The expulsion stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, a sensation of pelvic pressure is experienced, and, with it, an urge to begin pushing. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the  pelvic inlet . The fetal head then continues descent into the pelvis, below the pubic arch and out through the  vaginal opening . This is assisted by the additional maternal efforts of pushing, or bearing down, similar to  defecation . The appearance of the fetal head at the vaginal opening is termed  crowning .  At this point, the mother will feel an intense burning or stinging sensation.


When the  amniotic sac  has not  ruptured  during labour or pushing, the infant can be born with the membranes intact. This is referred to as "delivery en  caul ".


Complete expulsion of the baby signals the successful completion of the second stage of labour.  Some babies, especially preterm infants, are born covered with a waxy or cheese-like white substance called  vernix .  It is thought to have some protective roles during fetal development and for a few hours after birth.


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


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


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


Delaying the clamping of the  umbilical cord  for at least one minute or until it ceases to pulsate, which may take several minutes, improves outcomes as long as there is the ability to treat  jaundice  if it occurs. For many years it was believed that late cord cutting led to a mother's risk of experiencing significant bleeding after giving birth, called  postpartum bleeding . However a recent review found that delayed cord cutting in healthy full-term infants resulted in early  haemoglobin  concentration and higher birthweight and increased iron reserves up to six months after birth with no change in the rate of postpartum bleeding. [ 59 ] [ 60 ]


The fourth stage of labour is the period beginning immediately after childbirth, and extends for about six weeks. The terms  postpartum  and  postnatal  are often used for this period. [ 61 ]  The woman's body, including hormone levels and uterus size, return to a non-pregnant state and the newborn adjusts to life outside the mother's body.  The  World Health Organization  (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period. [ 62 ]


Following the birth, if the mother had an  episiotomy  or a tearing of the  perineum , it is stitched. This is also an optimal time for uptake of  long-acting reversible contraception  (LARC), such as the  contraceptive implant  or  intrauterine device  (IUD), both of which can be inserted immediately after delivery while the woman is still in the delivery room. [ 63 ] [ 64 ]  The mother has regular assessments for uterine contraction and  fundal height , [ 65 ]  vaginal bleeding, heart rate and blood pressure, and temperature, for the first 24 hours after birth. Some women may experience an uncontrolled episode of shivering or  postpartum chills  following the birth. The first passing of urine should be documented within six hours. [ 62 ]  Afterpains (pains similar to menstrual cramps), contractions of the uterus to prevent excessive blood flow, continue for several days. Vaginal discharge, termed "lochia", can be expected to continue for several weeks; initially bright red, it gradually becomes pink, changing to brown, and finally to yellow or white. [ 66 ]


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


Skin-to-skin contact  (SSC), sometimes also called  kangaroo care , is a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent, typically their mother or possibly the father. This means without the shirt or undergarments on the chest of both the baby and parent. A 2011 medical review found that early skin-to-skin contact resulted in a decrease in infant crying, improved cardio-respiratory stability and blood glucose levels, and improved breastfeeding duration. [ 69 ] [ 70 ]  A 2016  Cochrane review  also found that SSC at birth promotes the likelihood and effectiveness of breastfeeding. [ 71 ]


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


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


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


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


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


In many cases and with increasing frequency, childbirth is achieved through  labour induction  or  caesarean section , also called a C-section. Labour induction is the process or treatment that stimulates childbirth and delivery. Inducing labour can be accomplished with pharmaceutical or non-pharmaceutical methods.  Inductions are most often performed either with  prostaglandin  drug treatment alone, or with a combination of prostaglandin and intravenous  oxytocin  treatment. [ 77 ]
Caesarean section is the removal of the  neonate  through a surgical incision in the abdomen, rather than through vaginal birth.  During the procedure the patient is usually numbed with an epidural or a spinal block, but general anaesthesia can be used as well. A cut is made in the patient's abdomen and then in the uterus to remove the baby. [ 78 ]  Before the 1970s, once a patient delivered one baby via C-section, it was recommended that all of her future babies be delivered by C-section, but that recommendation has changed. Unless there is some other indication, mothers can attempt a trial of labour and most are able to have a vaginal birth after C-section (VBAC). [ 79 ]  Induced births and elective cesarean before 39 weeks can be harmful to the neonate as well as harmful or without benefit to the mother. Therefore, many guidelines recommend against non-medically required induced births and elective cesarean before 39 weeks. [ 80 ]


The 2012 rate of labour induction in the United States was 23.3%, and had more than doubled from 1990 to 2010. [ 81 ] [ 82 ]  By 2022 it had climbed to 32%. [ 83 ]
The  American Congress of Obstetricians and Gynecologists  (ACOG) guidelines recommend a full evaluation of the maternal-fetal status, the status of the cervix, and at least a 39 completed weeks (full term) of gestation for optimal health of the newborn when considering elective induction of labour.  Per these guidelines, indications for induction may include:


Induction is also considered for logistical reasons, such as the distance from hospital or psychosocial conditions, but in these instances gestational age confirmation must be done, and the maturity of the fetal lung must be confirmed by testing. The ACOG also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including  vasa previa , complete  placenta praevia ,  umbilical cord prolapse  or active  genital herpes simplex  infection, in which cases a cesarean section is the safest delivery method. [ 84 ]


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


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


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


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


Eating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes, [ 92 ]  others continue to have concern regarding the increased possibility of an aspiration event (choking on recently eaten foods) in the event of an emergency delivery due to the increased relaxation of the oesophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anaesthetic in the event of an emergency cesarean. [ 93 ]  A 2013  Cochrane review  found that with good obstetrical anaesthesia there is no change in harms from allowing eating and drinking during labour in those who are unlikely to need surgery. They additionally acknowledge that not eating does not mean there is an empty stomach or that its contents are not as acidic. They therefore conclude that "women should be free to eat and drink in labour, or not, as they wish." [ 94 ]


At one time shaving of the  area around the vagina , was common practice due to the belief that hair removal reduced the risk of infection, made an  episiotomy  (a surgical cut to enlarge the vaginal entrance) easier, and helped with instrumental deliveries. It is currently less common, though it is still a routine procedure in some countries even though a systematic review found no evidence to recommend shaving. [ 95 ]  Side effects appear later, including irritation, redness, and multiple superficial scratches from the razor. Another effort to prevent infection has been the use of the antiseptic  chlorhexidine  or  providone-iodine solution  in the vagina. Evidence of benefit with chlorhexidine is lacking. [ 96 ]  A decreased risk is found with providone-iodine when a cesarean section is to be performed. [ 97 ]


An assisted delivery is used in about 1 in 8 births, and may be needed if either mother or infant appears to be at risk during a vaginal delivery.  The methods used are termed  obstetrical forceps  extraction and  vacuum extraction , also called ventouse extraction.  Done properly, they are both safe with some preference for forceps rather than vacuum, and both are seen as preferable to an unexpected C-section.  While considered safe, some risks for the mother include vaginal tearing, including a higher chance of having a more major vaginal tear that involves the muscle or wall of the anus or rectum.  For women undergoing operative vaginal delivery with vacuum extraction or forceps, there is strong evidence that  prophylactic antibiotics  help to reduce the risk of infection. [ 98 ]  There is a higher risk of blood clots forming in the legs or pelvis – anti-clot stockings or medication may be ordered to avoid clots.   Urinary incontinence  is not unusual after childbirth but it is more common after an instrument delivery.  Certain exercises and physiotherapy will help the condition to improve. [ 99 ]


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


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


Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled  nitrous oxide  gas for pain control, especially as 53% nitrous oxide, 47% oxygen, known as  Entonox ; in the UK, midwives may use this gas without a doctor's prescription. [ 105 ]   Opioids  such as  fentanyl  may be used, but if given too close to birth there is a risk of respiratory depression in the infant. [ needs update ] [ 106 ]


Popular medical pain control in hospitals include the regional anaesthetics  epidurals  (EDA), and  spinal anaesthesia . Epidural analgesia is a generally safe and effective method of relieving pain in labour, but has been associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. [ 107 ]  However, a more recent (2017) Cochrane review suggests that the new epidural techniques have no effect on labour time and the use of instruments or the need for C-section deliveries. [ 108 ]  Generally, pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but rise again later. [ 109 ]
Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. [ 110 ]  Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores. [ 108 ]


Augmentation is the process of stimulating the uterus to increase the intensity and duration of contractions after labour has begun. Several methods of augmentation are commonly been used to treat slow progress of labour (dystocia) when uterine contractions are assessed to be too weak.  Oxytocin  is the most common method used to increase the rate of vaginal delivery. [ 111 ]  The World Health Organization recommends its use either alone or with  amniotomy  (rupture of the amniotic membrane) but advises that it must be used only after it has been correctly confirmed that labour is not proceeding properly if harm is to be avoided.  The WHO does not recommend the use of  antispasmodic  agents for prevention of delay in labour. [ 112 ]


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


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


For external  monitoring  of the fetus during childbirth, a simple  pinard stethoscope  or  doppler fetal monitor  (" doptone ") can be used.
A method of external (noninvasive) fetal  monitoring  (EFM) during childbirth is  cardiotocography  (CTG), using a  cardiotocograph  that consists of two sensors: The  heart  (cardio) sensor is an  ultrasonic sensor , similar to a  Doppler fetal monitor , that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound. The pressure-sensitive  contraction  transducer, called a  tocodynamometer  (toco) has a flat area that is fixated to the skin by a band around the belly. The pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction. [ 114 ]
Monitoring with a cardiotocograph can either be intermittent or continuous. [ 115 ]  The  World Health Organization  (WHO) advises that for healthy women undergoing spontaneous labour continuous cardiotocography is not recommended for assessment of fetal well-being. The WHO states: "In countries and settings where continuous CTG is used defensively to protect against litigation, all stakeholders should be made aware that this practice is not evidence-based and does not improve birth outcomes." [ 116 ]


A mother's water has to break before internal (invasive) monitoring can be used. More invasive monitoring can involve a  fetal scalp electrode  to give an additional measure of fetal heart activity, and/or  intrauterine pressure catheter  (IUPC). It can also involve  fetal scalp pH testing . [ medical citation needed ]


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


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


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


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


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


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


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


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


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


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


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


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


Most new mothers may experience mild feelings of unhappiness and worry after giving birth.  Babies require a lot of care, so it is normal for mothers to be worried about, or tired from, providing that care.  The feelings, often termed the  "baby blues" , affect up to 80% of mothers.  They are somewhat mild, last a week or two, and usually go away on their own. [ 134 ]


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


Childbirth-related post-traumatic stress disorder  is a psychological disorder that can develop in women who have recently given birth. [ 135 ] [ 136 ] [ 137 ]  Causes include issues such as an emergency C-section, preterm labour, inadequate care during labour,
lack of social support following childbirth, and others.  Examples of symptoms include  intrusive symptoms ,  flashbacks  and  nightmares , as well as symptoms of  avoidance  (including  amnesia  for the whole or parts of the event), problems in developing a  mother-child attachment , and others similar to those commonly experienced in  posttraumatic stress disorder  (PTSD).  Many women who are experiencing symptoms of PTSD after childbirth are misdiagnosed with postpartum depression or  adjustment disorders .  These diagnoses can lead to inadequate treatment. [ 138 ]


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


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


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


Worldwide prevention of most stillbirths is possible with improved health systems. [ 141 ] [ 142 ]  About half of stillbirths occur during childbirth, and stillbirth is more common in the  developing  than  developed world . [ 141 ]  Otherwise depending on how far along the pregnancy is,  medications may be used to start labour  or a type of surgery known as  dilation and evacuation  may be carried out. [ 143 ]  Following a stillbirth, women are at higher risk of another one; however, most subsequent pregnancies do not have similar problems. [ 144 ]


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


Preterm birth is the birth of an infant at fewer than 37 weeks  gestational age . Globally, about 15 million infants were born  before 37 weeks of gestation . [ 147 ]  Premature birth is the leading cause of death in children under five years of age though many that survive experience disabilities including learning defects and visual and hearing problems. Causes for early birth may be unknown or may be related to certain chronic conditions such as diabetes, infections, and other known causes.  The World Health Organization has developed guidelines with recommendations to improve the chances of survival and health outcomes for preterm infants. [ 148 ] [ 149 ]


If a pregnant woman enters preterm labour, delivery can be delayed by giving medications called  tocolytics . Tocolytics delay labour by inhibiting contractions of the uterine muscles that progress labour. The most widely used tocolytics include beta agonists, calcium channel blockers, and magnesium sulfate. The goal of administering tocolytics is not to delay delivery to the point that the child can be delivered at term, but instead to postponing delivery long enough for the administration of  glucocorticoids  which can help the fetal lungs to mature enough to reduce morbidity and mortality from  infant respiratory distress syndrome . [ 149 ]


The term postterm pregnancy is used to describe a condition in which a woman has not yet delivered her baby after 42 weeks of  gestation , two weeks beyond the usual 40-week duration of pregnancy. [ 150 ]  Postmature births carry risks for both the mother and the baby, including  meconium aspiration syndrome , fetal malnutrition, and  stillbirths . [ 151 ]  The  placenta , which supplies the baby with oxygen and nutrients, begins to age and will eventually fail after the 42nd week of gestation. Induced labour is indicated for postterm pregnancy. [ 152 ] [ 153 ] [ 154 ]


Newborns are prone to infection in the first month of life. The  pathogenic bacterium   Streptococcus agalactiae  (a group B streptococcus) is most often the cause of these occasionally fatal infections. The baby contracts the infection  from the mother  during labour. In 2014 it was estimated that about one in 2000 newborn babies had a group B streptococcuss infection within the first week of life, usually evident as  respiratory disease , general  sepsis , or  meningitis . [ 156 ]


Untreated  sexually transmitted infections  (STIs) are associated with  birth defects , and infections in newborn babies, particularly in the areas where rates of infection remain high. The majority of STIs have no symptoms or only mild symptoms that may not be recognised.  Mortality rates resulting from some infections may be high, for example the overall perinatal mortality rate associated with untreated syphilis is 30%. [ 157 ]


Perinatal asphyxia  is the medical condition resulting from  deprivation of oxygen  to a newborn infant that lasts long enough during the birth process to cause physical harm. [ 158 ]  Hypoxic damage can also occur to most of the infant's organs ( heart ,  lungs ,  liver ,  gut ,  kidneys ), but  brain damage  is of most concern and perhaps the least likely to quickly or completely heal. [ 158 ]  Oxygen deprivation can lead to permanent disabilities in the child, such as  cerebral palsy . [ 159 ]


Risk factors for fetal birth injury include  fetal macrosomia  (big baby),  maternal obesity , the need for instrumental delivery, and an inexperienced attendant. Specific situations that can contribute to birth injury include breech presentation and  shoulder dystocia . Most fetal birth injuries resolve without long term harm, but  brachial plexus injury  may lead to  Erb's palsy  or  Klumpke's paralysis . [ 160 ]


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


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


Both preterm and full term infants benefit from skin to skin contact, sometimes called  kangaroo care , immediately following birth and for the first few weeks of life. Some fathers have begun to hold their newborns skin to skin; the new baby is familiar with the father's voice and it is believed that contact with the father helps the infant to stabilise and promotes father to infant bonding. Looking at recent studies, a 2019 review found that the level of  oxytocin  was found to increase not only in mothers who had experienced early skin to skin attachment with their infants but in the fathers as well, suggesting a  neurobiological  connection. [ 74 ]  If the infant's mother had a caesarean birth, the father can hold their baby in skin-to-skin contact while the mother recovers from the anaesthetic. [ 72 ]


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


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


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


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


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


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


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


There are many conflicting stories of the first successful  cesarean section  (or C-section) in which both mother and baby survived. It is, however, known that the procedure had been attempted for hundreds of years before it became accepted in the beginning of the twentieth century. [ 161 ]  While forceps have gone through periods of high popularity, today they are only used in approximately 10% of deliveries. The c-section has become the more popular solution for difficult deliveries. In 2005, one-third of babies were born via C-section. Historically, surgical delivery was a last-resort method of extracting a baby from its deceased or dying mother but today  caesarean delivery on maternal request  is a medically unnecessary caesarean section, where the infant is born by a caesarean section requested by the parent even though there is not a medical  indication  to have the surgery. [ 170 ]


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


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


Outcomes for mothers in childbirth were especially poor before  antibiotics  were discovered in the 1930s, because of high rates of  puerperal fever . [ 165 ]  Until  germ theory  was accepted in the mid-1800s, it was assumed that puerperal fever was caused by a variety of sources, including the leakage of breast milk into the body and anxiety. Later, it was discovered that puerperal fever was transmitted by the dirty hands and tools of doctors. [ 161 ]


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


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


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


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


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


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


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


Childbirth routinely occurs in hospitals in many  developed countries . Before the 20th century and in some countries to the present day, such as  the Netherlands , it has more typically occurred at home. [ 182 ]


In rural and  remote communities  of many countries, hospitalised childbirth may not be readily available or the best option. Maternal evacuation is the predominant risk management method for assisting mothers in these communities. [ 183 ]  Maternal evacuation is the process of relocating pregnant women in remote communities to deliver their babies in a nearby urban hospital setting. [ 183 ]  This practice is common in Indigenous  Inuit  and Northern Manitoban communities in  Canada  as well as  Australian aboriginal  communities. There has been research considering the negative effects of maternal evacuation due to a lack of social support provided to these women. These negative effects include an increase in maternal newborn complications and postpartum depression, and decreased breastfeeding rates. [ 183 ]


The  exact location  in which childbirth takes place is an important factor in determining nationality, in particular for  birth aboard aircraft and ships .


Facilities for childbirth include:


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


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


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


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


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


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


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


Medical doctors  who practise in the field of childbirth include categorically specialised  obstetricians ,  family practitioners  and  general practitioners  whose training, skills and practices include obstetrics, and in some contexts  general surgeons . These physicians and surgeons variously provide care across the whole spectrum of normal and abnormal births and pathological labour conditions. Categorically specialised obstetricians are qualified  surgeons , so they can undertake surgical procedures relating to childbirth. Some family practitioners or general practitioners also perform obstetrical surgery. Obstetrical procedures include  cesarean sections ,  episiotomies , and assisted delivery. Categorical specialists in obstetrics are commonly trained in both  obstetrics and gynaecology  (OB/GYN), and may provide other medical and surgical gynaecological care, and may incorporate more general, well-woman,  primary care  elements in their practices.  Maternal–fetal medicine  specialists are obstetrician/gynecologists subspecialised in managing and treating high-risk pregnancy and delivery.


Anaesthetists  or  anaesthetists  are medical doctors who specialise in pain relief and the use of drugs to facilitate surgery and other painful procedures. They may contribute to the care of a woman in labour by performing an  epidural  or by providing  anaesthesia  (often  spinal anaesthesia ) for Cesarean section or  forceps delivery . They are experts in  pain management during childbirth .


Obstetric nurses  assist midwives, doctors, women, and babies before, during, and after the birth process, in the hospital system. They hold various  nursing certifications  and typically undergo additional obstetric training in addition to standard  nursing training .


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


Lactation consultants  assist the mother and newborn to  breastfeed  successfully. A  health visitor  comes to see the mother and baby at home, usually within 24 hours of discharge, and checks the infant's  adaptation to extrauterine life  and the mother's  postpartum physiological changes .


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


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


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


Ceremonies and customs can vary greatly between countries. See;


It is currently possible to collect two types of  stem cells  during childbirth:  amniotic stem cells  and umbilical  cord blood  stem cells. [ 192 ]  They are being studied as possible treatments of a number of conditions. [ 192 ]


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


Natural birth topics:


Emergency childbirth  is the precipitous birth of an infant in an unexpected setting. In planned  childbirth , mothers choose the location and  obstetric  team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned  childbirth  are low. [ 1 ] [ 2 ] [ 3 ]  If the  birth  is imminent, emergency measures may be needed. [ 4 ]  Emergency services can be contacted for help in some countries. [ 5 ] [ 6 ]


Emergency childbirth can follow the same steps as a planned childbirth. However, the birth can have increased risks for complications due to the prematurity of the baby or the less than ideal location.


In 2020, 1.34% of births took place outside of a hospital in California, USA, [ 7 ]  where 1 out of 8 births in the country happen. [ 8 ]  Most of the out-of-hospital births are planned, and thus, not considered an emergency childbirth. [ 9 ]  However, about 12% of attempted home deliveries need urgent transport to a hospital. Some of the reasons for transferring to a hospital include failure of labor to progress, parental exhaustion, need for more pain medication, or parental/fetal complications. [ 10 ]


In the United States, 0.61% of all births happen in an unplanned setting. The percent is even lower in countries like Finland and France. [ 5 ]


Each year more than 250,000 women around the world die from complications due to  childbirth  or pregnancy, with  bleeding  and  hypertension  as the leading causes. [ 11 ]  Many of these deaths are preventable by emergency care, which include antibiotics,  drugs that stimulate contraction of the uterus ,  anti-seizure drugs ,  blood transfusion , and delivery of baby with assistance (vacuum or forceps delivery) or  C-section . [ 11 ]  In addition, it is important to prevent  hypothermia  in the newborn because this is linked to poor outcomes. [ 5 ]


Many pregnant women seek medical care throughout pregnancy and plan for the birth of a baby with a healthcare team. Access to high quality care lowers the risk-averse events in pregnancy. [ 12 ]  In an emergency childbirth situation, it is recommended to seek further education and make a plan. [ 13 ]


Many childbirth education classes cover emergency birth procedures. Parents are trained to learn the signs of early labor or other indications that may require assistance. Signs of early labor include regular  contractions  (4 or more within one hour) accompanied with cervical changes, such as  effacement  or  dilation . [ 14 ]  Caregivers can take a class on infant and child life support. Some recommend having a kit of emergency supplies in the home such as: clean towels,  receiving blanket , sheets, clean scissors, clean clamps or ties,  ID bands for mother and baby, pencil, soap, sterile gloves, sanitary pads, diapers, and instructions for infant-rescue breathing. [ 15 ] [ 16 ] [ 17 ]


Additional help may be found by calling 911 (in the United States) or an applicable number to get emergency medical services or nearby medical staff. [ 18 ]


A vehicle driven safely toward medical care may be considered an acceptable option during the first stage of  labor  (dilation and effacement).  During the second stage of labor (pushing and birth), a vehicle is usually stopped unless imminently arriving at a medical facility.  If a vehicle is taken, additional occupants can support the mother and baby should assist in delivery.  The mother and baby are kept warm throughout. [ 19 ]


If unable to reach a medical facility, a safe building with walls and a roof are sought that will provide protection from the environment.  A warm and dry area with a bed is preferable. [ 17 ]


Supplies are collected for both the mother and the baby. Possible supplies may include blankets, pillows, towels, warm clean water, warm water bottles, soap, clean towels, baby clothes, sheets, sterile gloves, sanitary pads, diapers, identification tags for mother and baby, and instructions for infant-rescue breathing. [ 15 ] [ 16 ] [ 17 ]   A bed may be prepared for the baby with a basket or box lined with a blanket or sheets. [ 17 ]   Items are needed to clamp or tie the umbilical cord in two places.  Shoestrings or strips of a sheet folded into narrow bands may be used. [ 17 ]   These items can be sterilized by boiling (20 minutes) or soaking in alcohol (up to 3 hours). [ 17 ]   Scissors or a knife are needed to cut the umbilical cord and may be sterilized with the same procedure. [ 17 ]


A background obstetric history should be obtained: how many prior births has the patient had (if this is not her first birth, the patient's labor could be short), how many weeks along is she or what is her estimated date of delivery, any special concerns related to this pregnancy such as being told she has twins, being told she has a complication, or even if she has received regular prenatal care. Any other relevant medical history, allergies, drugs, recent signs of infections (fever) should be asked. [ 10 ]


If time permits and if trained: one should obtain vital signs to include maternal heart rate, respiratory rate, blood pressure, temperature, and oxygen rate. [ 10 ]


The patient should be draped with available blankets for privacy.


The patient's abdomen should be examined and felt for the presence of contractions, [ 10 ]  and the intensity, frequency, and length of contractions should be noted. [ 20 ]


With the patient's permission and privacy, an exam of the pelvic area should be performed; in general, one would:


After the physical exam and if the patient is not crowning, the patient should be placed in the left lateral decubitus position (laying on her left side). [ 10 ]


This stage of labor on average lasts from 2 to 18 hours, but can last even longer in normal pregnancies. [ 22 ]  This stage can be further broken up into the latent stage and active stage depending on how dilated the cervix is. The latent stage, when the cervix is dilated less than 3–5 cm along with regular contractions, can last as long as 20 hours without being considered prolonged. The active stage, when regular contractions are accompanied with dilation greater than 3–5 cm, can also be significantly long, with anything less than 11.7 hours being considered normal. [ 23 ]  Further care may be sought during this time.


This stage may last from 5 minutes to 3 hours. [ 22 ]


The baby is attached to the  placenta  by the umbilical cord.  After the cord is cut, the placenta is usually still inside the mother.  The placenta usually comes out in 2–10 minutes, but it may take up to 60 minutes. [ 17 ] [ 22 ]  This process is usually a spontaneous one, but may also require pushing from the mother. [ 21 ]


Complications of emergency childbirth include the complications that occur during normal childbirth. Potential complications for the gestational parent include perineal tearing (tearing of the vagina or surrounding tissue) during delivery, excessive bleeding ( postpartum hemorrhage ), hypertension (high blood pressure), and seizures.


Bleeding during pregnancy  is fairly common (experienced by up to 25% of pregnant women [ 25 ] ) and may not always indicate a problem. However, bleeding can be a sign of a serious complication, including miscarriage or another condition that threatens the health of the mother or fetus. It is important to get medical attention for any of the following:


Causes of vaginal bleeding early in pregnancy include  miscarriage  (including inevitable, incomplete, or complete abortion), embryo implantation and growth outside the uterus ( ectopic pregnancy ), and placenta attachment at the bottom of the uterus over the cervix ( placenta previa ), all of which can cause significant bleeding.


Vaginal bleeding early in pregnancy may also be a sign of a threatened abortion, which is when there is light to moderate vaginal bleeding but the cervix is still closed. Threatened abortion does not mean that miscarriage is inevitable; about 50% of women with bleeding before the third trimester will progress to a live birth. [ 26 ]


Prior to and during delivery, bleeding can occur from tears in the cervix, vagina, or perineum, sudden placental detachment ( placental abruption ) and placental attachment over the cervix ( placenta previa ), and  uterine rupture .


Postpartum hemorrhage occurs in 3% of pregnant women, leading to ~150,000 annual deaths worldwide. Hemorrhages are an indication to seek care from a healthcare provider. The hemorrhages are usually slow and continuous and can last more than 90 minutes after delivery before they are fatal to the mother. This time should be used to quickly transfer the woman to a hospital.


Postpartum hemorrhage is defined by “cumulative blood loss ≥1000 mL, or bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process”. [ 27 ]  It is difficult to predict and has few known risk factors. Once uncontrolled bleeding occurs, management can be manual (fundal massage from the outside, packing the uterus, tamponading bleeding from the inside with balloon or condom catheter), and pharmacological (with  oxytocin ,  ergotamine ,  misoprostol ). Alongside these treatments, shock should be addressed with IV fluids or blood transfusions as discussed below.


After delivery of the baby and placenta, the uterus should contract to close off blood vessels in the uterine wall that were attached to the placenta. If the uterus is not contracting ( atonic uterus ) or ruptures during delivery, severe bleeding can occur. Massaging the lower abdomen ( fundal massage ) increases contraction of the uterus and can be used preventatively to manage postpartum bleeding. Uterine bleeding can also occur if parts of the placenta or fetal tissue remain stuck in the uterus after delivery. While waiting to transfer, the placenta can be delivered with gentle massages of the uterus through the lower  abdominal wall . [ 28 ]  When the placenta is delivered, steady traction is applied to the cord as it is pulled out to prevent trauma, cord avulsion (tearing of the umbilical cord), uterine inversion, and retained placental products, all of which can increase blood loss and/or the risk of infection.


When a woman is in shock she may have cold clammy skin, pale skin (especially around eyes, mouth, and hands), sweating, anxiousness, and loss of consciousness. She may have a fast heartbeat (110 beats per minute or more), low blood pressure (90mmHg systolic or less), and decreased urine output. The mother should be laid on her left side, with legs and buttocks elevated to encourage blood flow back to the heart with gravity. Most importantly, seek medical attention. [ citation needed ]


Seizures related to pregnancy may be caused by  eclampsia , which typically progresses from  preeclampsia , a condition in pregnant women that is characterized by new-onset high blood pressure and  protein in urine from kidney failure . Associated symptoms include headaches, blurry vision,  trouble breathing from fluid in lungs , elevated liver enzymes from liver dysfunction, and possibly coagulation defects from platelet dysfunction. [ citation needed ]


If a pregnant woman begins to have seizures, additional help and assistance should be sought. One should not restrain the mother, but lie her down on her left side and check the airway (mouth, nose, throat). Turning the mother on her side decreases risk of  breathing in vomit and spit . In a medical setting, magnesium sulfate is the preferred treatment for seizures in pregnant women. [ citation needed ]


Almost 10% of newborns require some resuscitative care. Common complications of childbirth that relate to the baby include  breech presentation ,  shoulder dystocia ,  infection , and umbilical cord wrapped around the baby's neck ( nuchal cord ).


The newborn is evaluated at 1 and 5 minutes after birth using the  Apgar  score, which assigns points based on appearance (color), pulse, grimace (cry), activity (muscle tone), and respiration (breathing effort), with each component scored from 0 to 2. A healthy baby at birth usually has an Apgar score of 8 or 9. This means they look pink (indicating good oxygen flow) and have a heart rate greater than 100 bpm, a strong cry, and good muscle tone (i.e. is not limp). Scores below 7 generally require further care (see resuscitation below).


After initial evaluation, babies with good Apgar scores are dried and rubbed, any obstruction of breathing is cleared, and they are warmed either with skin-to-skin contact with the mother or under a heat source. [ citation needed ]


Neonatal complications can happen. In the United States home births, umbilical cord wrapped around the head happens 12-37% of the time ( nuchal cord ). Insufficient oxygenation ( birth asphyxia ) presents 9% of the time. 6% present with pulselessness and 3% have breech presentation. [ 29 ]


Normally, the head is the first part of the body to present out of the birth canal. However, other parts such as the buttocks or feet can present first, which is referred to as  breech presentation . Risk for breech presentation may increase with multiple pregnancies (more than one baby), when there is too little or too much fluid in the uterus, or if the uterus is abnormally shaped. [ 24 ]  Babies in breech presentation can be delivered vaginally depending on the experience of the provider and if the fetus meets specific low risk criteria, however C-section is recommended if available. [ 30 ]  Ideally, the fetus can be turned to the right position with maneuvers on the abdomen of the mother. This is called  external cephalic version  and it is a way to avoid  Cesarean surgery  and its possible risks. The maneuver cannot be performed on every woman. Contraindications to attempting to turn the baby with external cephalic version include  oligohydramnios  (when there is not enough  amniotic fluid  surrounding the baby), growth restrictions, or some abnormalities of the uterus. [ 31 ]


Vaginal delivery of a baby in breech position should not be performed without the availability of nearby emergency C-section capabilities and extensive efforts should be made to bring a woman in labor with breech presentation to a hospital. There are many variations of breech presentations and multiple ways the baby can get stuck during delivery. If a breech delivery is occurring, the provider will guide the hips out by giving light, downward traction holding the pelvis until the scapula is present. Then at the level of the armpits, each shoulder is delivered by rotating the baby as required, then subsequently rotating 180 degrees to deliver the other shoulder. The head is delivered with careful attention to the baby's arms. The arms will be delivered downwards through the vulva and may have to be gently held downwards by the provider's fingers. [ 20 ]  It is important to note that when the infant in breech position has been delivered to the point in which the umbilical cord is seen but not the baby's head, the head has to be delivered within 8 to 10 minutes, or the baby will suffocate. This is because the umbilical cord provides oxygen to the baby from the mother, and if it is pressed in the birth canal, blood cannot pass to the baby to deliver oxygen. [ 28 ]


Incidence of preterm delivery is approximately 12%, and preterm births are a significant contributing cause of unplanned emergency delivery. [ 10 ]  Pre-term labor is defined as occurring before 37 weeks, and risks for pre-term labor include pregnancy with multiple fetuses, prior history of premature labor, structural abnormalities of the cervix or uterus, urinary tract, vaginal, or sexually transmitted infections, high blood pressure, drug use, diabetes, blood disorders, or pregnancy occurring less than 6 months after a prior pregnancy. [ 20 ]  The same principles of term emergency delivery apply to emergency delivery for a  preterm fetus , though the baby will be at higher risk of other problems such as  low birth weight , trouble breathing, and infections. The newborn will need additional medical care and monitoring after delivery and should be taken to a hospital providing neonatal care, which may include antibiotics and breathing treatments. [ 32 ]


In  shoulder dystocia , the shoulder is trapped after the head is delivered, preventing delivery of the rest of the baby. The major risk factor (other than prior history of shoulder dystocia) is the baby being too large ( macrosomia ), which can result from the mother being obese or gaining too much weight, diabetes, and the pregnancy lasting too long ( post-term pregnancy ). [ 24 ]  Shoulder dystocia can lead to further fetal complications such as nerve compression and injury at the shoulder ( brachial plexus ), fracture of the collarbone, and low oxygen for the fetus (whether due to compression of the umbilical cord or due to inability of the baby to breathe). Shoulder dystocia is often signaled by retreat of the head between contractions when it has already been delivered ("turtle sign"). Treatment includes the  McRoberts maneuver , where the mother flexes her thighs up to her stomach with her knees wide apart as pressure is applied on her lower abdomen, and  Wood's screw maneuver , where the deliverer inserts a hand into the vagina to rotate the fetus. [ 33 ]  If all maneuvers fail, then C-section would be indicated.


A prolapsed cord refers to an umbilical cord that is delivered from the uterus while the baby is still in the uterus and is life-threatening to the baby. Cord prolapse creates a risk of decreased blood flow (and oxygen flow) to the baby as delivery will cause cord compression. However, if the cord delivers before the baby, the cord should not be placed back into the uterus through the cervix since this increases risk of infection. [ 34 ]  Emergent obstetric care for C-section would be indicated, and in the meantime, one should elevate the foot of the bed if possible to attempt to keep the baby above the level of the cord. [ 10 ]  If no specialized care is available, one may attempt to reduce pressure of the cord manually and continue delivery, but this is often difficult to do.


After the baby crowns, the umbilical cord may be found to be wrapped around the neck or body of the baby, which is known as nuchal cord. This is common, occurring in up to 37% of term pregnancies, and most do not cause any long-term problems. [ 35 ]  This wrapped cord should be slipped over the head so it is not pulled during delivery. If the wrap is not removed, it can choke the baby or can cause the placenta to detach suddenly which can cause severe uterine bleeding and loss of blood and oxygen supply to the baby. The cord may also be wrapped around a limb in breech presentation, and should similarly be reduced in these cases.


If the baby is not doing well on its own, further care may be necessary. Resuscitation typically starts with warming, drying, and stimulating the newborn. If breathing difficulty is noted, the airway is opened and cleared with suction and oxygen is monitored; if necessary, one may consider using a positive airway pressure ventilator (which gives oxygen while keeping the airway open) or intubation. If the heart rate is below 60 beats per minute, CPR is started at 3:1 compression to ventilation ratio, with compressions given at the lower breastbone. If this fails to revive the newborn, epinephrine will be given. [ 10 ]


Resuscitation is not indicated for newborns below 22 weeks of gestation and weighing below 400 grams. Resuscitation may also be discontinued if the baby's heart does not start after 10–15 minutes of full resuscitation (including breathing treatments, medications, and CPR).


The reports of emergency childbirth are typically of general interest. They are frequently portrayed in dramatic scenes of movies and telenovelas. [ citation needed ]


A mobile app was developed in Ethiopia that guides users through the procedures of assisting with an emergency birth. [ 36 ]


Using Wikipedia for Research


Pain management during childbirth  is the   partial treatment  and a way of reducing any  pain  that a woman may experience during labor and  delivery . The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her  pelvis , her  emotions , the strength of the  contractions , and her outlook. [ 1 ]   Tension increases pain during labor. [ 2 ]  Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain. [ 1 ]


Pain in childbirth also serves to protect the child and the mother during the childbirth process. Pain has some function roles to warn the body of potential danger or to the presence of injury. In the case of pregnancy, it can help the pregnant individual to detect any danger to the child, as well as adjusting to an optimal position for childbirth. In addition, Whiteburn et al. (2019) mentioned that there are also psychological functions that come with childbirth pain. As labour pain is part of a natural process, the experience is unique and hard to describe for many pregnant individuals. Many women embrace the pain as part of the process of childbirth, allowing them to better see the pain as emotional and meaningful rather than an unnecessary sensation(Whiteburn et al., 2019).  "The nature of labour pain: An updated review of the literature" .


Many women find that improving their environment and adopting a positive mindset towards childbirth significantly reduces the need for  pain medication , contrary to the belief that natural methods benefit only a select few. Recognizing that labour pain, unlike that caused by injury or illness, is a purposeful process associated with uterine contractions underscores the effectiveness of natural  pain relief  techniques. Such an approach implies that with the proper support and outlook, the majority of women can manage labour pain effectively without defaulting to medical interventions. This perspective not only challenges the notion that medication is frequently necessary but also highlights the power of natural pain management strategies in creating a positive and empowering childbirth experience.


Women who have negative expectations for the process of delivery are more likely to experience increased perceptions of pain, due to the effects of nocebo hyperalgesia. These negative expectations can come from negativity in the mass media or a pre-existing distrust for the medical system. [ 3 ]


Labor pain is commonly thought to occur due to the stretching of the cervix and contraction of the uterine muscle. However, in reality, we still do not know the exact mechanism of why labor hurts, and the previous explanation is challenged by scientific explanations. For instance, the stretch receptors in the uterus disappear during pregnancy, stretch receptors in the cervix disappear at the onset of labor, and muscle fibers in the cervix are almost completely replaced by connective tissue (extracellular matrix, or ECM).


When studying uterine receptors during pregnancy and labour, it was found that the pertinent stretch receptors disappear during pregnancy, meaning that the stretching or contracting of the uterus would not be felt during that time. It was also found that stretch receptors in the cervix also disappear at the onset of labour, meaning that no sensation would be felt in that region either (Tingåker & Irestedt, 2010). [ 4 ]  It is not common knowledge that sensory denervation of the uterus and cervix occurs, therefore it is a common heuristic that many people attribute the stretching sensations as the reason for pain. So, if denervation occurs, why does labour pain continue to occur? There are several reasons as to why this pain may occur, such as some of the reasons mentioned earlier on this page, however one reason that has been studied says that labour pain occurs due to vasoconstriction within the uterus. Vasoconstriction works to cause labour pain during uterine contractions. When the uterus contracts, there is a reduction in blood flow to the uterus causing hypoxia (disruption in oxygen homeostasis). This decrease in blood volume causes pain because although the uterus is denervated, the surrounding blood vessels remain innervated, and the disruption of homeostasis causes an imbalance in the system, which results in sensations of pain. Furthermore, the stronger and longer a person's contractions, the longer blood flow is reduced to the uterus, and thus the pain sensations are exacerbated (Smiley & Herman, 2006). [ 5 ]


Prior to the 20th century, childbirth predominantly happened in the home, without access to any medical interventions for  pain management . [ 6 ]  Childbirth was a leading  cause of death  for women, and many were fearful of the process, creating a large desire for pain management. [ 7 ]  But despite the demands of female patients, little relief was offered before the mid-19th century. Chemical  anesthesia  during labor was first introduced in 1847, receiving support from women and reluctance from physicians. [ 7 ]  Some doctors and religious authorities argued that pain relief in childbirth went contrary to God's choice to make childbirth painful; however, others specifically disputed this interpretation. Most opposition to anesthesia, though, was framed in terms of concern about its health consequences and physical effects on labour. [ 8 ] [ 9 ]


Anesthesia's use was popularized in 1853 by  Queen Victoria 's decision to use  chloroform  for pain relief during the birth of her  eighth child . [ 7 ] [ 10 ]  The procedure became known to women as "chloroform  à la reine " (in the style of the queen). [ 8 ]


In the early 20th century, a drug-induced state known as " twilight sleep " was developed by Carl Gauss and Bernhardt Kronig, two doctors in  Freiburg, Germany . The procedure, especially when performed by untrained doctors, had a number of risks and side-effects. Its rise and fall coincided with both  first-wave feminism  and the  anti-German sentiment  that arose during  World War I .


In 1956,  Pope Pius XII  approved the use of painless childbirth. [ 10 ]  The 1960s saw the rise of  epidural analgesics  for pain management.


Preparation for childbirth can affect the amount of pain experienced during childbirth. It is possible to take a childbirth  class , consult with those managing the pregnancy, and write down questions that can assist in getting the information that a woman needs to help manage pain. Additionally, pregnant women can alleviate concerns by having positive discussions about pregnancy with their friends and family. Positive context and associations with childbirth can help women perceive labour as a rewarding experience, which may reduce the amount of pain felt.  [ 1 ]  On the other hand, interactions with friends and family can also create negative expectations for childbirth, which increases future labour pain. As a result, it is best to prepare by receiving positive and calming encouragement to induce positive expectations that will help modulate labour pain.


Many methods help women to relax and make pain more manageable.   A review of the effectiveness of non-medical approaches to pain relief found that water immersion, relaxation methods, and  acupuncture  relieved pain. [ 11 ]  These and other non-pharmacologic pain management options are further discussed below.


According to the American  Office of Women's Health , laboring in a tub of warm water, also called hydrotherapy, helps women feel physically supported, and keeps them warm and relaxed. It may also be easier for laboring women to move and find comfortable positions in the water. [ 1 ]


Immersion in specifically warm water during the first stage of labor may decrease the need for analgesia and possibly shorten the duration of labor; However, warm water is known to slow down contractions, so it is advised to avoid it too early in stage 1. There is little data to suggest that water immersion during the second and third stages of labor significantly reduces the use of pharmacologic interventions. [ 17 ] [ 18 ]


In waterbirthing, a woman remains in the water for delivery. The  American Academy of Pediatrics  has expressed concerns about delivering in water because of a lack of studies showing its safety and because of the rare but reported chance of complications. [ 1 ]


Physicians ,  nurse practitioners ,  physician assistants ,  nurses  and  midwives  will typically ask the woman in labor if there is a  need of pain relief.  Many pain relief options work well when given by a trained and experienced clinician. Clinicians also can use different methods for pain relief at different  stages of labor . Still, not all options are available at every hospital and  birthing center . Depending on the health history of the mother, the presence of allergies or other concerns, some choices will work better than others. [ 1 ]


There are many methods of pain relief during labor.  Opioids are a type of analgesia that is commonly used during childbirth to assist in pain relief. [ 19 ]   They can be injected directly into the muscle in the form of a shot or put into an IV. These medications may cause unwanted side effects like drowsiness, itching, nausea, or vomiting to the laboring mother. [ 19 ]  Although they are short acting in the laboring mother, it takes longer for an infant to clear these medications. All opioids can cross the placenta and may poorly affect the baby by causing problems with heart rate, breathing, or brain function.  For this reason, opioids are not given close to delivery. [ 19 ]  They can be beneficial in early labor, however, since they can help dull pain, but do not impair the mother's ability to move or push.  Their use also does not seem to be linked to a higher chance of cesarean sections. [ 19 ]  There are many things to consider when deciding to use opioids during a delivery and these options, as well as the risks and benefits, should be discussed early in the first stage of labor with a trained medical professional.  Asking questions about the procedures and medications which may affect the baby are valid questions. [ 20 ]


An epidural is a procedure that involves placing a tube ( catheter ) into the lower back, into a small space below the  spinal cord . Small doses of medicine can be given through the tube as needed throughout labor. With a spinal block, a small dose of medicine is given as a shot into the spinal fluid in the lower back. Spinal blocks usually are given only once during labor. Epidural and spinal blocks allow most women to be awake and alert with very little pain during labor and childbirth. With an epidural, pain relief starts 10 to 20 minutes after the medicine has been given. The degree of numbness felt can be adjusted. With spinal block, good pain relief starts right away, but it only lasts one to two hours. [ 1 ]


Although movement is possible, walking may not be if the medication affects motor function. An epidural can lower  blood pressure , which can  slow the baby's heartbeat . Fluids given through IV are given to lower this risk. Fluids can cause shivering. But women in labor often shiver with or without an epidural. If the covering of the spinal cord is punctured by the catheter, a bad headache may develop. Treatment can help the headache. An epidural can cause a backache that can occur for a few days after labor. An epidural can prolong the first and second stages of labor. If given late in labor or if too much medicine is used, there is the risk of labor dystocia, [ 21 ]  difficult or obstructed labor, where the cervix may not be thinned and dilated sufficiently, possibly entrapping the fetal shoulders. An epidural increases the risk of instrumental or  assisted vaginal delivery . [ 1 ]


In this procedure a doctor injects numbing medicine into the  vagina  and the nearby  pudendal nerve . This nerve carries sensation to the lower part of the vagina and  vulva . This method of pain control is only used late in labor, usually right before the baby's head comes out. With a pudendal block, there is some pain relief but the laboring woman remains awake, alert, and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages. [ 1 ] [ 22 ]


Another form of pharmacologic pain relief available for laboring mothers is inhaled  nitrous oxide .  This is typically a 50/50 mixture of nitrous oxide with air that is an inhaled analgesic and anesthetic.  Nitrous oxide has been used for pain management in childbirth since the late 1800s. The use of inhaled analgesia is commonly used in the UK, Finland, Australia, Singapore and New Zealand, and is gaining in popularity in the United States. [ 23 ]


Although this method of pain control does not provide as much pain relief as an epidural, there are many benefits to this type of analgesia.  Nitrous oxide is inexpensive and can be used safely at any stage of labor.  It is useful for women wanting mild pain relief while maintaining mobility and have less monitoring than would be required with an epidural. [ 23 ]   It is also useful in early labor to assist with pain relief and used in conjunction with other non-pharmacologic pain methods such as birthing balls, position changes, and even possibly water birth.  The gas is self-administered so the laboring mom has full control of how much gas she wishes to inhale at any given time. [ 23 ]


Nitrous oxide has the added benefit of limited side effects.  Some mothers may experience some dizziness, nausea, vomiting, or drowsiness, however, since dosing is determined by the patient, once these symptoms begin she can limit her use.  The gas takes effect quickly, but also lasts a short period of time so she must hold the mask to her face in order to benefit from the effects of analgesia. [ 23 ]  There is very little effect to the baby since it is quickly eliminated by the baby as soon as it begins breathing. [ 23 ]  Evidence does not suggest any clinically significant risk factors in the use of nitrous oxide gas as opposed to other methods of pain management both non-pharmacologic and pharmacologic in terms of Apgar or cord blood gas.  There is also limited evidence to determine whether there are any increased occupational risks to the healthcare provider associated with the use of nitrous oxide. [ 23 ]


Perineal pain after childbirth has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant. [ 24 ]  The pain from injection sites and possible  episiotomy  is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. [ 25 ]  Routine episiotomies have not been found to reduce the level of pain after the birth. [ 26 ]


The postpartum physiological changes  are those expected changes that occur in the woman's body after  childbirth , in the  postpartum period . These changes mark the beginning of the return of pre-pregnancy physiology and of  breastfeeding . Most of the time these postnatal changes are normal and can be managed with medication and comfort measures, but in a few situations complications may develop. [ 1 ]  Postpartum physiological changes may be different for women delivering by  cesarean section . [ 2 ]  Other postpartum changes, may indicate developing complications such as,  postpartum bleeding , engorged breasts,  postpartum infections .


The breasts change during pregnancy to prepare for lactation, and more changes occur immediately after the birth.  Progesterone  is the hormone that influences the growth of breast tissue before the birth. Afterwards, the  endocrine system  shifts from producing hormones that prevent lactation to ones that trigger milk production. [ 3 ]  The first secretions are known as  colostrum  and are rich in substances that help the newborn adjust to life outside the womb. About two to five days  after the birth the breasts begin to produce milk. This sometimes is described as "the milk coming in". [ 4 ]


Information can be provided to the mother before the birth to enhance the understanding of breastfeeding and the support that will be available to make it successful. [ 5 ]  The mother is encouraged to breastfeed and spend time bonding with her infant immediately after the birth.


Sucking causes the  pituitary gland  to release  oxytocin , which contracts the uterus and prevents bleeding. [ 1 ] [ 6 ]  This can be felt by the mother in the breasts. The crying of the infant can also induce the release of oxytocin.  Cracked nipples  can develop at this time, which can be managed with pharmacological and nonpharmacological treatment. [ 4 ]


The most drastic change in the uterus is the contraction from an organ weighing one kilogram and a volume of about 10 litres down to a 60 gram organ that only contains 5 ml of fluid. [ 7 ]  Immediately after delivery, the fundus of the uterus begins to contract. This is to deliver the  placenta  which can take up to 30 minutes and may involve a feeling of  chills . [ 8 ]  In a normal and healthy response it should feel firm and not boggy. It begins to  involute  with contractions of the smooth muscle of the uterus. It will contract midline with the umbilicus. It begins its contractions and by twelve hours after the birth it can be felt to be at the level of the umbilicus. [ 9 ]  The uterus changes in size from one kilogram to 60-80 grams in the space of six weeks. After birth, the fundus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and return into the pelvis. [ 9 ]  The sensation and strength of postpartum uterine contractions can be stronger in women who have previously delivered a child or children. [ 10 ]


The cervix remains soft after birth. The vagina contracts and begins to return to the size before pregnancy. For four to six weeks of the postpartum period the vagina will discharge  lochia , a discharge containing blood, mucus, and uterine tissue. [ 11 ]


During pregnancy the normal inflammatory  immune response  is shut down in order to allow the acceptance of the embryo to the body. In the postpartum period this needs to be quickly reversed back to normal. This immune reconstitution can result in the symptomatic expression of infections that were present but previously not responded to, especially infections with an autoimmune basis. [ 12 ]


Education and discussion before the birth can alleviate some of the fear of the unknown and the anxiety when treatments are experienced for the first time. Providing continuous updates on the status of the infant is beneficial.


Perineal pain after childbirth has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant. [ 13 ]  The pain from injection sites and possible  episiotomy  is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. [ 14 ]  Routine episiotomies have not been found to reduce the level of pain after the birth. [ 15 ]  Comfort is enhanced with changing linens, urination, the cleaning of the perineum and ice packs. Privacy also in implemented to promote comfort. [ 16 ]


Hemorrhoid pain can be managed with a variety of methods. Some recommendations for reducing the pain of hemorrhoids include: cleansing with warm water, hemorrhoid creams, increasing fluids, lying on the site and sitz baths. [ 17 ]


Medications controlling pain will begin to wear off. This is also true when an epidural or spinal block is given. [ 5 ]  Uterine contractions are sometimes painful and comfort can be provided by suggesting different positions. Walking around, with assistance, can decrease pain. Since uterine cramping may become more painful during breastfeeding, medications can be given half an hour before nursing. Pain control and comfort can be managed by anticipating the return of sensation and bodily reactions to bruises, tears, incisions and punctured sites.