There is a movement to encourage certification and provide documentation of it on consumer websites such as DoulaMatch where an individual can find certified doulas, childbirth educators, yoga instructors, and other birth-related professionals. [ 46 ]  Doulas not trained by a formal organization can be controversial within medical settings due to a lack of formal medical education when a discussion regarding  medical interventions in labor  versus pursuing  natural childbirth  without an  epidural  or  cesarean section  arises. [ 45 ]


Major doula organizations that offer certification programs include Birth Arts International, Birth Works, Birthing from Within, Childbirth and Postpartum Professional Association (CAPPA),  DONA International ,  Hypnobirthing, International Childbirth Education Association (ICEA), and ProDoula. [ 50 ]  Because of the lack of standardization, doula organizations provide different courses with varying requirements and anyone can refer to themselves as a doula. [ 51 ]  Doulamatch.net, an online referral page for doulas, has offered a list of items that students should look for as they begin looking for training. Amy Gilliland, a researcher on doula care and culture, also lists some qualities a training program should have. [ 52 ]  Some theorists have stated that it might take college-level work or more in-depth online education in order to provide some of the communication skills that might be necessary. [ 53 ]


In 2010, a survey of professional Canadian doulas found that the common motivations for doula work include "desire to support women in childbirth, personal interest, and a wish to share their own positive birth experience with others" but did not see the work as a means to create steady income. [ 54 ]  Doulas of color also found motivation in providing care for their racial, ethnic and cultural communities so as to provide culturally competent care. [ 55 ]  Volunteer doulas often saw doula work as a way to "help others, to establish a practice as an employed doula, and to have a route into nursing or midwifery." [ 56 ]  From 2021 to present, Canada has specifically focused research on the cultural significance of indigenous practices in doula work. [ 57 ] [ 58 ] [ 59 ]


A 2004 study of North American doulas identified challenges to doula work such as lack of support from clinicians, balancing doula work with family and other work obligations, and being on call. [ 60 ]  Volunteer doulas also found challenges in individuals' poor understanding of the doula's role, lack of clear boundaries, and complex socio-economic issues. [ 56 ]  Additionally, doulas often are challenged with the task to navigate their role in  medicalized  (hospital) births. [ 61 ]  Due to the social hierarchy and privilege that medical professionals have in medical settings doulas are often subordinate to doctors and physicians. Doulas have to negotiate the power dynamics between the patient and medical provider, while also establishing their legitimacy and role in the process of childbirth. [ 62 ]  They, therefore, have to be cognizant of the medical environment in which their client chooses to give birth in order to effectively advocate for their client's needs. [ 63 ]


An antepartum doula provides help and support to someone who has been put on bed rest or is experiencing a high-risk pregnancy. Emotional, physical and practical support can be provided by an antepartum doula in this circumstance. [ 64 ]


Postpartum doulas provide educational support and practical support in the home in the first weeks and months after childbirth or after adding an infant to the family. The same doula often provides both birth and postpartum services. [ 2 ]  Their services include a mixture of emotional support and practical help, such as infant care, breastfeeding support, information, advocacy and referral, partner support, sibling care, and household organization/work as the family adjusts to the addition of a new baby. [ 65 ]  There is some evidence that postpartum doula support can increase  breastfeeding  and decrease  postpartum depression . [ 5 ] [ 66 ]


Other workers overlap in some of these services, such as maternity nurses, health visitors, newborn care specialists, lactation consultants, and, historically,  monthly nurses .


Full-spectrum doulas extend the role of a birth attendant and provide support for all reproductive experiences which connect the role to the larger  reproductive justice  movement. [ 3 ]  This can include support for  abortion ,  miscarriage ,  stillbirth , queer family planning,  adoption , and fertility as well as extending services to women, men,  transgender  and  gender non-conforming  individuals. [ 3 ] [ 67 ] [ 68 ]   Abortion doulas focus on providing support to clients having an induced abortion. They provide emotional, physical, and informational support virtually or in person. [ 3 ] [ 15 ]  Full-spectrum doulas often identify as  activists  as well as service providers and emphasize the  human rights  of their clients in the hopes of ending social stereotypes. [ 3 ]


Abortion  doulas provide care before, during, and after an abortion, with support varying by person and their informational, emotional, physical, and practical needs. Doulas work in a variety of situations, including community collectives and as solo practitioners, and provide abortion support as a service in their full-spectrum practice. There are no certifications specifically for abortion doulas that are administered nationally or through individual states. [ 69 ]


In the United States following the landmark decision,  Dobbs v. Jackson Women's Health Organization , doulas expect to be contacted more frequently about abortion support as access becomes more limited. They are taking precautions to retain online anonymity to better protect patients and themselves and navigate the threat of legal action. [ 69 ]


A gender doula provides care before, during, and after the  gender transition  process for transgender and non-binary individuals. [ 70 ]  Gender doulas may also serve as patient advocates for their clients against medical practitioners who may misgender or undermine the gender identity of the client.


End-of-life or  death doulas  care for critically ill adults in  geriatric care , [ 17 ]  and during death. [ 71 ]  While some doulas work independently or on a volunteer basis, others might work in association with a health care service, such as a palliative care service. The roles of an end-of-life doula include not only physical tasks, such as assisting with posture or making the bed comfortable but also emotional and psychological tasks, such as providing guidance and support.


In the United States, doulas can be found in hospital, community-based programs as well as private practice or doula agencies. They might also be reimbursed by insurance companies or out-of-pocket by clients. [ 72 ] [ 73 ] [ 74 ]  Since insurance companies typically do not cover the cost of hiring a doula, they are more popular among middle- and upper-class parents than amongst parents with lower incomes. [ 45 ] [ 75 ]  Since doula care has the potential to lower maternity costs and reduce health disparities, there is a push for coverage through Medicaid reimbursement programs. As of 2022, four states,  Oregon ,  Minnesota ,  Virginia  and  Wisconsin , have implemented reimbursement programs. [ 34 ] [ 76 ]  In 2019,  New York State  launched a doula pilot program for Medicaid reimbursement in  Erie  and  Kings  Counties. [ 77 ]  In that same year, New York State passed a bill to certify doulas to lend legitimacy to the profession and to pave the way for Medicaid reimbursement from the federal government, becoming the first state to do so. Doulas in New York, however, expressed concern about the bill, having not been involved with the bill's writing, citing that state certification would make doulas more beholden to the formal medical system, be a hit to business if certification programs are not approved by the state, and might prevent community doulas from working with low-income individuals. [ 78 ] [ 79 ]


In the UK, the  National Health Service  and promotion of midwifery for low-risk pregnancies provide a continuity of care unavailable to North American pregnant women, but still are seeing an upswing in doulas. This pattern has been suggested to result from the lack of midwives available and a move to provide doulas to individuals at greater risk for poor outcomes. [ 56 ]


A 2019 study reviewed perceptions of labor companionship across mostly high income countries and found barriers that prevent the universal implementation of doula care. These challenges are due to a multitude of factors dealing with perception (for example, providers not understanding the benefits or roles and other medical aspects being seen as more important) and logistics (chiefly, gaps in policy, difficulty of integration, and lack of training). [ 80 ]


Community-based doulas work with underserved communities of which they are often members to provide a sense of cultural humility that fosters trust and strengthens relationships between the doula and their client. The services provided are often low cost, and expand in the amount of support offered compared to traditional doulas and consider physical, social spiritual and emotional needs. Services include an increased amount of home visits, preparation for the birthing experience, education, guidance navigating health care systems, language support, screening for mental health, and food security needs. [ 81 ]


Additionally, community-based doula models provide insight in the creation of policies that will support those families and underserved communities. [ 81 ]  These doulas also actively engage policy makers by recommendations on certification and Medicaid coverage, integration into medical care, and participating on advisory boards. [ 82 ]


Since the 1980s,  women incarcerated in the US  has increased nearly 800 percent, of which an estimated 12,000 pregnant women are incarcerated annually. Pregnant prisoners are allowed to be shackled in more than 20 states and are forced to return to jail within 24 hours without their infants. [ 83 ]  The environmental factors of the penal system are shown to increase the risks associated with poor perinatal outcomes and have long-term health risks for the women and their children. [ 84 ]  The implementation of prison doulas rose out of the movement to end shackling for pregnant and laboring women from the  prison abolition , human rights, reproductive justice, and birth justice movements in the early 2000s. [ 84 ] [ 85 ]  Prison doula organizations work with those incarcerated to provide prenatal care, childbirth education, birth attendance, and breast feeding support. By providing doula services to jails, prisons, recovery centers, and county hospitals, doulas work to improve birth experiences and bonding as well as to challenge the dehumanizing penal environment. [ 85 ]  In studies of women who received doula services while incarcerated, the women reported increased happiness around their pregnancy; greater feelings of empowerment; a sense of normalcy around birth; and support during separation from their infant. [ 84 ] [ 86 ]


While well-received, prison doula support is not widespread in the United States and most programs are local due to the lack of an established federal standard of medical care for pregnant incarcerated individuals. [ 83 ]  In 2018,  Washington  was the first state to provide access to midwifery and doula services for incarcerated women for prenatal care, delivery, and postpartum care. However, the bill does not establish means of funding the services, and does not establish guidelines for care. [ 87 ]


Epidural administration  (from  Ancient Greek  ἐπί, "upon" +  dura mater ) [ 1 ]  is a  method of medication administration  in which a medicine is injected into the  epidural space  around the  spinal cord . The epidural route is used by physicians and  nurse anesthetists  to administer  local anesthetic  agents,  analgesics ,  diagnostic  medicines such as  radiocontrast agents , and other medicines such as  glucocorticoids . Epidural administration involves the placement of a  catheter  into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon  Fidel Pagés .


Epidural anaesthesia causes a loss of  sensation , including  pain , by blocking the transmission of signals through  nerve fibres  in or near the spinal cord. For this reason, epidurals are commonly used for  pain control  during  childbirth  and  surgery , for which the technique is considered safe and effective, and is considered more effective and safer than giving pain medication by mouth or through an  intravenous line . An epidural injection may also be used to administer  steroids  for the treatment of  inflammatory  conditions of the spinal cord. It is not recommended for people with severe bleeding disorders, low platelet counts, or infections near the intended injection site. Severe complications from epidural administration are rare, but can include problems resulting from improper administration, as well as  adverse effects  from medicine. The most common complications of epidural injections include bleeding problems,  headaches , and inadequate pain control. Epidural analgesia during childbirth may also impact the mother's ability to move during labor. Very large doses of anesthetics or analgesics may result in  respiratory depression .


An epidural injection may be administered at any point of the spine, but most commonly the  lumbar spine , below the end of the spinal cord. The specific administration site determines the specific  nerves  affected, and thus the area of the body from which pain will be blocked. Insertion of an epidural catheter consists of threading a needle between bones and ligaments to reach the epidural space without going so far as to puncture the  dura mater . Saline or air may be used to confirm placement in the epidural space. Alternatively, direct imaging of the injection area may be performed with a  portable ultrasound  or  fluoroscopy  to confirm correct placement. Once placed, medication may be administered in one or more single doses, or may be continually infused over a period of time. When placed properly, an epidural catheter may remain inserted for several days, but is usually removed when it is possible to use less invasive administration methods (such as oral medication).


Epidural injections are commonly used to provide pain relief ( analgesia ) during childbirth. [ 2 ]  This usually involves epidural injection of a local anesthetic and  opioids , commonly called an "epidural". This is more effective than oral or  intravenous  (IV) opioids and other common modalities of analgesia in childbirth. [ 3 ]  After an epidural is administered, the recipient may not feel pain, but may still feel pressure. [ 4 ]  Epidural  clonidine  is rarely used but has been extensively studied for management of analgesia during labor. [ 5 ]


Epidural analgesia is considered a safer and more effective method of relieving pain in labor as compared to intravenous or oral analgesia. In a 2018  Cochrane review  of studies which compared epidural analgesia with  oral  opioids, some advantages of epidural analgesia versus opioids included fewer instances of  naloxone  use in newborns, and decreased risk of maternal hyperventilation. [ 3 ]  Some disadvantages of epidural analgesia versus opioids included longer labor durations, an increased need for  oxytocin  to stimulate  uterine contractions , and an increased risk of fever, low blood pressure, and muscle weakness. [ 3 ]


However, the review found no difference in overall Caesarean delivery rates between epidural analgesia versus no analgesia. Additionally, there was no difference found on the immediate neonatal health of the child between epidural analgesia versus no analgesia. Furthermore, the occurrence of long-term backache was unchanged after epidural use. [ 3 ]  Complications of epidural analgesia are rare, but may include headaches, dizziness, difficulty breathing and seizures for the mother. The child may experience a slow heartbeat, decreased ability to regulate temperature, and potential exposure to the drugs administered to the mother. [ 6 ]


There is no overall difference in outcomes based on the time the epidural is administered to the mother, [ 7 ]  specifically no change in the rate of caesarean section,  birth which must be assisted by instruments , and duration of labor. There is also no change in the  Apgar score  of the newborn between early and late epidural administration. [ 7 ]  Epidurals other than low-dose ambulatory epidurals also impact the ability of the mother to move during labor. Movement such as walking or changing positions may help improve labor comfort and decrease the risk of complications. [ 8 ]


Epidural analgesia has been demonstrated to have several benefits after other surgeries, including decreasing the need for the use of oral or systemic opioids, [ 9 ]  and reducing the risk of postoperative respiratory problems, chest infections, [ 10 ]   blood transfusion  requirements, [ 11 ]  and  myocardial infarctions . [ 12 ]  Use of epidural analgesia after surgery in place of systemic analgesia is less likely to decrease  intestinal motility  which would occur with systemic opioid therapy through blockade of the sympathetic nervous system. [ 11 ] [ 13 ]  Some surgeries that spinal analgesia may be used in include lower abdominal surgery, lower limb surgery, cardiac surgery, and perineal surgery. [ 11 ] [ 14 ] [ 15 ]


The injection of steroids into the epidural space is sometimes used to treat  nerve root pain ,  radicular pain  and  inflammation  caused by conditions such as  spinal disc herniation ,  degenerative disc disease , and  spinal stenosis . [ 16 ]  The risk of complications from steroid administration is low and complications are usually minor. The specific drug, dose, and frequency of administration impacts the risk for and severity of complications. Complications of epidural steroid administration are similar to the side effects of steroids administered in other manners, and can include higher than normal blood sugar, especially in patients with  type 2 diabetes . [ 16 ]
An  epidural blood patch  consists of a small amount of a person's own blood is injected into the epidural space. This is done as a method of sealing a hole or leak in the epidural. [ 17 ]  The injected blood clots at the site of the puncture, closes the leak, and modulates CSF pressure. [ 18 ] [ 19 ]   This may be used to treat  post-dural-puncture headache  and leakage of  cerebrospinal fluid  due to dural puncture, which occurs in approximately 1.5% of epidural analgesia procedures. [ 20 ]


The use of epidural analgesia and anesthetic is considered safe and effective in most situations. Epidural analgesia is contraindicated in people who have complications such as  cellulitis  near the injection site or severe coagulopathy. [ 20 ]  In some cases, it may be contraindicated in people with low platelets, increased  intracranial pressure , or decreased  cardiac output . [ 20 ]  Due to the risk of disease progression, it is also potentially contraindicated in people with preexisting progressive neurologic disease. [ 20 ]  Some heart conditions such as  stenosis  of the aortic or mitral valves are also a contraindication to the use of epidural administration, as is low blood pressure or  hypovolemia . [ 16 ]  An epidural is generally not used in people who are being administered  anticoagulation therapy  as it increases the risk of complications from the epidural. [ 16 ]


In addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though  sensory nerve fibers  are more sensitive to the effects of the local anesthetics than  motor nerve fibers . For this reason, adequate pain control can usually be attained without blocking the motor neurons, which would cause a loss of muscle control if it occurred. Depending on the drug and dose administered, the effects may last only a few minutes or up to several hours. [ 21 ]  As such, an epidural can provide pain control without as much of an effect on muscle strength. For example, a woman in labor who is being administered continuous analgesia via an epidural may not have impairment to her ability to move. Larger doses of medication are more likely to result in side effects. [ 22 ]  Very large doses of some medications can cause paralysis of the  intercostal muscles  and  thoracic diaphragm  responsible for breathing, which may lead to respiratory depression or arrest. It may also result in loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure. [ 22 ]   Obese  people, those who have  given birth prior , those with a history of opiate use, or those with  cervical dilation  of more than 7 cm are at a higher risk of inadequate pain control. [ 23 ]


If the dura is accidentally punctured during administration, it may cause cerebrospinal fluid to leak into the epidural space, causing a post-dural-puncture headache. [ 24 ]  This occurs in approximately 1 in 100 epidural procedures. Such a headache may be severe and last several days, or rarely weeks to months, and is caused by a reduction in CSF pressure. Mild post-dural-puncture headaches may be treated with caffeine and gabapentin, [ 25 ]  while severe headaches may be treated with an epidural blood patch, though most cases resolve spontaneously with time. Less common but more severe complications include  subdural hematoma  and  cerebral venous thrombosis . The epidural catheter may also rarely be inadvertently placed in the subarachnoid space, which occurs in less than 1 in 1000 procedures. If this occurs, cerebrospinal fluid can be freely aspirated from the catheter, and this is used to detect misplacement. When this occurs, the catheter is withdrawn and replaced elsewhere, though occasionally no fluid may be aspirated despite a dural puncture. [ 26 ]  If dural puncture is not recognized, large doses of anesthetic may be delivered directly into the cerebrospinal fluid. This may result in a high block, or, more rarely, a  total spinal , where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes  seizures . [ 26 ]


Epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people. [ 27 ]  This occurs when epidural veins are inadvertently punctured with the needle during the insertion. It is a common occurrence and is not usually considered a problem in people who have normal blood clotting. Permanent neurological problems from bloody tap are extremely rare, estimated at less than 0.07% of occurrences. [ 28 ]  However, people who have a  coagulopathy  may have a risk of epidural hematoma, and those with thrombocytopenia might bleed more than expected. A 2018 Cochrane review found no evidence regarding the effect of  platelet transfusions  prior to a  lumbar puncture  or epidural anesthesia for participants that have  thrombocytopenia . [ 29 ]  It is unclear whether major surgery-related bleeding within 24 hours and the surgery-related complications up to 7 days after the procedure are affected by epidural use. [ 29 ]


Rare complications of epidural administration include formation of an  epidural abscess  (1 in 145,000) [ 30 ]  or  epidural hematoma  (1 in 168,000), [ 30 ]  neurological injury lasting longer than 1 year (1 in 240,000), [ 30 ]   paraplegia  (1 in 250,000), [ 31 ]  and  arachnoiditis . [ 32 ]  Rarely, an epidural may cause death (1 in 100,000). [ 31 ]  In circumstances where contraindications exist, there are numerous fascial plane blocks that may be provided instead of an epidural. [ 33 ]


If bupivacaine, a medication commonly administered via epidural, is inadvertently administered into a vein, it can cause excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures as well as  central nervous system depression , loss of consciousness, respiratory depression and apnea. Bupivacaine intended for epidural administration has been implicated in cardiac arrests resulting in death when accidentally administered into a vein instead of the epidural space. [ 34 ] [ 35 ]  The administration of large doses of opioids into the epidural space may cause  itching  and respiratory depression. [ 36 ] [ 37 ]  The sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids. [ 38 ]  Because of this, a  urinary catheter  is often placed for the duration of the epidural infusion. [ 38 ]


In many women given epidural analgesia during labor oxytocin is also used to augment uterine contractions. In one study which examined the rate of breastfeeding two days following epidural anesthesia during childbirth, epidural analgesia used in combination with oxytocin resulted in lower maternal oxytocin and prolactin levels in response to breastfeeding on the second day following birth. [ 39 ]  The lower maternal oxytocin level negatively affects the baby’s feeding rooting reflex, decreasing the amount of milk produced. The consequence of these effects from epidural analgesia is higher weight loss. [ 40 ]


An epidural is injected into the epidural space, inside the bony  spinal canal  but just outside the  dura . In contact with the inner surface of the dura is another membrane called the  arachnoid mater , which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4. [ 16 ]  Below the spinal cord there is a bundle of nerves known as the  cauda equina  or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure. [ 16 ]


Epidural administration is a procedure which requires the person performing the insertion to be technically proficient in order to avoid complications. Proficiency may be trained using bananas or other fruits as a model. [ 41 ] [ 42 ]


The person receiving the epidural may be seated, or lying on their side or stomach. [ 16 ]  The level of the spine at which the catheter is placed depends mainly on the site of intended operation – based on the location of the pain. The  iliac crest  is a commonly used anatomical landmark for lumbar epidural injections, as this level roughly corresponds with the fourth lumbar vertebra, which is usually well below the  termination of the spinal cord . [ 16 ]  The  Tuohy needle , designed with a 90-degree curved tip and side hole to redirect the inserted catheter vertically along the axis of the spine, may be inserted in the midline, between the  spinous processes . When using a paramedian approach, the tip of the needle passes along a shelf of vertebral bone called the  lamina  until just before reaching the  ligamentum flavum  and the epidural space. [ 43 ]


Along with a sudden loss of resistance to pressure on the plunger of the syringe, a slight clicking sensation may be felt by the operator as the tip of the needle breaches the ligamentum flavum and enters the epidural space.  Saline  or air may be used to identify placement in the epidural space. A systematic review from 2014 showed no difference in terms of safety or efficacy between the use of saline and air for this purpose. [ 44 ]  In addition to the loss of resistance technique, direct imaging of the placement may be used. This may be conducted with a  portable ultrasound  scanner or  fluoroscopy  (moving X-ray pictures). [ 45 ]  After placement of the tip of the needle, a catheter or small tube is threaded through the needle into the epidural space. The needle is then withdrawn over the catheter. The catheter is generally inserted 4–6 cm into the epidural space, and is typically secured to the skin with adhesive tape, similar to an  intravenous line . [ 46 ]


If a short duration of action is desired, a single dose of medication called a  bolus  may be administered. Thereafter, this bolus may be repeated if necessary provided the catheter remains undisturbed. For a prolonged effect, a continuous infusion of medication may be used. There is some evidence that an automated intermittent bolus technique may provide better pain control than a continuous infusion technique even when the total doses administered are identical. [ 47 ] [ 48 ] [ 49 ]  Typically, the effects of the epidural block are noted below a specific  level or portion of the body , determined by the site of injection. A higher injection may result in sparing of nerve function in the lower  spinal nerves . For example, a thoracic epidural performed for upper abdominal surgery may not have any effect on the  area surrounding the genitals  or pelvic organs. [ 50 ]


For some procedures where both the rapid onset of a  spinal anesthetic  and the post-operative analgesic effects of an epidural are desired, both techniques may be used in combination. This is called  combined spinal and epidural anesthesia  (CSE). The spinal anesthetic may be administered in one location, and the epidural at an adjacent location. Alternatively, after locating the epidural space with the Tuohy needle, a spinal needle may be inserted through the Tuohy needle into the  subarachnoid space . [ 16 ]  The spinal dose is then given, the spinal needle withdrawn, and the epidural catheter inserted as normal. This method, known as the "needle-through-needle" technique, may be associated with a slightly higher risk of placing the catheter into the subarachnoid space. [ 51 ]


Epidural analgesia is generally well tolerated, with recovery time quick after administration is complete and the epidural is removed. The epidural catheter is usually removed when it is possible to safely switch to oral administration of medications, though catheters can safely remain in place for several days with little risk of bacterial infection, [ 52 ] [ 53 ] [ 54 ]  particularly if the skin is prepared with a  chlorhexidine  solution. [ 55 ]  Subcutaneously tunneled epidural catheters may be safely left in place for longer periods, with a low risk of infection or other complications. [ 56 ] [ 57 ]  Regardless of the length of use, the effects of a medicine administered epidurally, including numbness if used for analgesia, usually wear off within a few hours of the epidural being stopped, with full recovery of normal function within 24 hours. [ 58 ]


The use of epidural analgesia during a birth does not have any effect on whether a caesarean section must be performed during future births. Epidural analgesia during childbirth also generally has no negative effects on the long-term health of the mother or child. [ 3 ]  Use of epidural analgesia versus oral analgesia or no analgesia has no effect on the normal length of hospital stay after childbirth, the only difference being that care must be performed around the epidural insertion site to prevent infection. [ 59 ]  Following epidural analgesia used for gastrointestinal surgery, the time to recovery of normal gastrointestinal function is not significantly different from recovery time after intravenous analgesia. [ 60 ]  The use of epidural analgesia during cardiac surgeries may shorten the amount of time a person requires ventilator support following surgery, but it is unknown whether it shortens the overall post-surgery hospital stay overall. [ 61 ]


The first record of an epidural injection is from 1885, when American neurologist James Corning of  Acorn Hall  in Morristown, New Jersey, used the technique to perform a  neuraxial blockade . Corning inadvertently injected 111 mg of cocaine into the epidural space of a healthy male volunteer, [ 62 ]  although at the time he believed he was injecting it into the subarachnoid space. [ 63 ]  Following this, in 1901 Fernand Cathelin first reported intentionally blocking the lowest sacral and coccygeal nerves through the epidural space by injecting local anesthetic through the  sacral hiatus . [ 20 ]  The loss of resistance technique was first described by Achile Dogliotti in 1933, following which Alberto Gutiérrez described the hanging drop technique. Both techniques are now used to identify when the needle has correctly been placed in the epidural space. [ 64 ] [ 20 ]


In 1921  Fidel Pagés , a military surgeon from Spain, developed the technique of "single-shot" lumbar epidural anesthesia, [ 65 ]  which was later popularized by Italian surgeon Achille Mario Dogliotti. [ 66 ]  Later, in 1931  Eugen Aburel  described using a continuous epidural catheter for pain relief during childbirth. [ 67 ] [ 64 ]  In 1941, Robert Hingson and Waldo Edwards recorded the use of continuous caudal anesthesia using an indwelling needle, [ 68 ]  following which they described the use of a flexible catheter for continuous caudal anesthesia in a woman in labor in 1942. [ 69 ]  In 1947, Manuel Curbelo described placement of a lumbar epidural catheter, [ 70 ]  and in 1979, Behar reported the first use of an epidural to administer narcotics. [ 71 ]


Some people continue to be concerned that women who are administered epidural analgesia during labor are more likely to require a cesarean delivery, based on older observational studies. [ 72 ]  However, evidence has shown that the use of epidural analgesia during labor does not have any statistically significant effect on the necessity to perform a cesarean delivery. A 2018 Cochrane review found no increase in the rate of Caesarean delivery when epidural analgesia was employed. [ 3 ]  However, epidural analgesia does lengthen the second stage of labor by 15 to 30 minutes, which may increase the risk a delivery must be assisted by instruments. [ 73 ] [ 74 ]


In the United States in 1998, it was reported that over half of childbirths involved the use of epidural analgesia, [ 75 ]  and by 2008 this had increased to 61% of births. [ 76 ]  In the United Kingdom, epidurals have been offered through the  National Health Service  for all women during childbirth since 1980. By 1998, epidural analgesia was used in the UK for almost 25% of childbirths. [ 77 ]  In Japan, most childbirths take place in primary or secondary hospitals in which epidural analgesia is not offered. [ 78 ]


In some developed countries, over 70% of childbirths involve epidural analgesia. [ 79 ]  Other studies have shown that minority women and immigrants are less likely to receive epidural analgesia during childbirth. [ 80 ]  Even in countries with universal healthcare coverage such as Canada, socioeconomic factors such as race, financial stability, and education influence the rate at which women receive epidural analgesia. [ 81 ]  One survey in 2014 found that over half of pregnant women in a Nigerian antenatal clinic (79.5%) did not know what epidural analgesia was or what it was used for, while 76.5% of them would utilize epidural analgesia if offered after it was explained to them. [ 82 ]


Fetal abduction  refers to the rare crime of  child abduction  by kidnapping of an at term pregnant woman and extraction of her fetus through a crude  cesarean section . [ 1 ]  Dr.  Michael H. Stone  and Dr. Gary Brucato have alternatively referred to this crime as "fetus-snatching" or "fetus abduction." [ 2 ]  Homicide expert Vernon J. Geberth has used the term "fetal kidnapping." [ 3 ]  In the small number of reported cases, a few pregnant victims and about half of their fetuses survived the assault and non-medically performed cesarean.


Fetal abduction does not refer to medically  induced labor  or obstetrical extraction. The definition of the subject does not include compulsory cesarean sections [ 4 ]  for medical reasons nor  child removal from parents  for court-approved  child protection . However, the "Children of the Disappeared" (desaparecidos) in the  Argentine Dirty War  are an example of criminal fetal abduction in state institutions as detailed by testimonies on cesarean delivery on desaparecidas and child adoption in a military hospital. [ 5 ] [ 6 ]  Historical cases of cesarean extraction for fetal murder (not for child adoption) fall outside the subject definition. [ 7 ]


Fetal abductions typically start with the lie that the perpetrator is pregnant and often coincide with a fear of losing a romantic partner. Then the perpetrator murders a pregnant woman to claim the fetus as her own (as a  stillborn baby  or, if the fetus survives, as a newborn child). [ 8 ]


Fetal abduction is mostly perpetrated by women, usually after organized planning. [ 9 ]  The abductor may befriend the pregnant victim. In some cases, the abductor impersonates a pregnant woman and later a puerperal mother, using weight gain and a prosthesis to fake a pregnancy and cutting of the reproductive organs to replicate injuries gained during birth. Some abductors then take the neonate to a hospital. The  National Center for Missing and Exploited Children ’s spokesperson, Cathy Nahirny, stated in 2007, “Many times the abductor fakes a pregnancy and when it is time to deliver the baby, must abduct someone else's child”. [ 10 ]  Criminal motives include delusions of fulfilling a partner relationship, child-bearing and childbirth. [ 11 ] [ 12 ] [ 13 ] [ 14 ]


The  National Center for Missing and Exploited Children  recorded 18 cases of fetal abductions in the United States between 1983 and 2015, which represented 6% of the 302 recorded cases of infant abduction. [ 1 ]


Out of the 25 documented cases of fetal abduction, excluding attempts, there have been 4 instances where the mothers survived and 13 where the fetus survived. This list distinguishes actual abductions from attempted abductions. An attempt can involve severe harm inflicted on both the mother and fetus, but it does not result in the mother's murder or the extraction of the fetus.


The  Hmong People  society originally from  Thailand ,  Laos ,  Vietnam , and southeast  China . As of 2011 [update]  the worldwide Hmong population is about four million. The Hmong culture is  patrilineal , allowing a husband's family to make all major decisions, even when they solely concern the woman.  However, the Hmong women have traditionally carried a large amount of responsibility and some power due to their necessary contribution of food and labor to the family.


Hmong children learn gender expectations at a young age. Women belong to their marital family, and before  marriage  are considered "other people’s women" by their birth family or clan. Girls traditionally learned household skills from their female elders by the age of eight. Hmong women worked as housekeepers, child-bearers and caretakers, cooks, and tailors, and were responsible for making all of their families’ clothes and preparing all meals. Women also planted, harvested, and cleared fields with their husbands, carried water from the river, tended to the animals, and helped build their own houses and furniture.


"Marriage is considered vital in every Hmong person's life and is the basis for establishing ties with other family groups." [ 1 ]  Hmong men traditionally chose a bride from another clan, with the man's father arranging the marriage. It was taboo for a man to choose a bride from his own clan.  The father would consult with his own relatives and the  bride . She could decline the match, but if she and her family agreed, drinks were made and a  bride price  was discussed.


A traditional Hmong  wedding  consisted of three separate ceremonies of animal sacrifices and feasts. In the Hmong society, a woman keeps close relationships with her family and never takes her husband's last name. However, after marriage, she joins her husband's family to work and live with them. [ 2 ]  If widowed, a Hmong woman has few choices. According to a Hmong saying, "Widows cry to death". The woman's children belong to her husband's family and a woman cannot inherit wealth, which leaves her with virtually nothing. If her husband's brother marries her she can remain in her husband's family.  Polygamy  is condoned in Hmong society, but rare.


A large part of Hmong women's culture is sewing. Hmong women are highly skilled and famous for their fine  needlework  and  embroidery  called paj ntaub (flower cloth). An example of this ancient craft can be found in Chinese art albums. Women spend years on one piece of clothing for a wedding or other celebratory attire. The cross-stitching, if done exceptionally well, is so fine it can appear to the naked eye as beading. There are five traditional patterns including an eight-point star, a snail shell, a ram's head, an elephant's footprint and a heart, which, when combined create a beautiful display. [ 3 ]  Women work all day in the fields and in the house and then sew by oil lamp throughout the night so that their children will have appropriate clothes for  New Year ’s.


Hmong families usually consist of many children, fulfilling several crucial purposes. First and foremost, children guarantee the continuation of the lineage and  clan . Children also provide helping hands for farm work, housework, and childcare. Being able to produce many children adds to a sense of importance for women, helping them feel a stronger sense of belonging within their clan. Children are also very highly celebrated in Hmong culture, as the Hmong people believe in reincarnation and center their lives around the family. [ 4 ]


During  pregnancy , Hmong women carried out their daily responsibilities until the day they went into labor. A Hmong woman would follow her  food cravings  to guarantee that her child would not be born with a deformity. Once her water broke she would then walk to the nearest water source and carry water to her house to wash her baby when it was born.


In the book  The Spirit Catches You and You Fall Down ,  Anne Fadiman  discusses a woman who gave birth to twelve of her fifteen children alone in the middle of the night. The woman, Foua, delivered each child into her own hands in complete silence, believing that noise would "thwart the birth". The father then cut the  umbilical cord  and the mother washed her newborn. The father proceeded to dig a deep hole in the dirt floor of the house to bury the  placenta . If the baby was a girl the placenta was buried underneath her parents' bed, but if it was a boy it was buried with greater honor under the central column of the house. The Hmong believe that after death a soul returns to its birthplace, retrieves its placental jacket, puts it on, and begins its voyage to the sky. Women had a strict postpartum diet that consisted solely of hot foods and drinks. Cold food would "make the blood congeal in the womb instead of cleansing it by flowing freely". [ 5 ]  These beliefs were closely followed to ensure the continued fertility of the new mother and her ability to produce enough breastmilk. [ 6 ]


A baby was not considered part of the community until a ceremony called the hu plig (soul-calling) occurred three days after its birth. Chickens were sacrificed and if the soul was content in its new body, the chickens' tongues would be curled upward and the skulls translucent. Either string or silver necklaces or bracelets were put on the infant to prevent the soul from wandering from the body. After this ceremony, the infant would be named and considered an official member of the human race.


Foua, the woman from  The Spirit Catches You and You Fall Down , noted that her personal life was based on her cultural life. Hmong culture is centered around  legends , the religion of  shamans , souls, high regard for ancestors, and the many rituals and ceremonies the Hmong perform. Women's social life and status is often a direct result of the completion of and attendance at the proper rituals and ceremonies. One Hmong legend tells of a girl who took every man who passed by her as a lover. Eventually, "her sexual excesses so destroyed her health that she fell ill and died". [ 7 ]  In this story, the woman's failure to follow one of the religious tenets of Hmong culture resulted in her death. The Hmong also has stories of great female shamans, showing how social life and cultural life of Hmong women are interrelated. Hmong culture shapes gender roles in that female culture is a culture in itself. The female gender is shaped beginning in childhood and to gain high status, a woman must always fulfill the expectations for the female sex.


The Hmong people's way of life changed drastically during the  Vietnam War . The  United States  could not send troops into Laos, so they instead trained Hmong men to fight in the hopes that they could keep Laos an anti-communist nation. Since the Hmong were fighting against Laos, they had to evacuate their homes there and live in refugee camps in Thailand. After the war was over, Thailand closed the refugee camps and Hmong people were dispersed all over the world to Western countries such as the United States,  Australia ,  France , and  Canada . The rest of the Hmong people fled to various countries in  Asia .


Hmong women in the Western world had a difficult time adjusting to a new way of life, having trouble transferring skills they had learned in Asia to a different culture. The newer generation of Hmong women are generally more assimilated. In Fadiman's book the mother, Foua, declares herself stupid because she is not familiar with American culture. She cannot read or speak English and due to that inability cannot perform simple yet necessary tasks such as grocery shopping. She can no longer farm or provide for her children as she once could.


The patrilineal and  patriarchal  family system has changed little since for those Hmong who emigrated to the Global North. Decisions about any family member of either gender are still passed down through the husband's family elders. Women contribute greatly to their families, but in different ways. Women tend to have somewhat more freedom in choosing a husband, but the families of the bride and groom still have the final say in the match. The woman does not live outside the home before she is married to protect her reputation.


Childbirth is also a different process now that hospitals are located in every neighborhood. Once Foua, from Fadiman's book, relocated to the United States she no longer birthed her own children; a doctor did. She no longer bathed her infants; a nurse took care of it. Fiona's husband brought in the proper postpartum food because the hospital offered only ice water. Often a doctor will not release the placenta to the parents of the newborn and the Hmong fear that they will never recover the placental jackets necessary for the afterlife. Over time, the women of this group have lost some of their power and agency. As a result of globalization and assimilation into another culture, women have less control over their lives because they cannot provide food for their families as they did, birth children traditionally, or perform many traditional ceremonies.


The  husband stitch  or  husband's stitch , [ 1 ]  also known as the  daddy stitch , [ 2 ]   husband's knot  and  vaginal tuck , [ 3 ]  is a medically unnecessary and potentially harmful surgical procedure in which one or more additional  sutures  than necessary are used to repair a woman's  perineum  after it has  been torn  or  cut during childbirth . [ a ]  The purported purpose is to tighten the opening of the  vagina  and thereby enhance the pleasure of the patient's male sex partner during  penetrative intercourse . [ 4 ]


While repair of the perineum may be medically necessary, an extra stitch is not, and may cause discomfort or pain. [ 2 ] [ 5 ]  Use of the term in the medical literature can be traced to  Transactions of the Texas State Medical Association  in 1885, where a doctor claimed to have performed one. [ 6 ]


Dr. Geo. Cupples was called upon to explain the "Husband Stitch," which he did as follows: He said that when he was stitching up a ruptured perineum, of a married lady, the husband was an anxious and interested observer, and when he had taken all the stitches necessary, the husband peeped over his shoulders and said, "Dr., can't you take another stitch?" and he did, and called it the "Husband Stitch".


The term is also referenced in  What Women Want to Know  (1958), [ b ]  and in  The Year After Childbirth: Surviving and Enjoying the First Year of Motherhood,  written by  Sheila Kitzinger  in 1994. [ 8 ]


Some medical practitioners have asserted that the procedure is mostly an  urban legend , and false attribution, [ 2 ]  while others have claimed to know doctors who perform the procedure. [ 9 ]  The  American College of Obstetricians and Gynecologists , according to a report by  Fatherly , does not deny that the procedure happens but alleges that it "is not standard or common". [ 2 ]  Other doctors, such as Jean Marty, head of the Union of Gynecologists in France, have claimed that the idea of a husband stitch comes from botched  episiotomies  and poor stitching, that lead women to have pain during sexual intercourse and while urinating. [ 10 ]


However, there are several accounts of women who claim to have undergone this procedure without their consent. [ 11 ]  There have been several journalistic investigations on the existence of the husband stitch, trying to determine if it was real. They have overwhelmingly determined that the practice does exist, as seen in reports by Chelsea Ritschel, [ 5 ]  by Kaitlin Reilly for  Yahoo Life , [ 12 ]  by Anam Alam to Thred, [ 13 ]  in reports from French Newspapers  Grazia , [ 14 ]  and  Le Monde . [ 10 ]


Belgian researchers Julie Dobbeleir, Koenraad Van Landuyt and Stan J. Monstrey have studied the practice, finding evidence of it happening in Belgium at least since the 1950s: [ 15 ]


Vaginal tightening surgery has been around since the mid-fifties, where gynecologists used to tighten the entrance of a woman's vagina with an extra stitch while repairing vaginal and perineum tears or episiotomies after giving birth. At that time it was notoriously known as the "husband's stitch," the "husband's knot," or the "vaginal tuck," and doctors discreetly referred to this procedure as "improving a woman's well-being."


The husband stitch has also been referenced in a 2004 study about the abuse of episiotomies in  São Paulo : [ 16 ]


Professionals we have interviewed often mention the ponto do marido (husband's stitch), intended to make the vaginal opening even tighter after delivery. Frequent complications are vulval and vaginal pain, scarring problems, and deformities that need further surgical correction. Long-term consequences for sexual relations of episiotomy need further study.


Similarly, in Cambodia, the practice has been linked to high rates of episiotomy: [ 17 ]


A study in the NIH database found that the continued use of episiotomies in Cambodia was due to many doctors' belief that they would provide women with a 'tighter and prettier vagina' if they gave her an episiotomy.


A short story by  Carmen Maria Machado , "The Husband Stitch", first published in 2014 by  Granta  and later published in the collection  Her Body and Other Parties , describes a woman undergoing the procedure. [ 18 ]


In  Doom Patrol ' s season 2 2020 premiere, Cliff's father tells him, "When that baby doctor asks if you want the husband stitch, you tell him, 'I'll take two. ' " [ 19 ]


In  Colin From Accounts '  2022 season 1 episode 4, a patient's male companion asks the protagonist student doctor to "throw another stitch in there, make it like new" and later on a different patient's male companion asks her to "chuck a husband stitch in there". [ 20 ]


Impurity after childbirth  is the concept in many cultures and religions that a new mother is in a state of uncleanliness for a period of time after childbirth, requiring  ritual purification . Practices vary, but typically there are limits around what she can touch, who she can interact with, where she can go, and what tasks she can do. Some practices related to impurity after childbirth, such as seclusion, overlap with the more general practice of  postpartum confinement .


The Ancient Greek philosopher  Theophrastus  compared the impurity of childbirth to the impurity of death. [ 1 ]  The entire household, all those who assisted at the birth, and the new baby incurred this impurity; this most likely ended with the ritual washing of hands at the  amphidromia , five to seven days later. [ 1 ] [ 2 ] [ 3 ]  The mother's purification may also have occurred then, [ 1 ]  or she may have remained heavily polluted until the  dekate , ten days after giving birth. [ 3 ]  A period of lighter pollution followed, during which the new mother  remained confined to her home  and was especially banned from entering sacred spaces. [ 2 ]  After forty days, she left her home, made a sacrifice to the gods (possibly a dog to  Hekate ), and was considered clean again. [ 3 ]


Not much is known about postpartum impurity in Ancient Rome.  Festus , in his  De verborum significatione , describes a ritual purification of newborn girls on the eighth day after birth and boys on the ninth day.  Augustine of Hippo  mentions a tradition of sweeping the threshold after a birth, a purification rite also practiced by the Romans after a death in the household. Along with customs such as decorating the door with laurel branches and lighting a candle to  Candelifera , these purification rites may have indicated a belief in postpartum impurity. However, such impurity does not seem to have extended to the household as a whole: the father of a newborn could enter temples, and visitors were welcomed after a birth. [ 2 ]


In traditional  Hindu  practice, a woman who is in labor or has recently given birth (a  jachcha ) is considered impure, a state called  sutak . [ 4 ] [ 5 ] [ 6 ]  Based on passages from the  Aitareya Brahmana , anthropologist  Gabriella Eichinger Ferro-Luzzi  infers that this practice  dates back to the Vedic era .  Pandurang Vaman Kane  theorizes that it most likely originated with the indigenous  Harappan  culture, rather than with the arrival of  Indo-Aryans . [ 7 ]  Like many Hindu purity practices, the impurity after childbirth has been decreasingly observed since the 19th century; many modern Hindus observe a shortened period of impurity, welcome visitors after the birth of a child, and are willing to touch the new mother and baby. [ 8 ]


Traditionally, the puerperal impurity is attributed to nine months of menstrual blood accumulated during the pregnancy, and thought to be more severe than even the impurity associated with death. [ 4 ] [ 5 ] [ 9 ]  Women are therefore expected to give birth in a secluded location, in order to confine the impurity. Depending on the local tradition and the family's resources, this may be a dedicated hut ( atur-ghar  or  sutikagara ), a repurposed shed or outhouse, or simply an unused room of the house. [ 4 ] [ 10 ] [ 11 ]  The  traditional midwife  ( dai ), often belonging to the  dalit  caste, is considered impure by association. [ 4 ] [ 12 ]  She is especially responsible for those tasks which are considered impure, such as cutting the  umbilical cord , touching the genitals of the woman in labor, and bathing the mother and child. [ 4 ] [ 5 ] [ 9 ] [ 13 ]


The new mother remains heavily impure for three days after the birth. During this  Sor  period, she remains secluded from the family, attended by the  dai . [ 4 ]  The new baby's father and his household are also considered impure during this period, regardless of where the birth occurred. [ 4 ] [ 6 ]  The newborn may be considered to share the mother's state of heavy impurity, or to be too young to be impure. [ 4 ] [ 10 ]  On the third day, the  jai  bathes and anoints the mother and child, bringing them to a state of lesser impurity. [ 4 ]  The mother's bangles and all the clay pots in the household are broken; the clothes worn during labor, the bedding, and the  receiving blanket  are disposed of; dirt floors are refinished; and the tool used to cut the umbilical cord is purified. [ 4 ] [ 7 ] [ 13 ]  Other members of the household also bathe, returning them to a state of purity. [ 4 ]


After the end of the  Sor  period, the new mother can rejoin her household, but remains in her state of lesser impurity for about forty days after the birth. [ 4 ]  She traditionally remains confined to the house for this period, and while she may resume many of her ordinary household tasks, she continues to avoid cooking, grinding flour, and touching water. [ 4 ] [ 5 ]  She may be expected to avoid various foods, such as buttermilk and curds. [ 7 ]  Another woman may share her bed in order to ensure that the husband does not engage in sexual intercourse with the new mother, which is held to be harmful to him. [ 4 ]  Due to the continued impurity, the household does not accept visitors during this period;  hijras , however, are welcomed, and may be paid to bless the new baby. [ 6 ]  All members of the household avoid temples and auspicious events, and the new mother may not engage in worship or touch holy images. [ 4 ] [ 6 ]


The exact span of the period of lesser impurity varies according to local custom; it may depend on the sex of the infant or the caste of the mother, or the end date may be set by a  Brahmin . [ 4 ] [ 7 ] [ 10 ] [ 11 ]  Towards the end of this time, the new mother may participate in a ritual touching of earthenware, marking the point at which she is allowed to handle pots and enter the kitchen. [ 7 ]  At the end of the period of impurity, the woman bathes, her clothes and bedding are washed, and some women engage in a "well worship" ( Daghar Puja ) ritual. [ 4 ] [ 11 ]  After this, she and her household are considered clean, and can return to their normal activities. [ 4 ]


Many  indigenous people of New Guinea  observe various forms of postpartum impurity, although some anthropologists argue that this is best understood, not as pollution, but as a dangerous proximity to the sacred. Women in these tribes typically give birth in dedicated huts at some distance from the village, alone or with female attendants;  lochia , like menstrual blood, is thought to be dangerous to men. [ 14 ]


The  Kaulong , along with the nearby  Sengseng , observe some of the most intense known practices regarding female impurity. [ 15 ] [ 16 ]  Among these practices is the belief that, during childbirth, women spread pollution horizontally in all directions. Kaulong women therefore give birth in a remote location wearing disposable clothing, which they destroy before returning to the village. [ 17 ]  Similar practices are observed among peoples including the  Murik , [ 18 ]  the  Gadsup , [ 19 ]  the  Mae Enga , [ 20 ]  and the  Wogeo . [ 21 ]


In Tanzania,  Bena  women are considered impure after childbirth, and for this reason commonly delay breastfeeding for one to two days until  uterine involution  occurs. The new mother remains secluded afterwards for up to three months, usually in a dedicated room of the house, and avoids cooking or serving food. During this period, she bathes and washes her clothes frequently, and other people avoid contact with her and her children.  Kumlehedzya umwana , the cleansing ritual which marks the end of the period of seclusion, involves traditional herbs ( mugoda  or  mafikho ) given to all members of the household. [ 22 ]


Among the  Swahili people  of  Pemba Island , women are considered impure until the discharge of lochia ends, usually about 40 days after birth. During this period, the new mother is expected to remain secluded and avoid praying, preparing food, and having sex or sharing a bed with her husband. Especially for a first birth, a Swahili woman often observes this period of seclusion at her parents' house. A special diet is prescribed for her, including some foods (special teas, octopus, squid,  wrasse ,  cassava , chicken, rice, and cornmeal) and excluding others (eel,  mandazi , meat, beans, and bananas). After her bleeding stops, she cleanses herself with a ritual bath of herb-infused water. [ 23 ]


According to  Leviticus  12, a woman who gives birth to a son remains impure for a week, and afterwards immerses in a body of water to purify herself. In the rabbinical interpretation of Leviticus 12, any subsequent blood she sees over the next 33 days would be considered  dam tohar  (דַּם טׂוהַר – ritually clean blood), and that blood does not prohibit her from sexual relations with her husband. The law for a woman who gives birth to a daughter is the same, however, the durations are doubled. The mother becomes impure for 2 weeks, and after immersion, any blood she sees over the next 66 days is  dam tohar .


There is no scholarly consensus for the Biblical law, including the difference between the birth of sons and daughters.  Tikva Frymer-Kensky  suggested that "like the person who touched death, the person who has experienced birth has been at the boundaries of life/non-life...." [ 24 ]


Other rationales include moments of crisis or danger, fear of demons, health, and a lack of wholeness. [ 25 ] [ 26 ]


Within the realm of Biblical law and post-Biblical Jewish religious discourse surrounding  tumah and taharah , the impurity is called in Hebrew  tumat yoledet .  Halakhah  treats a  yoledet  (woman who gives birth) similarly to any woman with  niddah  status.


In some Jewish communities, ceremonies and a degree of seclusion were applied to postparturient women. For example, there was a Sana Yemenite custom of women visiting the mother during 4–6 weeks after childbirth. The mother would be visited in a special room in her home and she would sit in a decorated triangle box. [ 27 ]


Some early churches followed the Jewish custom of restricting women from worship after giving birth until the purification ceremony. [ 28 ] [ 29 ]  Today, many Christians commemorate  Candlemas , the feast of the purification of the  Virgin Mary . Some continue to celebrate a  Churching of Women  ceremony, derived from the Jewish tradition but not necessarily implicating ritual impurity. [ 30 ] [ 31 ]


Labor induction  is the process or treatment that stimulates  childbirth  and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. [ 1 ]  Inductions are most often performed either with  prostaglandin  drug treatment alone, or with a combination of prostaglandin and intravenous  oxytocin  treatment. [ 1 ]


Commonly accepted medical reasons for induction include:


Induction of labor in those who are either at or after term improves outcomes for newborns and decreases the number of  C-sections  performed. [ 4 ]


Methods of inducing labor include both pharmacological medication and mechanical or physical approaches. [ citation needed ]


Mechanical and physical approaches can include artificial rupture of membranes or membrane sweeping. Membrane sweeping may lead to more women spontaneously going into labor (and fewer women having labor induction) but it may make little difference to the risk of maternal or neonatal death, or to the number of women having  c-sections  or spontaneous vaginal births. There are also risks associated with membrane sweeping. The risks include irregular contractions, bleeding, and in 1 out of every 10 women an amniotic sac rupture, which can lead to a formal induction within 24 hours of the rupture if labor hasn't been induced. [ 5 ]


The use of intrauterine catheters are also indicated. These work by compressing the cervix mechanically to generate release on prostaglandins in local tissues. There is no direct effect on the uterus. Results from a 2021 systematic review found no differences in  cesarean delivery  nor  neonatal  outcomes in women with low-risk pregnancies between inpatient nor outpatient cervical ripening. [ 6 ]


The  American Congress of Obstetricians and Gynecologists  has recommended against elective induction before 39 weeks if there is no medical indication and the cervix is unfavorable. [ 14 ]  One recent study indicates that labor induction at term (41 weeks) or post-term reduces the rate of  caesarean section  by 12%, and also reduces fetal death. [ 15 ]
Some observational/retrospective studies have shown that non-indicated, elective inductions before the 41st week of gestation are associated with an increased risk of requiring a caesarean section. [ 14 ]  Randomized clinical trials have not addressed this question. However, researchers have found that multiparous women who undergo labor induction without medical indicators are not predisposed to caesarean sections. [ 16 ]  Doctors and pregnant women should have a discussion of risks and benefits when considering an induction of labor in the absence of an accepted medical indication. [ 14 ]  There is insufficient evidence to determine if inducing a woman's labor at home is a safe and effective approach for both the women and the baby. [ 17 ]


Studies have shown a slight increase in risk of infant mortality for births in the 41st and particularly 42nd week of gestation, as well as a higher risk of injury to the mother and child. [ 18 ]  Due to the increasing risks of advanced gestation, induction appears to reduce the risk for caesarean delivery after 41 weeks' gestation and possibly earlier. [ 15 ] [ 19 ]  Inducing labour after 41 weeks of completed gestion is likely to reduce the risk of  perinatal death  and  stillbirth  compared with waiting for labour to start spontaneously. [ 20 ]


Although there has been a recorded increase in the risk of perinatal death and stillbirth after 41 weeks of gestation, this risk is small. In fact, a study conducted in 2012 examined stillbirth rates in the state of California, and excluded babies with genetic or congenital problems. The study determined that the risk of stillbirth per 1000 births after 40, 41 and 42 weeks of gestation were 0.42, 0.61 and 1.08, respectively. [ 21 ]
Thus, it is important to acknowledge the probabilistic evidence when discussing formal medical inductions, because it highlights the how small the likelihood of having a stillbirth post-term is.


Inducing labor before 39 weeks in the absence of a medical indication (such as hypertension, IUGR, or pre-eclampsia) increases the risk of complications of prematurity including difficulties with respiration, infection, feeding,  jaundice ,  neonatal intensive care unit  admissions, and perinatal death. [ 22 ]


Inducing labour after 34 weeks and before 37 weeks in women with hypertensive disorders ( pre-eclampsia ,  eclampsia ,  pregnancy-induced hypertension ) may lead to better outcomes for the woman but does not improve or worsen outcomes for the baby. [ 23 ]  More research is needed to produce more certain results. [ 23 ]  If waters break ( membranes rupture ) between 24 and 37 weeks'  gestation , waiting for the labour to start naturally with careful monitoring of the woman and baby is more likely to lead to healthier outcomes. [ 24 ]  For women over 37 weeks pregnant whose babies are suspected of not coping well in the womb, it is not yet clear from research whether it is best to have an induction or caesarean immediately, or to wait until labour happens by itself. [ 25 ]  Similarly, there is not yet enough research to show whether it is best to deliver babies prematurely if they are not coping in the womb or whether to wait so that they are less premature when they are born. [ 26 ]


Clinicians assess the odds of having a vaginal delivery after labor induction by a " Bishop score ". However, recent research has questioned the relationship between the Bishop score and a successful induction, finding that a poor Bishop score actually may improve the chance for a vaginal delivery after induction. [ 15 ]  A Bishop Score is done to assess the progression of the cervix prior to an induction. In order to do this, the cervix must be checked to see how much it has effaced, thinned out, and how far dilated it is. The score goes by a points system depending on five factors. Each factor is scored on a scale of either 0–2 or 0–3, any total score less than 5 holds a higher risk of delivering by caesarean section. [ 27 ]


Sometimes when a woman's waters break after 37 weeks she is induced instead of waiting for labour to start naturally. [ 28 ]  This may decrease the risks of infection for the woman and baby but more research is needed to find out whether inducing is good for women and babies longer term. [ 28 ]


Women who have had a caesarean section for a previous pregnancy are at risk of having a  uterine rupture , when their caesarean scar re-opens. [ 29 ]  Uterine rupture is very serious for the woman and the baby, and induction of labour increases this risk further. [ 29 ]  There is not yet enough research to determine which method of induction is safest for a woman who has had a caesarean section before. [ 29 ]  There is also no research to say whether it is better for these women and their babies to have an elective caesarean section instead of being induced. [ 30 ]


Membrane sweeping, a common method of labor induction, can cause bleeding and irregular contractions and is often done without informed consent by the pregnant person. [ 31 ]


The medical rationale for performing an induction is decreasing the risk of stillbirth. However, as mentioned in the above section, the probability of having a stillbirth post-term is very small, meaning that for the vast majority of post-term pregnancies, inductions are unnecessary. Approximately 500 inductions are performed in order to avoid 1 stillbirth. [ 32 ]  Many of these unnecessary inductions could potentially provoke other risks, forcing medical practitioners to perform other interventions such as caesarean sections. These additional interventions could cause labor to be more risky for the pregnant person.


Another criticism of inductions is that the pregnant person's bodily autonomy is overlooked. Many pregnant people might not want to be induced, and rather share in the decision-making process with their medical practitioner. [ 33 ]


Induced labor may be more painful for the woman as one of the side effects of intravenous oxytocin is increased contraction pains, mainly due to the rigid onset. [ 34 ]  This may lead to the increased use of  analgesics  and other pain-relieving pharmaceuticals. [ 35 ]  These interventions may also lead to an increased likelihood of  caesarean section  delivery for the baby. [ 36 ]  However, studies into this matter show differing results. One study indicated that while overall caesarean section rates from 1990 to 1997 remained at or below 20 per cent, elective induction was associated with a doubling of the rate of Caesarean section. [ 37 ]  Another study showed that elective induction in women who were not post-term increased a woman's chance of a C-section by two to three times. [ 38 ]  A more recent study indicated that induction may increase the risk of caesarean section if performed before the 40th week of gestation, but it has no effect or actually lowers the risk if performed after the 40th week. [ 39 ] [ 40 ]


A 2014 systematic review and meta analysis on the subject of induction and its effect on cesarean section indicate that after 41 weeks of gestation there is a reduction of cesarean deliveries when the labour is induced. [ 15 ] [ 41 ]


The Institute for Safe Medication Practices labeled  pitocin  a "high-alert medication" because of the high likelihood of "significant patient harm when it is used in error." [ 42 ]


The  Lamaze technique , also known as the  psychoprophylactic method  or simply  Lamaze , began as a prepared childbirth technique. As an alternative to medical intervention during  childbirth , it was popularized in the 1950s by French  obstetrician   Fernand Lamaze  and based on his observations in the  Soviet Union . The goal of Lamaze is to build a mother's confidence in her ability to give birth, through classes that help pregnant women understand how to cope with pain in ways that both facilitate labor and promote comfort, including  relaxation techniques , movement, and  massage . [ 1 ]


There is a training and certification program available to practitioners, leading to the Lamaze Certified Childbirth Educator (LCCE) designation. [ 2 ]


Fernand Lamaze visited the  Soviet Union  in the 1950s, and was influenced by birthing techniques which involved breathing and relaxation methods. [ 3 ]  The Lamaze method gained popularity in the United States after Marjorie Karmel wrote about her experiences in her 1959 book  Thank You, Dr. Lamaze , as well as  Elisabeth Bing 's book  Six Practical Lessons for an Easier Childbirth  (1960). Both Karmel and Bing would later found the American Society for Psychoprophylaxis in Obstetrics in 1960, later renamed to  Lamaze International . [ 4 ]


Lamaze himself has been criticized for being over-disciplinary and  anti-feminist . Natural childbirth activist  Sheila Kitzinger 's description of the methods he deployed while working in a Paris clinic during the 1950s expresses concern regarding "the disciplinary nature" of Lamaze's approach to childbirth. According to Kitzinger, Lamaze consistently ranked the women's performance in childbirth from "excellent" to "complete failure" on the basis of their "restlessness and screams". Those who "failed" were, he thought, "themselves responsible because they harbored doubts or had not practiced sufficiently", and "intellectual" women who "asked too many questions" were considered by Lamaze to be the most "certain to fail". [ 5 ]


The Lamaze technique has also been criticized for being ineffective. [ 6 ] [ 7 ]


The  lithotomy position  is a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for  childbirth  in Western nations. The lithotomy position involves the positioning of an individual's feet above or at the same level as the hips (often in stirrups), with the  perineum  positioned at the edge of an examination table. References to the position have been found in some of the oldest known medical documents including versions of the  Hippocratic oath  (see  lithotomy ); the position is named after the ancient surgical procedure for removing  kidney stones  and  bladder stones  via the perineum. The position is perhaps most recognizable as the 'often used' position for childbirth: the patient is laid on the back with knees bent, positioned above the hips, and spread apart through the use of  stirrups .


The position is frequently used and has many obvious benefits from the doctor's perspective. Most notably the position provides good visual and physical access to the perineal region. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures including those involving  reproductive organs ,  urology , and  gastrointestinal  systems. New observations and scientific findings, combined with a greater sensitivity to patient needs have raised awareness of the physical and psychological risks the position may pose for prolonged surgical procedures, pelvic examinations, and, most notably, childbirth.


Some studies have found a significant relationship between prolonged surgical procedures with the patient in the lithotomy position and a circulatory complication known as  compartment syndrome . [ 1 ] [ 2 ]  Nerve injury by pressure is also possible, the femoral or peroneal nerve are at risk. [ 3 ]


A  Cochrane Review  found that the lithotomy position may not be the ideal position for  childbirth , noting that while it makes care easier for physicians by placing the patient in an easily accessible position, it is often harder on the patient as use of the lithotomy position can narrow the birth canal by up to a third. In lieu of the lithotomy position, the Cochrane Review recommended women make informed choices about birthing positions and find the position that is most comfortable for them. [ 4 ]


Patients have reported feeling a loss of control and increased sense of vulnerability when examined in the lithotomy position because they cannot see the area being examined. Other, equally effective positions have been suggested for examinations of conscious patients. [ 5 ] [ 6 ] [ examples needed ]


Lotus birth  (or  umbilical cord nonseverance - UCNS ) is the practice of leaving the  umbilical cord  uncut after  childbirth  so that the baby is left attached to the  placenta  until the cord naturally separates at the  umbilicus . [ 1 ]  This usually occurs within 3–10 days after birth. [ 2 ]  The practice is performed mainly for  spiritual purposes , including for the perceived spiritual connection between the placenta and the newborn. [ 3 ]


As of December 2008, no evidence exists to support any medical benefits for the baby. [ 4 ]  The  Royal College of Obstetricians and Gynaecologists  has warned about the risks of infection as the decomposing placenta tissue becomes a nest for infectious bacteria such as  Staphylococcus . [ 4 ]   In one such case a 20-hour old baby whose parents chose UCNS was brought to the hospital in an agonal state, was diagnosed with  sepsis  and required an antibiotic treatment for 6 weeks. [ 5 ] [ 6 ]


Although recently arisen as an alternative birth phenomenon in the West, super-delayed (1+ hours post-birth) umbilical severance is common in home births.


Early American pioneers, in written diaries and letters, reported practicing nonseverance of the umbilicus as a preventative measure, as they believed it protected the infant from an open wound infection. [ 7 ]


In the 1980s, yoga master and  midwife   Jeannine Parvati Baker  was the main advocate for the practice in the United States. [ 2 ]  The practice spread to Australia by a midwife, Shivam Rachana, founder of the  International College of Spiritual Midwifery  and author of the book  Lotus Birth . [ 8 ]  In the full lotus birth clinical protocol, the  umbilical cord , which is attached to the baby's  navel  and  placenta , is not clamped or cut. The baby is immediately placed on the mother's belly/chest (depending on the length of the cord) or kept in close proximity to the mother in cases when medically necessary procedures such as  resuscitation  may be needed. In Lotus birth, the placenta is delivered vaginally, often with the maternal informed choice for passive management of third stage of labor, allowing for natural detachment of the placenta within appropriate time allowed for it, with no hormonal injections (such as  oxytocin ) or via cesarean section. [ 9 ]


Following birth, the placenta is simply put in a bowl or quickly wrapped in absorbent toweling and placed near the mother-baby. Caregivers step back to allow for undisturbed maternal-child bonding to occur as the primary event for an hour or more. It is only after this initial intense bonding period that the placenta is managed by rinsing, drying, applying preservatives, and positioning it in a way that allows for plentiful air circulation and proximity to the baby. The placenta, once ejected from the womb, has no circulation and quickly dies; [ 4 ]  and within 3–10 days postpartum the umbilical cord dries and detaches from the baby's belly. [ 2 ]  The practice requires the mother and baby to be home bound as they wait for the placenta and umbilical cord to dry, decompose, and separate from the baby. [ 10 ]


Lotus births are an extremely rare practice in hospitals. [ 3 ]  The  Royal College of Obstetricians and Gynaecologists  (RCOG) has stated, "If left for a period of time after the birth, there is a risk of infection in the placenta which can consequently spread to the baby. The placenta is particularly prone to infection as it contains blood. At the post-delivery stage, it has no circulation and is essentially dead tissue," and the RCOG strongly recommends that any baby that undergoes lotus birthing be monitored closely for infection. [ 4 ]  Other risks include  jaundice  caused by abnormally high bilirubin and  polycythemia , which is an abnormally high percentage of red blood cells in circulation. [ 11 ]  Case descriptions about adverse medical conditions related to this praxis are emerging, indicating severity of potential complications. [ 12 ] [ 13 ]
The  World Health Organization  does not support Lotus Birth, instead recommending a delayed cord clamping. [ 14 ]


In May 2020, the  Coroners Court of Victoria  concluded that a baby died 16 hours after birth from sepsis in the setting of a lotus birth, which took place in 2017 at the Royal Children's Hospital in Melbourne. [ 15 ]  The investigation identified that the most significant and severe risk factors for sepsis were vaginal seeding and lotus birth.


In the animal world, the placenta is usually consumed by the mother. This is called  placentophagy . Primates have been observed keeping the placenta attached to their newborns for a longer period. Primatologist  Jane Goodall , who was the first person to conduct long-term studies of  chimpanzees  in the wild, reported that they did not chew or cut their offspring's cords, instead leaving the umbilicus intact, like many other monkeys. [ 16 ]  Other researchers report that chimpanzees consume placentas after birth. [ 17 ]  Though other mammals may sever their offspring's cords, they only do so after initial maternal sensory reception, unwinding of the cord, massage/cleaning (through touch), and initiation of nursing. [ 18 ]  This has been observed to last at least one hour, if left undisturbed.


Pseudo-scientific  proponents of lotus births view the baby and the placenta as one on a cellular level, as they are from the same source, the egg and sperm conceptus. They also assert that the newborn and the placenta exist within the same quantum field, thus influencing various expressions of  quantum mechanics  that influence health. [ 19 ]  They claim transfers of energy & cellular information continue to take place, moving gradually from the tissue of the placenta to the baby during the drying process. Scientists challenge this claim of a metaphysical dimension related to  quantum mechanics . [ 20 ]


Lying-in  is the term given to the European [ citation needed ]  forms of  postpartum confinement , the traditional practice involving long  bed rest  before [ 1 ]  and after   giving birth . The term and the practice it describes are old-fashioned or  archaic , but lying-in used to be considered an essential component of the  postpartum period , even if there were no medical complications during  childbirth . [ 2 ]


A 1932 publication refers to lying-in as ranging from two weeks to two months. [ 3 ]   It also suggests not "getting up" (getting out of bed post-birth) for at least nine days and ideally for 20 days. [ 3 ] [ 4 ]  Care was provided either by her female relatives (mother or mother-in-law), or, for those who could afford it, by a temporary worker called the  monthly nurse . These weeks ended with the re-introduction of the mother to the community in the Christian ceremony of the  churching of women . When lying-in was a more common term, it was used in the names of several  maternity hospitals , for example the  General Lying-In Hospital  in London. Until the 1970s, standard NHS postpartum care involved 10 days in hospital, with the newborns taken to the nursery overnight, ensuring the mothers were well rested by the time they returned home. [ 5 ]


A  caudle  was a hot drink, well documented in  British cuisine , particularly in Victorian times, as suitable for invalids and new mothers. So much was it associated with the visits of friends to see the new baby that "cake and caudle" or "taking caudle" became a  metonym  for postpartum social visits.


Women received congratulatory visits from friends and family during the period; among many traditional customs around the world, the  desco da parto  was a special form of painted tray presented to the mother in  Renaissance   Florence . The many scenes painted on these trays show female visitors bringing presents, received by the mother in bed, while other women tend to the baby. Equivalent gifts in contemporary culture include  baby showers  and  push presents .


No fixed term of lying-in is recommended in Renaissance manuals on family life (unlike in some other cultures), but documentary records suggest that the mother was rarely present at the  baptism , which in Italian cities was usually held within a week of the birth at the local  parish church , normally a few minutes' walk from any house. [ 6 ]


In art, the immensely popular scene of the  Birth of Jesus  technically shows the Virgin Mary, who reclines on a couch in most medieval examples, lying-in, but in famously non-ideal conditions. More ideal images of lying-in in well-off households are represented in  Birth of the Virgin  and  Birth of John the Baptist . These are generally given contemporary settings, and differ little from other images that are purely secular, especially those on  desci da parto .


The  McRoberts maneuver  is an  obstetrical  maneuver used to assist in  childbirth . It is  named after William A. McRoberts, Jr. [ 1 ]  It is employed in case of  shoulder dystocia  during  childbirth  and involves hyperflexing the mother's legs tightly to her abdomen. It is effective due to the increased mobility at the sacroiliac joint during pregnancy, allowing rotation of the pelvis and facilitating the release of the fetal shoulder. [ 2 ]  If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure). Current guidelines strongly recommend against pulling on the infants head, as this could lead to brachial plexus injury. Instead, support while keeping the neck straight is indicated. The technique is effective in about 42% of cases.  [ 3 ]  Note that suprapubic pressure and McRobert's maneuver together will resolve 90% of cases. [ 4 ]


Midwifery  is the  health science  and  health profession  that deals with  pregnancy ,  childbirth , and the  postpartum period  (including care of the  newborn ), [ 1 ]  in addition to the sexual and reproductive health of women throughout their lives. [ 2 ]  In many countries, midwifery is a medical profession [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]  (special for its independent and direct specialized education; should not be confused with the medical specialty, which depends on a previous general training). A professional in midwifery is known as a  midwife .


A 2013  Cochrane review  concluded that "most women should be offered midwifery-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications." [ 8 ]   The review found that midwifery-led care was associated with a reduction in the use of  epidurals , with fewer  episiotomies  or instrumental births, and a decreased risk of losing the baby before 24 weeks' gestation. However, midwifery-led care was also associated with a longer mean length of labor as measured in hours. [ 8 ]


Trimester means "three months". A normal pregnancy lasts about nine months and has three trimesters. [ 9 ]


First trimester screening varies by country. Women are typically offered  urinalysis  (UA) and blood tests including a  complete blood count  (CBC),  blood typing  (including Rh screen),  syphilis ,  hepatitis ,  HIV , and  rubella  testing. [ 9 ]  Additionally, women may have  chlamydia  testing via a urine sample, and women considered at high risk are screened for  sickle cell disease  and  thalassemia . [ 9 ]  Women must consent to all tests before they are carried out. The woman's  blood pressure , height and weight are measured.  Her past pregnancies and family, social, and medical history are discussed.  Women may have an  ultrasound  scan during the first trimester which may be used to help find the  estimated due date .  Some women may have  genetic testing , such as screening for  Down syndrome .  Diet, exercise, and common disorders of pregnancy such as  morning sickness  are discussed. [ 9 ]


The mother visits the  midwife  monthly or more often during the second trimester.  The mother's partner and/or the birth companion may accompany her.  The midwife will discuss pregnancy issues such as fatigue, heartburn, varicose veins, and other common problems such as back pain. Blood pressure and weight are monitored and the midwife measures the mother's abdomen to see if the baby is growing as expected.  Lab tests such as a UA, CBC, and  glucose tolerance test  are done if clinically indicated. [ 10 ]


In the third trimester the midwife will see the mother every two weeks until week 36 and every week after that.  Weight, blood pressure, and abdominal measurements will continue to be done.  Lab tests such as a CBC and UA may be done with additional testing done for at-risk pregnancies.  The midwife palpates the woman's abdomen to establish the lie, presentation and position of the fetus and later, the engagement. A pelvic exam may be done to see if the mother's cervix is dilating. [ 11 ]   The midwife and the mother discuss birthing options and write a birth care plan. [ citation needed ]


Midwives are qualified to assist with a normal vaginal delivery while more complicated deliveries are handled by a health care provider who has had further training.  Childbirth is divided into four stages.


Following the birth, if the mother had an  episiotomy  or a tearing of the  perineum , it is sutured. The midwife does regular assessments for uterine contraction,  fundal height , [ 17 ]  and vaginal bleeding. [ 18 ]   Throughout labor and delivery the mother's  vital signs  (temperature, blood pressure, and pulse) are closely monitored and her fluid intake and output are measured. The midwife also monitors the baby's pulse rate, palpates the mother's abdomen to monitor the baby's position, and does vaginal examinations as indicated.  If the birth deviates from the norm at any stage, the midwife requests assistance from the multi-disciplinary team.


Until the last century most women have used both the upright position and alternative positions to give birth.  The  lithotomy position  was not used until the advent of forceps in the seventeenth century and since then childbirth has progressively moved from a woman supported experience in the home to a medical intervention within the hospital.
There are significant advantages to assuming an upright position in labor and birth, such as stronger and more efficient uterine contractions aiding cervical dilatation, increased pelvic inlet and outlet diameters and improved uterine contractility. [ 19 ]   Upright positions in the second stage include sitting, squatting, kneeling, and being on hands and knees. [ 20 ]


For women who have a hospital birth, the minimum hospital stay is six hours. Women who leave before this do so against medical advice. Women may choose when to leave the hospital. Full postnatal assessments are conducted daily whilst inpatient, or more frequently if needed. A postnatal assessment includes the woman's observations, general well-being, breasts (either a discussion and assistance with breastfeeding or a discussion about lactation suppression), abdominal palpation (if she has not had a caesarean section) to check for involution of the uterus, or a check of her caesarean wound (the dressing does not need to be removed for this), a check of her perineum, particularly if she tore or had stitches, reviewing her lochia, ensuring she has passed urine and had her bowels open and checking for signs and symptoms of a DVT. The baby is also checked for jaundice, signs of adequate feeding, or other concerns. The baby has a nursery exam between six and seventy two hours of birth to check for conditions such as heart defects, hip problems, or eye problems. [ 21 ]


In the community, the community midwife sees the woman at least until day ten. This does not mean she sees the woman and baby daily, but she cannot discharge them from her care until day ten at the earliest. Postnatal checks include neonatal screening test (NST, or heel prick test) around day five. The baby is weighed and the midwife plans visits according to the health and needs of mother and baby. They are discharged to the care of the health visitor. [ 22 ]


At birth, the baby receives an  Apgar score  at, at the least, one minute and five minutes of age. [ 23 ]  This is a score out of 10 that assesses the baby on five different areas—each worth between 0 and 2 points. These areas are: colour, respiratory effort, tone, heart rate, and response to stimuli. [ 24 ]  The  midwife  checks the baby for any obvious problems, weighs the baby, and measure head circumference. The midwife ensures the cord has been clamped securely and the baby has the appropriate name tags on (if in hospital). Babies lengths are not routinely measured. The midwife performs these checks as close to the mother as possible and returns the baby to the mother quickly. Skin-to-skin is encouraged, as this regulates the baby's heart rate, breathing, oxygen saturation, and temperature—and promotes bonding and breastfeeding. [ citation needed ]


In some countries, such as  Chile , the midwife is the professional who can direct neonatal intensive care units. This is an advantage for these professionals, who can use the knowledge of  perinatology  to bring a high quality care of the newborn, with medical or surgical conditions. [ 25 ]


Midwifery-led continuity of care is where one or more midwives have the primary responsibility for the  continuity of care  for childbearing women, with a multidisciplinary network of consultation and referral with other health care providers. This is different from "medical-led care" where an obstetrician or family physician is primarily responsible. In "shared-care" models, responsibility may be shared between a  midwife , an obstetrician and/or a family physician. [ 8 ]  The midwife is part of very intimate situations with the mother. For this reason, many say that the most important thing to look for in a midwife is comfort with them, as one will go to them with every question or problem. [ 26 ]


According to a  Cochrane review  of public health systems in Australia, Canada, Ireland, New Zealand and the United Kingdom, "most women should be offered midwifery-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications."  Midwifery-led care has effects including the following: [ 8 ]


There was no difference in the number of  Caesarean sections . All trials in the Cochrane review included licensed midwives, and none included lay or traditional midwives. Also, no trial included out of hospital birth. [ 8 ]


Compared to women in other care models, women in continuity models of midwifery care are more satisfied with their care. The updated version of the  Cochrane review  also shows a cost-saving effect in continuity models, compared to other midwifery models of care. [ 27 ]


In continuity models of midwifery care, the midwife-woman relationship is developing over time. The deepened relationship has shown to be of great importance and is in a  systematic review  described as "the viechle through which personalised care, trust and empowerment are achieved in the continuity of care midwifery model". [ 28 ]


In some cultures, midwifery is the most traditional way of carrying out a pregnancy and childbirth, and it has been conducted for multiple generations. Child birthing women in these cultures, take Zimbabwe for example, feel that health facilities are not as comforting as cultural roots of care. [ 29 ]  Also, according to the World Health Organization, women should be able to have their children where ever they feel the most safe, so if having a midwife and proceeding with an at-home birth is what makes some women feel safe, then midwifery-led continuity of care might be the best option for them. [ 30 ]


In  ancient Egypt , midwifery was a recognized female occupation, as attested by the  Ebers Papyrus  which dates from 1900 to 1550 BCE. Five columns of this papyrus deal with  obstetrics and gynecology , especially concerning the acceleration of parturition (the action or process of giving birth to offspring) and the birth prognosis of the newborn. The  Westcar papyrus , dated to 1700 BCE, includes instructions for calculating the expected date of confinement and describes different styles of birth chairs. Bas reliefs in the royal birth rooms at Luxor and other temples also attest to the heavy presence of midwifery in this culture. [ 31 ]


Midwifery in  Greco-Roman  antiquity covered a wide range of women, including old women who continued folk medical traditions in the villages of the  Roman Empire , trained midwives who garnered their knowledge from a variety of sources, and highly trained women who were considered physicians. [ 32 ]  However, there were certain characteristics desired in a "good"  midwife , as described by the physician  Soranus of Ephesus  in the 2nd century. He states in his work,  Gynecology , that "a suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses [i.e., sight, smell, hearing], sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips." Soranus also recommends that the midwife be of sympathetic disposition (although she need not have borne a child herself) and that she keep her hands soft for the comfort of both mother and child. [ 33 ]   Pliny , another physician from this time, valued nobility and a quiet and inconspicuous disposition in a midwife. [ 34 ]   There appears to have been three "grades" of midwives present: The first was technically proficient; the second may have read some of the texts on obstetrics and gynecology; but the third was highly trained and reasonably considered a  medical specialist  with a concentration in midwifery. [ 34 ]


Agnodice  or Agnodike (Gr. Ἀγνοδίκη) was the earliest historical, and likely apocryphal, [ 35 ]  midwife mentioned among the ancient Greeks. [ 36 ]