and encouraged birth plans with some units stating that the plans should be discussed and signed off at an antenatal visit.

Will I have met the person attending me in labour?

Women who have opted for midwifery-led care (MLU, DOMINO, community midwives etc.) are cared for by one of a team of midwives that they have met during pregnancy.

All other women will be assigned a midwife from the labour ward who they will probably not have met before. This applies to women who have opted for public, semi-private or private care.

Women who have opted for public care will be attended by midwives only (throughout labour, birth and the first hour after the baby is born) if there are no complications. If there are complications in any labour or birth (regardless of the care you’ve chosen), consultant obstetricians/doctors will provide any additional necessary care.

Consultant obstetricians/doctors check in on women who have opted for private/semi-private care who are labouring with no complications. They are also likely to be present as the baby is being born.

What is my maternity unit’s policy on eating and drinking in ESTABLISHED labour?

Research says it is not evidence-based to restrict what a low-risk woman eats or drinks in established labour. Policies vary from unit to unit and some have relaxed their policies since our last survey in 2011. There is quite a variation in policy from ’mother’s choice’ to ‘light diet’ to the more restrictive ‘fluids only’.

It is best to bring food from home for both the mother and her birthing partner. Bearing in mind that labour can sometimes take a long time, a variety of tasty nutritious foods will keep a labouring woman’s mood and energy levels up.

How many labour/birthing rooms are there in my local maternity hospital? How many have en-suite toilets, showers or baths?

The number of birthing rooms is given below. With the exception of the midwifery-led units, Coombe WIUH and CUMH, very few rooms have en-suite facilities. Women only have access to communal toilet and shower facilities and sometimes baths on the ward.

Accessibility of facilities where there is no en-suite

Women generally have access to communal toilet and shower facilities and sometimes baths on the ward. If that is the case in your local unit, perhaps consider writing to the Director of Midwifery to let her know that women deserve access to private facilities, and the lack of private facilities is not consistent with the protection of their rights and dignity.

Is there a pool in my local maternity unit for labour and birth?

Compared to our last survey, two more units have birth pools in use with another one planned for 2018 (UMH Limerick). Of the five units with a birth pool in use (MLU Cavan, MLU OLOL, CUMH, OLOL, Coombe WIUH) four specified that their use was for labouring only with only the Coombe stating that women can give birth in their pool. No other unit has a birth pool although some mentioned the use of baths.

No unit stated that they support a mother bringing her own portable birth pool with her.

What birthing aids are available to me in my local maternity unit?

Showers are available in all units, and baths are available in most. Not all units have chairs that are suitable for straddling or rocking/reclining. Almost all units have birthing balls and mothers are facilitated to bring in their own with one unit specifying that the balls should be anti-burst for safety reasons. About two-thirds of units have floor mats and about half have beanbags. All have pillows to use as birthing aids. Just under half the units have peanut balls. Only seven units have birthing stools but two other units use something comparable.

Lights can be adjusted in almost all units. We asked units about privacy (doors closed, knock and wait before entering) and all answered ‘yes’ but one unit said the policy was not adhered to. In all units there is a music system, but you may be advised to bring your own music and/or bring your own music player. Six units have aromatherapy vaporisers and six others said women can bring in their own.

Units were asked if there were any other comforts or birthing aids available to women. The MLU in OLOL described how their unit has air conditioning, flat screen TV, DVD, CD player, fridge, sofa beds for family and partner, tea /coffee making facilities, armchairs, and spacious waiting room with TV/DVD. The MLU in Cavan has a pole. The National Maternity Hospital has adjustable beds to facilitate all-fours position easily and the Coombe’s birthing room with the pool has two slings.

What self-help methods of coping in labour could I use in my local maternity unit?

All units support the use of TENS machines, but you may need to provide your own which also means that you can use it at home in very early labour. This is better than waiting until using one in hospital because TENS use in early labour promotes endorphins which build up over time. These endorphins help mothers cope with the sensations of labour. All but one unit stated that they facilitate the use of breathing and relaxation techniques during labour.

Seventeen units specified that they facilitate the use of hypnobirthing or GentleBirth by women who have been practicing during pregnancy. There seems to be a greater openness to its use since our last survey. Some units provide hypnobirthing classes and others have midwives undergoing training.

The use of hot and cold packs is supported in most units but some specify that women should bring their own. Fewer units facilitate the use of hot towels with some specifying that women should bring their own.

Sixteen units facilitate massage in labour but several specified that this would be done by the birth partner.

If I want to use a complementary therapy and/or bring a complementary practitioner/therapist with when I’m in labour, will my local unit support me?

Eleven units support the use of acupuncture/acupressure with several stating that they facilitate a practitioner accompanying the woman in labour. The use of homeopathy is supported in 12 units with some facilitating a practitioner being present if agreed in advance. Some units specified that women need to bring in their own remedies. The use of aromatherapy is supported by 13 units with some facilitating a practitioner being present if agreed in advance and others specifying that mothers bring in their own materials.

Some of the above can be self-administered/practiced but some require a practitioner. We asked the units whether these practitioners would be welcome in addition to birth partners/supporters.

I would like a doula to support me during labour. Will she be welcome at my unit?

Research has shown that the presence of a doula is associated with shorter labours, less need for pharmacological pain relief, fewer interventions and greater parental satisfaction with birth.

Almost all maternity units (19 out of 21) stated that doulas are welcome to support women. This has increased significantly since our last survey. Several units stated that it needs to be agreed in advance.

What facilities are available for the comfort for my birth partner(s)?

Only the two midwifery-led units (in Cavan and Drogheda) have sofa beds routinely used by birth partners/supporters. In two other units, beds can be made available in special circumstances. Most other units stated that there are comfortable chairs available.

Unless the birthing room has an en-suite toilet, birth partners/supporters usually have to use a public toilet elsewhere in the hospital.

What pain relief is available to me - and when - in my local maternity unit?

EARLY LABOUR Mothers can encourage labour to progress and help themselves cope with the sensations of labour by staying upright and moving around. Entonox (also known as ‘gas & air’) and pethidine are the most widely available forms of pain relief in early labour. Entonox is unlikely to limit a woman’s mobility whereas pethidine may restrict her to bed.

ESTABLISHED LABOUR Entonox (also known as ‘gas & air’), epidural anaesthesia and pethidine are the most widely available forms of pain relief in established labour. Pethidine should not be administered within 3-4 hours of the baby being born due to the risk of depressed respiratory function (difficulty breathing) and poor suck in babies after birth.

‘Mobile epidural’ (where a woman has enough sensation to be able to walk) is not currently available in the vast majority of maternity units in Ireland. (Spinal anaesthesia is usually reserved for caesarean births).

There is no epidural anaesthesia available in the two midwifery-led units (in Cavan and Drogheda) but these units have birth pools for labouring in, and many other aids to increase a mother’s comfort in labour.

BIRTH/2nd STAGE: Entonox (also known as ‘gas & air’) and epidural anaesthesia are the most widely available forms of pain relief at birth. (Usually an epidural would not be administered at this stage but would still be in place from earlier.)

Some units reported the use of spinal anaesthesia at this stage but it is usually reserved for caesarean births.

Some units reported availability of pethidine in 2nd stage/birth of the baby. Using pethidine later in labour increases the risk of depressed respiratory function (difficulty breathing) and poor suck in babies after birth.

3RD STAGE (delivery of the placenta): A woman would not usually need additional pain relief at this point unless she required stitches or manual removal of the placenta.

AFTER BIRTH: After birth, some women require pain relief for stitches or after-pains and use paracetamol, ibuprofen or difene (NSAID). A woman would not usually need additional pain relief from the list below at this point.

Additional information:

Indications for use:

What positions do mothers in my local maternity unit use for labouring and for giving birth?

Units reported facilitating a wide range of positions, including upright positions which are best for encouraging labour to progress. Upright positions also allow gravity to help the baby be born. All positions allow for the baby's heart rate to be checked intermittently as recommended for low-risk mothers and babies. Most positions also allow for continuous monitoring of the baby's heart rate if this is deemed necessary.

In some units, some positions are facilitated for one stage of labour but not the other. Fewer units support the use of some of the more active upright positions (walking/standing/squatting), especially for second stage.

I’m hoping to avoid using an epidural. How will I be supported in this by my local unit?

All but 5 units answered this question. They mentioned encouragement and support through one-to-one care, use of birthing aids (e.g. TENS, birthing balls, heat packs), use of water, other pain relief options, doulas, massage, music, breathing techniques, hypnobirthing, positions and movement.

How does my unit ensure that my decisions during labour and birth are informed decisions?

All units answered this question but with varying degree of detail. In general, the responses implied there would be provision of information through antenatal classes, leaflets and through discussion with your midwife or doctor and that practices are based on national or international guidelines. No unit mentioned informed refusal but there can be no informed consent without the possibility of informed refusal.

The more questions you ask the more information you will receive to help you make informed decisions - this applies to both routine and non-routine procedures. Evidence-based information on the benefits, risks, alternatives (including watch-and-wait approach) and implications (knock-on effects) will help you make the best decision for you and your baby.

If I choose/am offered something in labour, will I be told of the possible knock-on effects?

Certain routine and non-routine procedures and some types of pain relief can sometimes result in a negative impact on mother or baby and/or further interventions being necessary. Sixteen units responded that they 'always' made this clear to mothers and birth partners, with four units saying 'mostly' and one unit saying ‘sometimes’.

The more questions you ask the more information you will receive to help you make informed decisions - this applies to both routine and non-routine procedures. Evidence-based information on the benefits, risks, alternatives (including watch-and-wait approach) and implications (knock-on effects) will help you make the best decision for you and your baby.

What if I want a 2nd opinion during labour?

All units stated that where possible a 2nd opinion would be provided if requested.

What methods are available in my local maternity unit to check how my baby is coping during labour?

All units reported having a variety of methods available to check the baby's heart rate. These methods either involve checking at set intervals or monitoring continuously. For low-risk women and babies whose labour is straightforward, intermittent listening to the baby's heart (typically using a hand-held monitor/Doppler or a Pinard stethoscope) is recommended in the National Clinical Guidelines (every 15 minutes in the first stage of labour and every 5 minutes in the second stage). This allows for the women to move around and find comfortable positions.

Where there are concerns or where there have been certain interventions, continuous monitoring may be recommended. This can be done in two ways: externally using a belt monitor (cardiotocograph, CTG) or internally by clipping a small device (fetal scalp electrode, FSE) onto the baby's head via the vagina. Some units have wireless versions of these which enable a woman to move freely, but the majority have cables which restrict a woman to within a few metres of the machine and therefore less compatible with movement. Sometimes a mother’s position or movements result in loss of contact by the sensors which affects the readings. This may then require a woman to adopt a less helpful (stationary) position like lying propped up in bed in order to get continuous readings.

Research (Cochrane database) has shown that there is an increased risk of instrumental birth (forceps or ventouse) or caesarean birth linked to continuous monitoring. Less than half the units stated that they inform low-risk women of these risks. Only a third of units inform high-risk women of these risks.

More units now have the facility to analyse a tiny sample of the baby's blood taken from the scalp (fetal blood sampling, FBS). This method is used if there are increased concerns about the baby and it can show if a baby needs to be born by caesarean birth urgently.

Here is what the units reported about the various methods. Not all units answered all the questions.

Pinard stethoscope (funnel-shaped stethoscope for a midwife to listen to a baby’s heart)

Doppler (hand-held ultrasound monitor that picks up the baby’s heart rate)

Cardiotocography (CTG) (a method of measuring the baby’s heart rate and monitoring contractions requiring elasticated belts around the mother’s abdomen with cables attached to a machine)

Wireless CTG (as above but signals transmitted to the machine wirelessly enabling a mother to move about freely)

Fetal scape electrode (FSE) (a small device connected by cable to the monitor is inserted through the vagina and placed on the baby's scalp)

Fetal blood sampling (FBS) (a small sample of the baby’s blood taken from the scalp is tested to check oxygen levels):

Are the increased risks of instrumental or surgical birth with continuous electronic fetal monitoring explained?

How will the progress of my labour be assessed?

A combination of externally feeling the baby's position (palpation), checking how far dilated the cervix is (vaginal examination) and reading the mother's signals (body language, demeanour, sounds and frequency, length and strength of contractions) can tell you and your midwife how your labour is progressing.

Palpations are typically offered on admission and before vaginal examinations. In general, vaginal examinations are offered 2-4 hourly. International best practice is four-hourly. Reponses about assessment of the progress of labour by reading the mother’s signals varied from unit to unit.

First-time mothers

2nd- and subsequent-time mothers:

How is progress assessed using maternal indicators? (Please list as many as possible including emotional, physical, psychological and behavioural indicators.)

Does my local unit have a policy on the length of (the first stage of) labour?

There is a variation in practice across the maternity units from women being assessed on an individual basis with no particular time limits to stated policies of between 8 and 14 hours (often expressed as 1-2cm dilation per hour). As long as mother and baby are doing well and labour is progressing, albeit slowly, there is no evidence-based reason to apply a limit to the length of the first stage of labour.

Why might antibiotics be suggested to me during labour?

Not all units answered this question. Reasons most frequently given were waters released more than 18/24 hours, premature labour, Group B strep and a high temperature in the mother.

Why might releasing my waters be suggested to me during labour?

For most women, their ‘waters’ (amniotic fluid around their baby) will release naturally towards the end of labour. For a small proportion of women, labour starts with their waters releasing. Caregivers can offer to release the amniotic fluid manually; this intervention is called artificial rupture of membranes (ARM) and is also known as ‘breaking the waters’.

The units’ three most common reasons for offering this intervention are:

• if there are concerns about the baby's heart rate (to see the colour of the amniotic fluid around the baby)
• to speed up a labour that is deemed to be slow
• as part of the process of inducing labour

One unit stated it that it is routinely performed as part of Active Management of Labour.

The UK’s NICE guidelines state that ARM should not be performed routinely but is an option if there is delay in the first stage of labour (less than 2cms dilation in 4 hours). Women should be informed that ARM will shorten the length of labour by about an hour but that the strength and pain of her contractions may increase.

Only one unit indicated a difference between use of ARM for first-time and second- and subsequent-time mothers.

We asked what else labouring mothers or their caregivers could do first or instead of ARM. Only ten units answered this question, and some gave very little detail. Suggestions included staying mobile and using upright positions, using a birthing ball/bath/shower, nipple stimulation to encourage oxytocin production, visualisation, avoiding induction where possible and simply waiting longer.

Why might Syntocinon (artificial version of the hormone oxytocin given via a drip) be suggested to me during labour?

Syntocinon is given via an IV drip and can only be used if the waters have already released naturally or artificially. Units stated that they use it:

• to speed up labour
• as part of the induction of labour process
• later in labour, to speed up the birthing stage
• later again, to control bleeding and to speed up the delivery of the placenta.

Internationally, there is currently a shift from thinking of labour as being established at 3cm dilation to only being truly established at 6cm. With this new thinking, Syntocinon would not be used until after a woman reached 6cm and thereafter progress was genuinely slow.

We asked what else labouring mothers or their caregivers could do first or instead of using Syntocinon. Only nine units answered this question, and some gave very little detail. Suggestions included staying mobile and using upright positions, using a birthing ball/bath, nipple stimulation to encourage oxytocin production, visualisation, hypnobirthing, avoiding induction where possible and simply waiting longer.

Why might an unplanned caesarean birth be recommended during the first stage of labour?

Units listed reasons such as emergencies (e.g. cord prolapse or haemorrhage), concerns over the baby’s heart rate (indicating possible fetal distress) and labour not progressing. More units have the ability now to check the baby’s oxygenation levels with the fetal blood sample and can act on those readings if necessary.

Whilst caesarean births in Ireland are safer than a generation ago, they are still major abdominal surgery and most women and their caregivers would prefer for a woman to give birth vaginally if possible. Some caesarean births are necessary, life-saving operations. Others may be avoidable depending on the path the labour takes and on interventions along the way. This is because some procedures earlier in a labour may result in knock-on effects or further interventions which can lead to a circumstance which requires a caesarean birth.

Does my unit have a policy on the length of second stage (from full dilation to the baby's birth)?

This depends on whether it is your first baby or if you've had a baby before. For first-time mothers NOT using epidural, the units' policies vary from 1 hour to 1-2 hours, with two units stating no particular policy and three referring to NICE guidelines (up to 3 hours after the descent of the baby).

About half of units stated that the policy is to give more time for first-time mothers using epidurals as epidurals are known to slow down the second stage of labour. This is often given in the form of 1 hour for the baby to descend before pushing commences.

For women who have had a baby before and do NOT have an epidural in place the unit policies are quite varied. They start at only 30 mins, with many at 1 hour and only a few allowing time for descent before pushing and a few others referring to the NICE guidelines. If using an epidural the times vary from 30 minutes to 2 hours. One unit allows up to 2 hours for descent and then 1 hour pushing. NICE guidelines recommend 2 hours after descent for second- and subsequent-time mothers.

Will I push when I feel like it or will I be told when to push?

Over half the units stated that they facilitate a mother pushing instinctively when she feels like it, but many of those units also said they practiced coached pushing where the midwife instructs the mother when to push and to hold her breath when pushing. The vast majority of units reported a combination of the methods. Only the two midwifery-led units in OLOL and Cavan stated that they do not use coached pushing at all.

If my baby needed assistance being born, what procedures might be suggested?

Episiotomy (a surgical cut into the perineum to make room for the baby to come out) can be performed if the baby is struggling and needs to be born quickly or if required for a forceps or ventouse (vacuum) birth. No unit stated that this procedure is carried out routinely.

Current research tells us that episiotomies should only be performed to enable a baby to be born quickly where necessary and should not be performed in an attempt to minimise damage to a woman’s perineum as was common practice in the past. Some units did refer to this practice and others referred to using episiotomies because of previous perineal damage.

Perineal massage during pregnancy has been proven to reduce the need for episiotomies (particularly in first-time mothers) and several units recommend this. Other units mentioned warm compresses (pressed against the perineum as the baby’s head is crowning) and others mentioned birthing positions. Generally upright positions put less pressure on the perineum and instinctive (self-directed) pushing is also easier on the perineum compared to coached pushing.

Two units mentioned training and education of staff to reduce the rates of episiotomies.

Assistance by ventouse or forceps (instrumental birth) can be used to help a baby to be born quickly if a baby is distressed, and some units stated they can be used if progress is slow or if a mother becomes exhausted. Ventouse is preferred but forceps might be required in rare cases where a woman should not push for medical reasons. Typically, a ventouse is used if the baby is further down the birth canal whereas forceps are typically used if the baby is higher or needs assistance to turn. Upright positions can reduce the need for instrumental birth.

If the above procedures don't work or if they are not suitable for a particular situation an unplanned caesarean birth would then be recommended. In addition, there can also be emergencies that require a caesarean birth. In some cases, a second twin might be born by caesarean.

I've heard about natural delivery of the placenta (third stage of labour). Is this practiced at my local maternity unit?

Most units stated that the placenta was delivered naturally 'sometimes' or 'at maternal request' and it is encouraged in the midwifery-led unit (MLU) in Drogheda. Current research tells us that it is safe to aim for a natural delivery of the placenta in a labour that has started spontaneously and which has continued with no interventions (no artificial release of the waters, no speeding up of labour, no epidural and no episiotomy).

In contrast, all units except the two MLUs stated that the delivery of the placenta was routinely managed using drugs (either a synthetic form of oxytocin called Syntocinon or a mix of Syntocinon and ergometrine called Syntometrine). We only got figures on this from a few units but they indicate that the vast majority (about 99%) of women giving birth in Irish hospitals have an actively managed third stage of labour. The National Clinical Guidelines from 2012 recommend the use of Syntocinon, but only about half of the units do so, with the others routinely using Syntometrine which can have some side effects. Syntocinon is a better choice for a woman who wants to breastfeed.

Current research tells us that a managed third stage is advised in an induced labour or following interventions in a spontaneous labour (e.g. artificial release of the waters, speeding up of labour, epidural or episiotomy).

Just over a third of units reported some placentas delivered naturally in the statistics section.

Is optimal cord clamping practiced in my local maternity unit? Is it an option for my birth partner to cut the cord?

After birth, waiting 1-3 minutes or ideally until the cord stops pulsating completely is very beneficial for babies: the baby gets his/her full volume of blood which makes the transition to life outside the womb easier. The blood contains the full complement of iron which is very important for the baby’s development. (With immediate cord clamping, the baby ends up with only two-thirds of his natural blood volume.)

About half of the units stated that optimal (delayed) cord clamping is practiced routinely, with others saying it is done at maternal request. One unit stated that is it only done for a natural third stage and that for a manged third stage the cord is cut immediately.

About three-quarters of the units stated that partners are accommodated in cutting the cord.

The cord is clamped and cut immediately if the baby or mother needs assistance/medical attention.

Resuscitaires are used to examine babies in need of medical attention after birth and to provide assistance to them (breathing, suction, temperature regulation etc.). They are usually located in the birthing room but not right beside where the mother gives birth so the umbilical cord is cut immediately in the event that a baby needs assistance. We asked the units about the use of bedside Resuscitaires which enable the placenta and cord to continue to support the baby while s/he is getting medical attention. One unit mentioned a study involving their use.

If I want to harvest cord blood, can my unit assist me in this?

This is possible in just over half of the maternity units but in general seems to require a specific clinical reason and/or request from the Irish Blood Transfusion Service in advance.

What if I want to take my placenta home?

Five units did not answer this question but those that did indicated that it is facilitated. Some mentioned providing bags for the placenta whilst others specified that parents needed to provide their own lidded container. A few mentioned taking the placenta home on the same day as birth. Some said that parents needed to sign a declaration that they will dispose of the placenta responsibly.

I’d like skin-to-skin contact after my baby is born. How does my unit support this?

Skin-to-skin contact between mother and baby is promoted in all units after birth. The baby lies on the mother’s chest or abdomen. Countless studies show the benefits of skin-to-skin contact for babies. These include temperature stabilisation, improved heart and lung function, regulation of blood sugars, promotion of maternal bonding and initiation of breastfeeding. It also allows the seeding of the baby’s microbiome (optimal colonisation of the baby’s system with micro-organisms).

If a mother is unwell or needs medical attention, her partner can do skin-to-skin with their baby. (Even in cases where a mother is well, skin-to-skin contact between father and baby on the day of birth is beneficial to both.)

Most units stated that the baby is only cleaned and wrapped if skin-to-skin is not possible or appropriate (e.g. infections) during the first hour after birth. Babies are then wrapped or dressed to leave the labour ward.

When will I first feed my baby (after a vaginal birth)?

All units stated that they encouraged women to breastfeed in the first hour when the baby shows signs of readiness.

In the two midwifery-led units, women stay in the same room that they gave birth in until they go home. All other units have a policy that breastfed babies have their first feed in the birthing room typically in the first hour after birth. About half the units have the same policy for formula-fed babies.

What else happens in the first hour after birth in the birthing room?

Units told us that a full head-to-toe check is done on the baby – according to several units all elements of this except weight can be done while the baby is in the mother's arms. Others mentioned routine vitamin K injection, placing name and security bands on the baby and testing cord blood gases if necessary.

I’ve heard about ‘gentle’/’natural’ caesareans births. If I needed to birth my baby by caesarean, what options are there in my local unit?

We asked units if any of the following are available to women who wish to have a more ‘natural’ caesarean birth: lowered or see-through drapes, slow emergence of the baby, baby lifted out by mother, optimal cord clamping, parents discovering the baby’s sex etc. Not all units answered this question. Optimal cord clamping, lowering the drapes, parents discovering the sex of their baby themselves, and skin-to-skin contact were most frequently mentioned. UMH Limerick have been offering ‘Gentle Caesareans’ since 2016. (Note: no unit stated this, but the reason for/urgency of the caesarean might determine if these options are available.)

If I needed to give birth by caesarean, would my baby have optimal cord clamping?

After birth, waiting 1-3 minutes or ideally until the cord stops pulsating completely is very beneficial for babies: the baby gets his/her full volume of blood which makes the transition to life outside the womb easier. The blood contains the full complement of iron which is very important for the baby’s development. (With immediate cord clamping, the baby ends up with only two-thirds of his natural blood volume.)

Not all units answered this question and the responses varied from ‘never’ to ‘on request’ to ‘at all times when fetal well-being permits’.

If I have a caesarean birth, will I get skin-to-skin contact with my baby?

Most units stated that skin-to-skin contact for mother and baby is encouraged in the theatre directly after birth, with four units stating it is also facilitated in the recovery room after the operation is completed, where possible. Many units stated that where it is not possible for mother to provide skin-to-skin, the father/birth partner is encouraged to do so in theatre. This can be continued in a dedicated room or in the postnatal ward while the mother is in the recovery room.

Under what circumstances might my baby be cleaned and wrapped after a caesarean birth?

Most units dry babies after a caesarean birth but do not wrap babies until after skin-to-skin contact or for transfer to the ward. Only one unit stated that they routinely wrap babies. Many units mentioned that the condition of the baby at birth or certain medical needs may require the baby to be cleaned and wrapped immediately.

I’ve heard about seeding the baby’s microbiome after a caesarean birth. Does my local unit support this?

There is ongoing research into the benefits of using a vaginal swab to mimic the contact that a baby born vaginally would make. It is thought that this facilitates the baby in developing a healthy microbiome. This video explains the concept of the microbiome. https://www.youtube.com/watch?v=5DTrENdWvvM.

Generally the Irish maternity units do not support the practice of seeding. Three units stated that it could be accommodated on maternal request. One unit questioned the possibility of cross-contamination.

If I have a caesarean birth, what is my unit's policy on having my baby in the recovery room with me?

Less than a third of the units stated that mother and baby routinely stay together in the recovery room (unless the baby requires special care). Over one-third of units stated that it is not possible for mother and baby to go the recovery room together (often because recovery rooms in general hospitals are shared with post-operative patients from other departments), while the remainder stated that it can be facilitated at times.

If I have a caesarean birth what happens if I need help when giving my baby his/her first feed?

Nearly all units stated that a mother will get one-to-one support from a midwife to assist her with feeding her baby for the first time.

Given the nationwide rise in caesarean births in recent years, what strategies are in place to reduce the numbers of caesarean births in my maternity unit?

The units responded with a range of answers including close auditing of caesarean births, promotion of VBAC (vaginal birth after caesarean), use of fetal blood sampling, consultant input, delaying induction to 42 weeks where possible, education of women, external cephalic version to turn breech babies, and use of upright positions and birthing aids to help labour progress.