The  World Health Organization  (WHO) describes the postpartum period as the most critical and yet the most neglected phase in the lives of mothers and babies; most  maternal  and  newborn deaths  occur during the postpartum period. [ 5 ]


Diastasis recti  is a gap between the two sides of the  rectus abdominis muscle  that can occur in the antenatal and postnatal periods. [ 6 ]   This condition has no associated morbidity or mortality. [ 7 ]  Treatment is physiotherapy.


Primary postpartum haemorrhage is blood loss following childbirth of more than 500ml (minor) or 1000ml (major). [ 8 ]  Secondary postpartum haemorrhage is abnormal or excessive bleeding after 24 hours and before 12 weeks postnatally. [ 8 ]


Urinary incontinence  and  fecal incontinence  have been linked to all methods of childbirth, with the incidence of urinary incontinence at six months postpartum being 3–7% and fecal incontinence 1–3%. [ 4 ]


Postpartum infections , also known as childbed fever and puerperal fever, are any bacterial  infections  of the  female 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 . It usually occurs after the first 24 hours and within the first ten days following delivery.


Puerperal mastitis  is inflammation of the breast usually associated with  breastfeeding . Symptoms typically include local pain and redness. [ 9 ]  There is often an associated fever and general soreness. [ 9 ]  Onset is typically fairly rapid and usually occurs within the first few months of delivery. [ 9 ]  Complications can include  abscess  formation. [ 10 ]


Obstetric fistula  is a medical condition in which a  hole  develops in the  birth canal  as a result of childbirth, typically after a prolonged  obstructed labour [ 11 ] [ 12 ]  and is preventable with timely access to  Cesarean section . The fistula can occur between the  vagina  and  rectum ,  ureter , or  bladder . [ 12 ] [ 13 ]  It can result in incontinence of urine or feces. [ 12 ]


Perineal tearing  is the spontaneous (unintended) tearing of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tearing occurs in 85% of vaginal deliveries. [ 14 ]  At six months postpartum, 21% of women still report perineal pain [ 4 ]  and 11–49% report sexual problems or painful intercourse. [ 4 ]


Peripartum cardiomyopathy  is decrease in heart function which occurs in the last month of pregnancy, or up to six months post-pregnancy. It increases the risk of  congestive heart failure , heart  arrhythmias ,  thromboembolism , and  cardiac arrest . [ 15 ]


Postpartum thyroiditis  is a phenomenon observed following pregnancy [ 16 ]  and may involve  hyperthyroidism ,  hypothyroidism  or the two sequentially.  It affects about 5% of all women within a year after giving birth.


Pelvic organ prolapse  occurs when the uterus, bladder or rectum drop lower in the pelvis creating a bulge in the vagina. Approximately half of all women who have given birth experience some degree of pelvic organ prolapse, most frequently as they age and go through  menopause . [ 17 ]


Postpartum depression  is a moderate to severe depressive episode starting anytime during pregnancy or within the four weeks following delivery. It occurs in 4–20% of pregnancies, depending on its definition. [ 4 ]   Without treatment, postpartum depression can last for months or years. In addition to affecting the mother’s health, it can interfere with her ability to connect with and care for her baby and may cause the baby to have problems with sleeping, eating, and behavior as he or she grows. [ 18 ]  In 38% of the cases of postpartum depression, women are still depressed three years postpartum. [ 19 ]  In 0.2% of pregnancies, postpartum depression leads to psychosis. [ 20 ]


Postpartum psychosis  is one of the many conditions that may occur following pregnancy or within the six week postpartum period. It is listed under  mental and behavioral disorders associated with pregnancy, childbirth or the puerperium with psychotic symptoms , and involves significant mental and behavioural features, including  psychotic symptoms  such as  delusions  and  hallucinations . Mood symptoms associated with  depression or mania  are also typically present. [ 21 ]


Research shows that symptoms of  Posttraumatic stress disorder  are common following childbirth, with prevalence of 24–30.1% [ 22 ]  at six weeks, dropping to 13.6% at six months. [ 23 ]  PTSD is rarer; a review found that following normal childbirth (excluding stillbirth and some other complications) rates of PTSD ranged from 2.8–5.6% after six weeks, dropping to 1.5% at six months. [ 22 ]


Pre-labor  consists of the early signs before  labor  starts. It is the body's preparation for real labor.


Prodromal labor has been misnamed as “false labor."  Prodromal labor begins much as traditional labor but does not progress to the  birth  of the  baby .  Not everyone feels this stage of labor, though it does always occur. However, this does not mean that every woman will experience every symptom. The term is used to describe a cluster of physical changes that may take place in a pregnant woman before she goes into "real" labor, such as an increase in blood volume (sometimes resulting in  edema ),  Braxton Hicks contractions , the presence of  colostrum  in the breasts, and the dislodging of the  mucus plug  that has sealed the  cervix  during the pregnancy.


The term "false labor" is sometimes used to describe a cluster of Braxton Hicks contractions that are mistaken for real labor.


The term "false labor" and "false pains" are sometimes considered equivalent. [ 1 ]


Precipitate delivery  (also called rapid labor) refers to  childbirth  after an unusually rapid labor.  It is typically defined expulsion of the infant within 3 hours of regular  contractions  starting, although some providers consider anything less than 5 hours to be precipitous.  In contrast, typical labor lasts between 6 and 18 hours on average. It is uncommon, and an understudied topic.  In the United States it occurs in 1%-3% of all births.  [ 1 ] [ 2 ]


There is no way to predict rapid delivery, and sometimes no predisposing factors are present.  However, there are factors which make it more likely, including: [ 3 ]   [ 4 ]


Some associations commonly found include:  [ 3 ]


Lacerations of the  cervix ,  vagina , and/or  perineum  (25x greater odds than in typical labor). Rapid descent and delivery of an infant does not always allow maternal tissues adequate time to stretch and accommodate the passage of the infant.  There may be  hemorrhaging  (35x greater odds than in typical labor) originating from lacerations and/or  hematomas  of the cervix, vagina, perineum, or uterus. There may be infection as a result of unsterile delivery due to inability to reach a sterile environment in time.  Intense pain is more likely than in normal labor, where each contraction gradually opens the cervix and prods the baby out. In precipitous labor, the cervix still has to open just as wide, and the baby still has to move just as far—but in much less time.  [ 5 ]  This can also result in emotional effects, such as feeling disconnected and out of control of one's body.  Psychological trauma afterwards is common.  [ 6 ]


The risk of preterm delivery in future pregnancies is about 7.3% after a precipitate delivery, compared to 2.6% after a normal labor. [ 7 ]


Precipitate delivery may cause  aspiration  of  amniotic fluid , especially if the birth is unattended.  As with the mother, there may be infection in the newborn as a result of unsterile delivery.  [ 8 ]


Prenatal care , also known as  antenatal care , is a type of  preventive healthcare . It is provided in the form of medical checkups, consisting of recommendations on managing a healthy lifestyle and the provision of medical information such as maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins, which prevents potential health problems throughout the course of the pregnancy and promotes the mother and child's health alike. [ 1 ] [ 2 ]  The availability of routine prenatal care, including  prenatal screening and diagnosis , has played a part in reducing the frequency of  maternal death ,  miscarriages ,  birth defects ,  low birth weight ,  neonatal infections  and other preventable health problems.


Traditional prenatal care in high-income countries generally consists of:


The traditional form of antenatal care has developed from the early 1900s and there is very little research to suggest that it is the best way of giving antenatal care. [ 3 ]  Antenatal care can be costly and uses many staff. The following paragraphs describe research on other forms of antenatal care, which may reduce the burden on maternity services in all countries.


The  WHO  recommends that pregnant women should all receive at least eight antenatal visits to spot and treat problems and give immunizations. Although antenatal care is important to improve the health of both mother and baby, many women do not receive eight visits. [ 4 ]
There is little evidence behind the number of antenatal visits, pregnant women receive and what care and information is given at each visit. [ 3 ]  It has been suggested that women who have low-risk pregnancies should have fewer antenatal visits. [ 3 ]  However, when this was tested, women with fewer visits had babies who were much more likely to be admitted to neonatal intensive care and stay there for longer (though this could down to chance results). [ 3 ]  A 2015 Cochrane Review findings buttresses this notion, with evidence that in settings with limited resources, where the number of visits is already low, programmes of ANC with reduced visits are associated with an increase in perinatal mortality. [ 3 ]  Therefore, it is doubtful that the reduced visits model is ideal, even in low income countries (LICs), where pregnant women are already attending fewer appointments. [ 2 ]  Not only is visiting prenatal care early is highly recommended, but also a more flexible pathway allowing more visits, from the time a pregnant woman books for prenatal care, as it potentially enables more attention to those women who come late. [ 2 ]  Also, women who had fewer antenatal visits were not as satisfied with the care they received compared with women who had the standard number of visits. [ 3 ]  A new alternative for some of the routine prenatal care visits is  Telemedicine . [ 5 ]


There are many ways of changing health systems to help women access antenatal care, such as new health policies, educating health workers and health service re-organisation. Community interventions to help people change their behavior can also play a part. Examples of interventions are media campaigns reaching many people, enabling communities to take control of their own health, informative-education-communication interventions and financial incentives. [ 6 ]  A review looking at these interventions found that one intervention helps improve the number of women receiving antenatal care. [ 6 ]  However interventions used together may reduce baby deaths in pregnancy and early life, lower numbers of low birth weight babies born and improve numbers of women receiving antenatal care. [ 6 ]


The World Health Organization (WHO) reported that in 2015 around 830 women died every day from problems in  pregnancy  and  childbirth . [ 7 ]  Only 5 lived in high-income countries. The rest lived in low-income countries. [ 7 ]


A study examined the differences in early and low-weight birth deliveries between local and immigrant women and saw the difference caused by prenatal care received. The study, between 1997 and 2008, looked at 21,708 women giving birth in a region of Spain. The results indicated that very preterm birth (VPTB) and very low birth weight (VLBW) were much more common for immigrants than locals (Castelló et al., 2012). The study showed the importance of prenatal care and how universal prenatal care would help people of all origins get proper care before pregnancy/birth (Castelló et al., 2012).


Group antenatal care has a couple of obvious benefits: it costs less than one-to-one visits and the women have more hours of care as a group than on their own. [ 8 ]  Only small studies have been conducted looking at group care but they have found that mothers knew more about pregnancy, birth and parenting in the group setting. [ 8 ]  The mothers reported liking the group care and the review found no difference between how the pregnancies developed between the group and individual settings. [ 8 ]


Midwife-led care for low-risk women is where a midwife team (and GP if needed) leads the care a woman receives and she does not usually see a specialist doctor in her pregnancy. [ 9 ]  Women with midwife-led pregnancies are more likely to give birth without being induced but have natural labours. However they are less likely to have their waters broken, an instrumental delivery,  episiotomy  or preterm birth. [ 10 ]  Around the same number of women in each group had a caesarean section. [ 10 ]


At the initial antenatal care visit and with the aid of a special booking checklist the pregnant women become classified into either normal risk or high risk.


In many countries, women are given a summary of their case notes including important background information about their pregnancy, such as their medical history, growth charts and any scan reports. [ 11 ]  If the mother goes to a different hospital for care or to give birth the summary of her case notes can be used by the midwives and doctors until her hospital notes arrive. [ 11 ]


A review looking into women keeping their own case notes shows they have more risk of having a caesarean section. [ 11 ]  However the women reported feeling more in control having their notes and would like to have them again in future pregnancies. [ 11 ]  25% of women reported their hospital notes were lost in hospital though none of the women forgot to take their own notes to any appointments. [ 11 ]


Prenatal diagnosis or prenatal screening (note that "Prenatal Diagnosis" and "Prenatal Screening" refer to two different types of tests) is  testing  for diseases or conditions in a  fetus  or  embryo  before it is born.  Obstetricians  and  midwives  have the ability to monitor mother's health and  prenatal development  during pregnancy through series of regular check-ups.


Physical examinations generally consist of:


In some countries, such as the UK, the symphysial fundal height (SFH) is measured as part of antenatal appointments from 25 weeks gestation. [ 12 ]   (The SFH is measured from the woman's pubic bone to the top of the uterus. [ 13 ] ) A review into this practice found only one piece of research so there is not enough evidence to say whether measuring the SFH helps to detect small or large babies. [ 14 ]  As measuring the SFH is not costly and is used in many places, the review recommends carrying on this practice. [ 14 ]


Growth charts are a way of detecting small babies by the measuring the SFH. [ 15 ]  There are two types of growth chart:


A review looking into which of these charts detected small babies found that there is no good quality research to show which is best. [ 15 ]  More research is needed before the customized growth charts are recommended because they cost more money and take more time for the health care workers to make. [ 15 ]


Obstetric ultrasounds  are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy.
Among other things, ultrasounds are used to:


Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:


A review looking at routine ultrasounds past 24 weeks found that there is no evidence to show any benefits to the mother or the baby. [ 16 ]


Early scans mean that multiple pregnancies can be detected at an early stage of pregnancy [ 17 ]  and also gives more accurate due dates so that less women are induced who do not need to be. [ 17 ]


Levels of feedback from the ultrasound can differ. High feedback is when the parents can see the screen and are given a detailed description of what they can see. [ 18 ]  Low feedback is when the findings are discussed at the end and the parents are given a picture of the ultrasound. [ 18 ]  The different ways of giving feedback affect how much the parents worry and the mother's health behaviour although there is not enough evidence to make clear conclusions. [ 18 ]  In a small study, mothers receiving high feedback were more likely to stop smoking and drinking alcohol however the quality of the study is low and more research is needed to say for certain which type of feedback is better. [ 18 ]


Women experiencing a complicated pregnancy may have a test called a Doppler ultrasound to look at the blood flow to their unborn baby. [ 19 ]  This is performed to detect signs that the baby is not getting a normal blood flow and therefore is 'at risk'. A review looked at performing Doppler ultrasounds on all women even if they were at 'low risk' of having complications. [ 19 ]  The review found that routine Doppler ultrasounds may have reduced the number of preventable baby deaths but the evidence was not strong enough to recommend that they should be made routine for all pregnant women. [ 19 ]


Research suggests that physical activity levels during pregnancy can impact delivery outcomes. [ 20 ]  A study examining the effects of exercise intensity on delivery type and risk of preterm birth found that varying levels of physical activity were linked to different pregnancy outcomes and associated risks.


Very low levels of physical activity are associated with an increased risk of both preterm and instrumental deliveries. [ 21 ]  Pregnant individuals with minimal activity may experience lower overall fitness and muscle tone, which can impact the body’s ability to manage the physical demands of labor. Another study showed that individuals with higher handgrip strength are more likely to have a vaginal delivery, as greater muscle strength and endurance can support the labor process. In contrast, those who gained more weight during pregnancy or had larger arm and calf circumferences were more likely to undergo cesarean delivery, particularly in cases of nonprogressive labor. [ 22 ]


Low levels of physical activity during pregnancy have been linked to a slightly elevated risk of cesarean delivery. [ 21 ]  Regular moderate exercise may help enhance pelvic muscle tone and cardiovascular fitness, potentially reducing the likelihood of cesarean intervention by supporting the body’s endurance during labor.


For individuals seeking to engage in levels of vigorous or high intensity physical activity, one study did observe a slight increase in instrumental delivery, which involves the use of medical tools like forceps or vacuum devices. [ 21 ]  More intense physical activity may add extra demands on the body, potentially affecting labor progression and increasing the need for instrumental assistance.


It is important for pregnant individuals to consult with their healthcare provider before beginning or adjusting exercise routines, particularly if they are new to regular physical activity or have any health conditions that may affect pregnancy.


Proper prenatal care affects all women of various social backgrounds. While availability of such services have considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in both developing and developed nations, such as the US. Although women can benefit by utilizing prenatal care services, there exists various levels of health care accessibility between different demographics throughout the United States.


Prolonged labor  is the inability of a woman to proceed with  childbirth  upon going into labor. [ 1 ]  Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. [ 1 ]  Failure to progress can take place during two different phases; the latent phase and active phase of labor. [ 1 ]  The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. [ 1 ]  The active phase of labor, on the other hand, if prolonged, can result in long term complications. [ 1 ]


It is important that the vital signs of the woman and fetus are being monitored so preventive measures can be taken if prolonged labor begins. Women experiencing prolonged labor should be under supervision of a surgically equipped doctor. Prolonged labor is determined based on the information that is being collected regarding the strength and time between contractions. Medical teams track this data using intrauterine pressure catheter placement (IUPC) and continuous  electronic fetal monitoring  (EFM). [ 2 ]  IUPC is a straw that is inserted into the womb with a monitor that reads when contractions are coming and how strong they are. [ 2 ]  EFMs are used to track the fetal heart rate. [ 2 ]  If either devices indicate that vital signs are off and prolonged labor is beginning, it is important that the medical team begin discussing treatment and alternative options for delivery.


Prolonged labor can result from a variety of different issues, such as fetal malpresentation, issues with uterine contractions, cervical dystocia  or stenosis, and cephalopelvic disproportion. Both fetal malpresentation and cervical dystocia may result in  obstructed labor . [ 3 ]  The cause of prolonged labor will determine the medical intervention that needs to take place. Medical professionals can either engage in preventive measures or turn to surgical methods of removing the fetus. If not handled properly or immediately treated, both the woman and the fetus can suffer a variety of long term complications, the most serious of which is death. [ 4 ]  There is no "quick fix" to prolonged labor, but there are preventive measures that can be taken, such as  oxytocin  infusions. [ 4 ]  In order to properly and safely deliver the baby, doctors will often intervene in child birth and conduct assisted vaginal delivery through the use of forceps or a vacuum extractor, or perform a  Caesarean section . [ 5 ]


Symptoms include: [ 6 ]


The term describes labor that occurs very slowly. [ 2 ]  This does not necessarily mean that the woman or fetus's health is being compromised, but it is painful and is an important indication for doctors to pay attention to warning signs of prolonged labor. [ 2 ]


The phase of labor that extends into multiple hours (at least 14). The cervix usually dilates to over 4 cm before active labor occurs. [ 7 ]  When it first begins, it is encouraged that women stand up, walk around, and eat or drink. [ 8 ]  If failure to progress extends beyond this point, preventive measures need to be taken.


Fetal malpresentations are irregular positions of the crown of the fetal head in relation to the mother's pelvis (the fetus is in an abnormal position). [ 9 ]  Some important ways to manage fetal malpresentation are making rapid evaluations of the condition of the women pertaining to vital signs as well as the heart rate of the fetus. [ 9 ]  If fetal heart rate is abnormal, and if membranes have ruptured and amniotic fluid is atypical, it is important for medical professionals to determine the presenting part of the fetus and the position of the fetal head. [ 9 ]  Possible delivery methods, if this is the case, are compound presentation, vaginal breech delivery, or caesarean section for breech presentation depending upon the severity of the malposition. [ 9 ]


This refers to uterine conditions that result in the uterus not having enough coordination or strength to dilate the cervix and push the baby through the birth canal. Issues with uterine contractions are the main cause of prolonged labor during the latent phase. Contractions may not occur as of a result of uterine tumors. In addition, if the uterus is stretched, usually due to previous pregnancies or multiple gestation, contractions may be difficult. Irregular or weak contractions can be fixed through stimulation of the uterus or oxytocin infusions. Lack of contractions may be caused by an overwhelming amount of painkillers or anesthesia, by which the medications should be discontinued. In this case, it is appropriate for assisted vaginal delivery to be conducted.


Cervical dystocia, or stenosis, occurs when the cervix fails to dilate after a practical amount of time during positive uterine pains. The main problems in cervical dystocia is the lack of uterine inertia and cervical abnormalities, which prevent the cervix from fully dilating. [ 10 ]  It is very typical of patients that have  hypopituitarism . [ 11 ]  There are many preexisting complications that may result in stenosis. Common conditions that lead to stenosis are tumors, a full bladder, large size of the infant, multiple pregnancies, delay in rupture of membranes, or problems with the cervix. [ 11 ]  High stress may interfere with the progression of pregnancy in cases such as these, leading to prolonged labor. [ 11 ]


Cephalopelvic disproportion is the issue that arises when the fetus' body or head is too large to pass through the woman’s pelvis. [ 12 ]  Common conditions that lead to CPD are  diabetes , multiple pregnancies, small or abnormally shaped pelvis, atypical fetal positions, hereditary factors, and first time pregnancies. [ 12 ]  Medical professionals can usually estimate if fetal size is too large based on  ultrasounds , but they are not always entirely accurate. [ 12 ]  Doctors typically determine CPD when labor begins and the use of oxytocin is not effective. The safest way for delivery to take place when CPD is a factor is through Caesarean sections. [ 12 ]


If the woman is being closely monitored and begins to show signs of prolonged labor, medical professionals can take preventive measures to better the chances of delivery within 24 hours. [ 4 ]  A precise initial diagnosis of prolonged labor based on signs and symptoms is extremely important in applying proper precautionary treatment. [ 4 ]  Oxytocin infusions upon an initial amniotomy is typically used to move normal labor back on track. [ 4 ]  The application of oxytocin is only effective if administered on the basis of fetal distress. [ 4 ]  This treatment method only pertains to specific states of the fetus. If the baby is experiencing malpresentation, for example, the only safe and reliable method to proceed with childbirth is medical interference. [ 4 ]


In terms of medical care, preventive treatment or assisted delivery are typically the first options doctors consider. There is usually no quick fix to prolonged labor, especially if preventive measures do not revert the mother back to normal labor. Often, medical professionals resort to intervention methods. If the state of the fetus and mother are not especially serious or threatening to their health, doctors will perform assisted vaginal deliveries.


There are two different methods of assisted vaginal delivery that medical professionals typically utilize to aid in delivery in order to avoid surgical methods of fetal extraction. These procedures are only applied if a vaginal delivery has proven to still be safe to the woman and the baby, based on their vital signs. Assisted vaginal delivery is usually only used in the latent phase. [ 5 ]  Delivery during the active phase is usually associated with more complications for the woman. [ 5 ]  One approach to assisted vaginal delivery is the use of forceps. [ 5 ]  The forceps doctors use resemble two large salad spoons and are inserted into the cervix, around the baby's head and help to guide it out of the birth canal. [ 5 ]  The other option is the use of  vacuum extraction . Vacuums used have a cup on the end and are inserted into the cervix. [ 5 ]  The cup attaches to the fetus's head by suction and aids in guiding delivery. The choice between forceps and vacuum extraction is usually made by the doctor based on preference. It is important that these methods are used properly, or else they can cause severe birth injuries to the baby that may be permanent. [ 5 ]


Caesarean sections, also referred to as C-sections, are usually quick solutions to the issue of failure to progress. Often,  C-sections  are the best options to avoid harming the fetus or the woman, especially if labor proves to be life-threatening. One third of C-sections occur as a result of prolonged labor. [ 1 ]  C-sections are usually a necessary measure in prolonged labor to avoid serious birth complications. If the mother reaches the active phase of prolonged labor, a C-section is the safest solution. Caesarean sections need to be performed immediately if there are signs of fetal distress,  uterine rupture , or cord prolapse. It is important that medical professionals are equipped and prepared in the case of an imperative C-section. There is a window of time by which Caesarean sections need to be executed if any warning signs present themselves. If there is a delay in the C-section, permanent damage can result to the baby, such as cerebral palsy or hypoxic-ischemic encephalopathy (HIE). Due to all the risk factors that are present in the event of prolonged labor, it is extremely important that medical teams are well-suited and prepared to conduct a C-section if needed.


Pubiotomy  was a medical procedure where the pelvic bone was cut in two places, on either side of the  pubic symphysis  joint, [ 1 ]  in order to widen the pelvis during  obstructed labour . By 1922, it was considered outdated and  C-section  preferable. [ 2 ]


Gigli saw  was invented to perform this procedure.


Pudendal anesthesia  ( pudendal  nerve block ,  pudendal block  or  saddle block ) is a form of  local anesthesia . Pudendal anesthesia can be used to diagnose as well as treat illnesses. [ 1 ]  A  nerve  block is the use of  local anesthetic  (e.g  lidocaine ) to inhibit the sensation of pain caused by one or multiple nerves. [ 2 ]  A nerve block can help doctors confirm what nerve is causing the pain to support a diagnosis. A nerve block can also be used to prevent pain before a procedure, or relieve chronic pain. [ 2 ]  The pudendal block gets its name because a local anesthetic, such as  lidocaine  or  chloroprocaine , is injected into the pudendal canal where the pudendal nerve is located. The pudendal nerve branches off of the  sacral plexus  and is both a sensory and motor nerve. [ 2 ]  The pudendal nerve provides sensation information (i.e. innervates) for the  anal canal ,  external anal sphincter , and the  perineum . [ 3 ]  Pudendal nerve blocks can be used to provide pain relief to this region for about 30 days, but has been reported to last months in some patients. [ 2 ]  It is primarily used to provide analgesia during  obstetrics  procedures such as  forceps delivery . [ 4 ]  It can also be used during anorectal surgery,  urologic  surgery, diagnosing or treating chronic perineal pain (i.e.  pudendal neuralgia ), and other  gynecologic  procedures [ 2 ] [ 4 ]


Overall, the procedure involves injecting a local anesthetic drug (e.g. lidocaine or  bupivicaine ) with a 20 gauge spinal needle near the pudendal nerve in order to provide pain relief. [ 1 ] [ 2 ]  Lidocaine is usually preferred for a pudendal block because it has a longer duration than chloroprocaine which usually lasts less than one hour. [ 5 ]  The procedure can be done without imaging guidance, but  fluoroscopy  or  ultrasound  can be used. [ 2 ] [ 4 ]  Ultrasound is preferred because there is no exposure to  radiation , it is readily available, and it offers real-time guidance for needle insertion. [ 4 ]  There are different anatomical approaches for which the procedure can be performed such as; transvaginal, transperineal, or perirectal. [ 1 ]  The aim is to block the nerve as it enters the  lesser sciatic foramen , which anatomically is just below the and inwards from the attachment of the  sacrospinous ligament  to the  ischial spine  of the  pelvic bone . [ 2 ]  The transvaginal approach is used for obstetric and gynecological procedures. The ischial spines are identified by palpation of the vaginal walls and the needle is advanced through the vaginal wall. [ 2 ]  The transperineal approach more commonly requires image guidance and is used for anorectal and urologic procedures, and treatment of pudendal neuralgia. For both the transperineal and the perirectal approach the ischial spines are identified through palpation of the rectal walls. [ 2 ]  The perirectal approach requires the use of a nerve simulator that if placed in the correct position will cause the external anal sphincter to contract. This helps confirm the correct positioning of the needle as it is advanced laterally to the rectum. [ 2 ]


A pudendal nerve block has been historically used to provide pain relief during child birth. It is generally used as a second line option, when neuraxial (i.e. epidural) anesthesia is not available or contraindicated. [ 6 ]  It is normally used during the second stage of labor because it does not relieve the pain from contractions that occur during the first stage. [ 6 ] [ 7 ]  It may also prevent the bearing down reflex during a contraction, therefore it should not be used too early in labor. [ 8 ]  It can also be used for pain relief from episiotomy or perineal lacerations [ 6 ] [ 8 ]  Pudendal anesthesia is used during operative vaginal delivery which includes the use of forceps. [ 7 ]  It is best used in addition to  epidural anesthesia  because the pudendal nerve block alone is not usually sufficient to treat the pain. [ 7 ]  Pudendal anesthesia is not effective for other forms of vaginal delivery such as rotational deliveries. [ 7 ]  In regards to safety of the  neonate  during and after this procedure, there has not been enough investigation. [ 7 ]  Pudendal nerve blocks are also being studied for their use in minimally invasive  gynecological surgery  (MIGS). The use of this regional anesthesia may decrease postoperative pain and the need for  opioids . [ 9 ]


Chronic pain that arises in the  rectum ,  anus ,  urethra  or genitalia is considered chronic perineal pain or  pudendal neuralgia . Patients that suffer from chronic perineal pain are most commonly female, affecting 1 in 7 women. [ 1 ]  The pain may be described as a burning, tingling, stabbing, or electric-shock like sensation and it is usually only affects one side of the body. [ 2 ]  Pudendal neuralgia can arise from trauma, overuse, sports, surgery,  radiation therapy , tumors, viruses (e.g.  Herpes Zoster ,  HIV ),  endometriosis ,  multiple sclerosis ,  pudendal nerve entrapment, or other medical conditions. [ 1 ] [ 2 ]  The most common of these causes in repetitive and overuse injury. [ 2 ]  Generally, the sensory function of the pudendal nerve is affected more than the motor function. [ 2 ]  Pudendal nerve blocks can be used in diagnosis as well as treatment of pudendal neuralgia. [ 1 ]


The use of the pudendal nerve block is being explored in pediatric urologic procedures such as  circumcision . It allows pain relief from the perineum to the end of the penis. [ 10 ]  It lowers post operative pain and the need for opioids just as it does for MIGS. [ 9 ] [ 10 ]


A common anorectal surgery that utilizes pudendal anesthesia is a  hemorrhoidectomy . A pudendal nerve block provides a longer duration of pain relief versus the use of superficial local anesthetic or even  spinal anesthesia . It also may reduce opioid consumption, shorten hospital stay, and have fewer adverse effects like nausea and vomiting. [ 11 ]


Common


Uncommon


A  push present  (also called a push gift or a baby bauble [ 1 ] ) is a  present  a partner or family gives to the mother to mark the occasion of her  giving birth  to their child. In practice the present may be given before or after the birth, or even in the delivery room. The giving of push presents has supposedly [ neutrality  is  disputed ]  grown in the  United States  in recent years. However, it is at the discretion of the partner or father. [ 2 ]


"The exact origin of push presents or baby baubles is hard to pinpoint. Some believe this tradition hails back to several hundred years ago, stemming from places such as the UK, India, and Egypt, symbolizing fertility, strength, and the preciousness of new life. Jewelry is thought to have been the most customary gift. These lovely gestures of appreciation were given to the mother to acknowledge and commemorate the effort that went into such a momentous occasion." [1]


"Whether old or new, the practice seems to have gained a renewed popularity in the United States over the last few decades and has evolved beyond just jewelry. These gifts have become a cherished way for partners, family members, and friends to express their love and gratitude to the expectant parent for their incredible journey and sacrifices". [ 3 ]


Until recently it was passed on largely by word of mouth or peer pressure among both mothers and fathers. [ 4 ]  Though “push present” is a recent term, a gift of jewelry to a new mother has been practiced throughout different cultures and time periods. For example,  Napoleon  gave the  Napoleon Diamond Necklace  to his wife  Marie Louise  upon the birth of their son in 1811. [ 5 ]


According to Linda Murray, the executive editor of  BabyCenter , "It's an expectation of moms these days that they deserve something for bearing the burden for nine months, getting sick, ruining their body." [ 2 ]  Other sources trace the development of the present to the increased assertiveness of women, allowing them to ask for a present more directly, or the increased involvement of the men in pregnancy, making them more informed of the pain and difficulty of  pregnancy  and labor. [ 2 ]


A 2004 survey of over 30,000 respondents by BabyCenter found that 38% of new mothers received a push present, and 55% of pregnant mothers wanted one, though fewer thought it was actually expected. About 40% of both groups said the baby itself was already a present and did not wish an additional reward. [ 2 ]  A survey of  Today  viewers in 2015 found that 45% were opposed to the custom, 28% in support, and 26% did not know what “push present” referred to. [ 6 ]


The popularity of push presents has been attributed in part to media coverage of  celebrities  receiving them. [ 7 ]  Examples include a 10 carat diamond ring given to celebrity stylist  Rachel Zoe  by her husband Rodger after the 2011 birth of their son, a  Bentley  given to  reality TV  star  Peggy Tanous  of  The Real Housewives of Orange County  by her husband Micah after the 2007 birth of their daughter, and a  diamond  and  sapphire  necklace given to singer  Mariah Carey  by her husband  Nick Cannon  after the 2011 birth of their twins. [ 8 ] [ 9 ] [ 10 ]


Some couples would prefer increased help in chores or baby care, or save the money for the child's education. [ 2 ] [ 7 ]


According to  etiquette  expert Pamela Holland, there are no set guidelines for push presents. "The standard is that there is no standard," she said. "It does make sense to have etiquette around wedding or baby shower gifts because you're inviting other people into it. But this is far too intimate to have a rule." [ 4 ]  In general it is the woman who lets her man know about push presents, not the other way around, [ 2 ]  although there can be peer pressure from friends to buy one on either the man or the woman. [ 4 ]


Analysis of conversations on parenting website the BabyCenter's online community over the last three years found that mentions of push presents had increased by 41 per cent in the past 18 months, compared to only a two per cent increase between 2011 and 2012. [ original research? ]  A poll of 1,200 BabyCenter mothers also revealed that more than a quarter (27%) were expecting, or had already received, a push present this year. Diamonds were the most popular gift in the form of an  eternity ring  with the prices spent ranging from $600 to $1,700. Tablet computers, charm bracelets and designer watches, and handbags were also popular gifts to celebrate a new arrival.


A  rainbow baby  is a child born to a family that has previously lost one or more children due to  stillbirth ,  miscarriage ,  ectopic pregnancy , termination for medical reasons, or  death during infancy . [ 1 ]  These subsequent pregnancies can bring "strong feelings of anxiety, guilt, and even fear" but also "immense joy, reflection, healing, and mixed emotions". The term " rainbow " is symbolic of the hope brought by the child after the emotional storm of the previous loss. [ 2 ] [ 3 ]


Research conducted at the  University of Michigan  establishes that "parental relationships  have a higher risk of dissolving after a miscarriage or stillbirth, compared with a live birth", and that the risk is highest for those couples who have experienced a stillbirth. [ 4 ]


In the 21st century, such parents seeking to have another child often turn to online  support groups  for information and encouragement. [ 5 ]


According to physician Jennifer Kulp-Makarov, "It is an extremely emotional and devastating experience to lose a pregnancy or baby. To create a life or bring a baby into the world after such a loss is amazing like a miracle for these parents." [ 6 ]


Those interested in supporting such families have designated August 22 each year as "National Rainbow Baby Day". [ 7 ]  Some professional photographers volunteer to take free photos of these babies. [ 8 ]  In some cases, these are group photographs. [ 9 ] [ 10 ]


Although the term rainbow baby is widely used in the pregnancy loss community, some women feel discomfort with the term, each for their own reasons. They might feel the term focuses on the baby's death rather than their real life or they might think that there is no need to put a label that gives this child a special identity or title in relation to their other siblings. [ 11 ]


The  Robson classification , also known as the  10-groups classification  or  ten groups classification system  ( TGCS ), is a system for classifying  pregnant  women who undergo  childbirth . It was developed to allow more accurate comparison of  caesarean section  rates between different settings, whether they be individual hospitals or entire regions or countries. Endorsed by the  World Health Organization  in 2015, it differs from other classification systems in that it accounts for all women who undergo delivery, and not just those who proceed to cesarean section. [ 1 ]


The ten mutually-exclusive groups were first described by the  obstetrician  Michael Robson in 2001, and are defined based on the category of the pregnancy, the woman's previous obstetric record, the course of the labour and delivery, and the  gestational age  at delivery. [ 2 ]


The classification is increasingly used to monitor and compare rates of caesarean section in many countries, and some further subdivisions of the ten groups have been proposed. [ 3 ]


Sex after pregnancy  is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. [ 1 ]  Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. [ 1 ]  Injury to the  perineum  or surgical cuts ( episiotomy ) to the  vagina  during  childbirth  can cause  sexual dysfunction . Sexual activity in the  postpartum period  other than  sexual intercourse  is possible sooner, but some women experience a prolonged loss of  sexual desire  after giving birth, [ 2 ]  which may be associated with  postnatal depression . Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's  body image . [ 3 ] [ 4 ] [ 5 ]


Women with damage or tears to their  perineum  resume sex later than women with an intact perineum, [ 1 ] [ 6 ]  and women who needed perineal  sutures  report poorer sexual relations. [ 7 ]  Perineal damage is also associated with  painful sex . [ 8 ]  Not all lacerations or trauma during childbirth cause decreased sexual function, but certain types of lacerations are associated with increased risk of sexual dysfunction. [ 9 ]  Women who have an anal tear are less likely to have resumed sex after six months [ 10 ]  and one year, [ 11 ]  but they have normal sexual function 18 months later. [ 12 ]


Assisted vaginal delivery using  suction  or  forceps  is correlated with increases in the frequency or severity of painful sex, [ 8 ]  the delay in resuming sex, and sexual problems. [ 13 ]   Cesarean section  may result in less painful sex during the first 3 months, [ 14 ] [ 15 ] [ 13 ]  and there is no difference in sexual function or symptoms by six months. [ 14 ] [ 15 ] [ 16 ]  Also, the women who delivered by cesarean section report greater sexual satisfaction relating to vaginal tone six years on. [ 17 ]


Many doctors recommend waiting four to six weeks before resuming sex, to allow the cervix to close, bleeding (known as  lochia ) to stop, and tears to heal. [ 18 ]


A study of women in  Turkey  found that 42% resumed sexual intercourse within six weeks of giving birth. [ 19 ]  American and British studies found that at six weeks, 57% of women had resumed sexual intercourse, [ 20 ]  82–85% had by three months, [ 7 ] [ 20 ]  and 89–90% had by six months. [ 10 ] [ 15 ] [ 20 ]  Another American survey found that masturbation (74%) and oral sex (58%) were begun much more frequently within six weeks than vaginal penetration (34%). [ 21 ]  Sexual intercourse was resumed by two-thirds of Ugandan women within six months of childbirth, [ 22 ]  and among Chinese women 52% had resumed sex by two months and 95% had by six months. [ 16 ]


About half the men and women questioned eight months after childbirth in one British study described their sex life as ‘poor’ or ‘not very good’, [ 23 ]  though another found that 70% of British women and 89% of Taiwanese women were satisfied with their sex life during the postnatal period. [ 24 ]  Six months after giving birth, one quarter of American women said they had lower sexual sensation, satisfaction, and ability to reach orgasm, and 22% said that sex was painful. More than 80% of British women experienced sexual problems three months after giving birth, and nearly two-thirds at six months, compared to pre-pregnancy levels of 38%. [ 15 ]  Of Ugandan women who had resumed sex within six months of giving birth, nearly two-thirds experienced vaginal pain and about a third had discharge or bleeding. [ 22 ]


Vaginal dryness  may occur following giving birth for about three months due to hormonal changes, and breastfeeding women resume sexual intercourse later than those who do not breastfeed. [ 1 ] [ 25 ]  Women who  breast-feed  are much more likely to report painful sex [ 8 ] [ 15 ] [ 20 ] [ 25 ]  as well as reduced libido, both due to hormonal changes such as a reduction in levels of  estrogen . [ 26 ]  Women with major trauma reported less desire to be held, touched, or stroked by their partner. [ 7 ]


The risk of postpartum sexual dysfunction is increased in those with history of sexual dysfunction prior to pregnancy. [ 25 ]


Having given birth within the previous year is associated with persistent low sexual desire. [ 27 ]  More than a third of first-time mothers report a loss of  libido  at eight months, though only 1 in 7 of experienced mothers have a loss of libido. [ 23 ]  Women often have a poor body image after giving birth. [ 4 ] [ 28 ]  Women are often uncomfortable with their physical changes after birth, and often want sleep or to have time for themselves, which leads to a changed sexual pattern. Discordance of sexual desire with their partner is frequent. [ 4 ] [ 24 ]  Another potential cause of low libido is  postpartum depression ; depressed women are less likely to have resumed sex at six months and more likely to report more sexual health problems. [ 29 ]  Also, those with trauma during pregnancy are more likely to report reduced libido. [ 25 ]


Dissatisfaction with the sexual relationship a year after childbirth is associated with a lack of sex early in pregnancy as well as older ages of women, but not with factors relating to pregnancy or birth. [ 11 ]


A study of found that the sexual desire of partners is often low following the birth. Feelings of intimacy and sexual interest increased sexual desire in co-parents during postpartum period. In contrast, fatigue, stress, partner disinterest, and breastfeeding status decreased the sexual desire in this period. [ 21 ]


A fatal  air embolism , when air enters the bloodstream, can occur due to sex shortly after childbirth before the  placental  bed has healed, particularly if the woman's knees are pressed against her chest, but this is rare. [ 30 ] [ 31 ]  More common complications of having sex early after pregnancy are tears to incisions and infection of the uterus. [ 31 ]


Also, early resumption of sexual intercourse after childbirth may predispose patients to the risks associated with short interval pregnancy. [ 32 ]  The patients who became pregnant within 18 months from the last childbirth are at an increased risk of adverse pregnancy outcomes. [ 32 ]  To prevent such risks associated with short interval pregnancy, contraception is offered after childbirth. [ 32 ] [ 33 ]


Only 15% of London women who had a postnatal sexual problem reported discussing it with a health professional. [ 15 ]  In contrast, 59.4% of Ugandan women who had resumed sex and had a sexual problem sought medical assistance. [ 22 ]  Performing  pelvic floor muscle exercise  appears to improve sexual function, [ 17 ]  and painful sex and vaginal dryness can be reduced using different sexual positions and lubricants. [ 18 ]  83% of British and 60% of Taiwanese women thought they had sufficient information about sex during the postnatal period. [ 24 ]


Contraceptives are often offered immediately after childbirth. [ 33 ]  This is to prevent unintended pregnancy and reduce the risk of abortion and short-interval pregnancy, which may increase the risk of preterm delivery and neonatal complications. [ 33 ]


Of the many reversible contraceptive measures, the Long-Acting Reversible Contraception (LARC) is the most effective with greater compliance by the patients. It can be easily placed by a physician in a short period of time, and no additional maintenance measures are required. [ 33 ]


LARC can be broken down into two different categories: Implant and Intrauterine device (IUD). Implant is a small rod containing the progestin hormone. It is placed in the upper arm and can be effective for 3 or more years. [ 34 ]  No significant risks are associated with the use of implants during postpartum period, except for its theoretical effect on breastfeeding. The progesterone released from the implants are hypothesized to reduce the breast milk production, but such effect of exogenous progesterone during the postpartum period is yet to be proven. [ 33 ]  IUD is a device that is placed within the uterus. IUD placement during postpartum period does not carry any significant risks if the patient does not have infection or hemorrhage at the time of delivery. [ 33 ]  The two common forms of IUDs are copper IUD and Levonorgestrel (LNG) IUD. LNG IUD works by releasing progestin hormone, while the copper IUD does not involve hormone in its effect. [ 33 ] [ 34 ]  As LNG IUD involves progesterone hormone, it carries the theoretical risk of reducing breastfeeding, like the implants. [ 33 ]


Combined hormonal contraceptives, including the birth control pills, increase the risk of blood clotting in postpartum patients. Moreover, it can also interfere with breastmilk production. [ 35 ]  Thus, the patients are advised to avoid combined hormonal contraceptives for the first 3 weeks after childbirth if not breastfeeding and for 4 to 6 weeks if breastfeeding. [ 33 ] [ 35 ]


Another possible contraceptive measure after childbirth is depot-medroxyprogesterone acetate (DMPA), which is also commonly known as Depo Provera. It is a progestin injection that inhibits ovulation and thickens cervical mucus. The shot is safe to be administered immediately after childbirth. [ 36 ]  However, the shot must be re-administered every 12 weeks. [ 32 ]  Also, a backup contraception is recommended in the first 7 days of its use if the patient has started using it after 21 days from the childbirth or if the patient resumed menstrual cycle. [ 36 ]


Sex after  abortion  is generally safe according to the  National Health Service . [ 37 ]


Solitary birth  is the relatively unusual [ 1 ]  circumstance of human women delivering babies alone. Solitary birth is typically unplanned and thus is distinct from the  unassisted birth  movement.


Carla Emery  provided guidelines for solitary delivery of "wilderness babies" in her  Encyclopedia of Country Living . Key directives from the section "Giving Birth by Yourself" included don't yank on the  umbilical cord  and do clear mucus from the baby's nose and mouth. [ 2 ]  Many inadvertent  born before arrival  (BBA) outside-of-hospital deliveries in automobiles are de facto solitary births. [ 3 ]  These deliveries tend to be second or third or higher-order births. [ 3 ]


Solitary birth is a cultural practice of the  !Kung people ; solitary birth amongst the !Kung demonstrates female bravery. In practice,  primigravidas  are usually assisted by female relatives but  multigravidas  typically manage the entire birth process alone (and silently) in the bush. [ 4 ]   Bariba women  in  Benin  have also traditionally practiced solitary birth. [ 5 ]  The  Rarámuri  people of northern  Mexico  have been the focus of public health efforts to decrease maternal mortality by encouraging the use of birth attendants. [ 6 ] [ 7 ]


The common use of  midwives  or birth assistants in human culture is thought to date to the "pelvic reorientation associated with  bipedalism " and was reinforced by the "encephalization seen in the genus  Homo ." [ 8 ]  Humans may have evolved  obligate midwifery  as a cultural adjunct to childbirth due to the  occiput anterior  position of newborns emerging from the vagina, because human newborns are particularly  altricial , and for social-emotional reasons. [ 1 ]  However a 2018 observational study found that  bonobos  exhibit "midwifery" behaviors as well and postulated that the practice was related to a primate-level "capacity of unrelated females to form strong social bonds and cooperate." [ 9 ]


In  placental   mammals , the  umbilical cord  (also called the  navel string , [ 1 ]   birth cord  or  funiculus umbilicalis ) is a conduit between the developing  embryo  or  fetus  and the  placenta . During  prenatal development , the umbilical cord is physiologically and genetically part of the fetus and (in humans) normally contains two  arteries  (the  umbilical arteries ) and one  vein  (the  umbilical vein ), buried within  Wharton's jelly . The umbilical vein supplies the fetus with  oxygenated ,  nutrient -rich  blood  from the  placenta .  Conversely, the fetal heart pumps low-oxygen, nutrient-depleted blood through the umbilical arteries back to the placenta.


The umbilical cord develops from and contains remnants of the  yolk sac  and  allantois . It forms by the fifth week of  development , replacing the yolk sac as the source of nutrients for the embryo. [ 2 ]  The cord is not directly connected to the mother's circulatory system, but instead joins the  placenta , which transfers materials to and from the maternal blood without allowing direct mixing.  The length of the umbilical cord is approximately equal to the  crown-rump length  of the fetus throughout  pregnancy . The umbilical cord in a full term  neonate  is usually about 50  centimeters  (20  in ) long and about 2 centimeters (0.75 in) in diameter. This diameter decreases rapidly within the placenta. The fully patent umbilical artery has two main layers: an outer layer consisting of circularly arranged smooth muscle cells and an inner layer which shows rather irregularly and loosely arranged cells embedded in abundant  ground substance  staining  metachromatic . [ 3 ]  The smooth muscle cells of the layer are rather poorly differentiated, contain only a few tiny  myofilaments  and are thereby unlikely to contribute actively to the process of post-natal closure. [ 3 ]


Umbilical cord can be detected on ultrasound by six weeks of gestation and well-visualised by eight to nine weeks of gestation. [ 4 ]


The umbilical  cord lining  is a good source of mesenchymal and epithelial stem cells. Umbilical cord  mesenchymal stem cells  (UC-MSC) have been used clinically to treat osteoarthritis, autoimmune diseases, and multiple other conditions. Their advantages include a better harvesting, and multiplication, and immunosuppressive properties that define their potential for use in transplantations. Their use would also overcome the ethical objections raised by the use of  embryonic stem cells . [ 5 ]


The umbilical cord contains  Wharton's jelly , a gelatinous substance made largely from  mucopolysaccharides  that protects the blood vessels inside. It contains one vein, which carries oxygenated, nutrient-rich blood to the fetus,  and two arteries that carry deoxygenated, nutrient-depleted blood away. [ 6 ]  Occasionally, only two vessels (one vein and one artery) are present in the umbilical cord. This is sometimes related to fetal abnormalities, but it may also occur without accompanying problems.


It is unusual for a vein to carry oxygenated blood and for arteries to carry deoxygenated blood (the only other examples being the  pulmonary veins  and  arteries , connecting the lungs to the heart). However, this naming convention reflects the fact that the umbilical vein carries blood towards the fetus' heart, while the umbilical arteries carry blood away.


The blood flow through the umbilical cord is approximately 35 ml / min at 20 weeks, and 240 ml / min at 40  weeks of gestation . [ 7 ]  Adapted to the weight of the fetus, this corresponds to 115 ml / min / kg at 20 weeks and 64 ml / min / kg at 40 weeks. [ 7 ]


For  terms of location , the  proximal  part of an umbilical cord refers to the segment closest to the embryo or fetus in embryology and fetal medicine, and closest to the placenta in placental pathology, and opposite for the  distal  part, respectively. [ 8 ]


The umbilical cord enters the fetus via the  abdomen , at the point which (after separation) will become the  umbilicus  (belly button or navel). Within the fetus, the umbilical vein continues towards the  transverse fissure  of the  liver , where it splits into two.  One of these branches joins with the  hepatic portal vein  (connecting to its left branch), which carries blood into the liver.  The second branch (known as the  ductus venosus ) bypasses the liver and flows into the  inferior vena cava , which carries blood towards the heart.  The two umbilical arteries branch from the  internal iliac arteries  and pass on either side of the  urinary bladder  into the umbilical cord, completing the circuit back to the placenta. [ 9 ]


After birth, the umbilical cord stump will dry up and drop away by the time the baby is three weeks old. [ 10 ]  If the stump still has not separated after three weeks, it might be a sign of an underlying problem, such as an infection or immune system disorder. [ 10 ]


In absence of external interventions, the umbilical cord  occludes  physiologically shortly after birth, explained both by a swelling and collapse of  Wharton's jelly  in response to a reduction in temperature and by  vasoconstriction  of the blood vessels by smooth muscle contraction. In effect, a natural clamp is created, halting the flow of blood. In air at 18 °C, this physiological clamping will take three minutes or less. [ 11 ]  In  water birth , where the water temperature is close to body temperature, normal pulsation can be five minutes and longer.


Closure of the umbilical artery by vasoconstriction consists of multiple constrictions which increase in number and degree with time. There are segments of dilations with trapped uncoagulated blood between the constrictions before complete occlusion. [ 12 ]  Both the partial constrictions and the ultimate closure are mainly produced by muscle cells of the outer circular layer. [ 3 ]  In contrast, the inner layer seems to serve mainly as a plastic tissue which can easily be shifted in an  axial  direction and then folded into the narrowing lumen to complete the closure. [ 3 ]  The vasoconstrictive occlusion appears to be mainly mediated by  serotonin [ 13 ] [ 14 ]  and  thromboxane A 2 . [ 13 ]  The artery in cords of preterm infants contracts more to  angiotensin II  and  arachidonic acid  and is more sensitive to  oxytocin  than in term ones. [ 14 ]  In contrast to the contribution of Wharton's jelly, cooling causes only temporary vasoconstriction. [ 14 ]


Within the child, the umbilical vein and ductus venosus close up, and degenerate into fibrous remnants known as the  round ligament of the liver  and the  ligamentum venosum  respectively. Part of each umbilical artery closes up (degenerating into what are known as the  medial umbilical ligaments ), while the remaining sections are retained as part of the circulatory system.


A number of abnormalities can affect the umbilical cord, which can cause problems that affect both mother and child: [ 15 ]


The cord can be clamped at different times; however, delaying the clamping of the umbilical cord until at least one minute after birth improves outcomes as long as there is the ability to treat the small risk of  jaundice  if it occurs. [ 18 ]  Clamping is followed by cutting of the cord, which is painless due to the absence of  nerves .  The cord is extremely tough, like thick  sinew , and so cutting it requires a suitably sharp instrument.  While umbilical severance may be delayed until after the cord has stopped pulsing (one to three minutes after birth), there is ordinarily no significant loss of either venous or arterial blood while cutting the cord. Current evidence neither supports, nor refutes, delayed cutting of the cord, according to the  American Congress of Obstetricians and Gynecologists  (ACOG) guidelines.


There are umbilical cord clamps which incorporate a knife. These clamps are safer and faster, allowing one to first apply the cord clamp and then cut the umbilical cord.  After the cord is clamped and cut, the newborn wears a plastic clip on the navel area until the compressed region of the cord has dried and sealed sufficiently.


The length of umbilical left attached to the newborn varies by practice; in most hospital settings the length of cord left attached after clamping and cutting is minimal. In the United States, however, where the birth occurred outside of the hospital and an  emergency medical technician  (EMT) clamps and cuts the cord, a longer segment up to 18 cm (7 in) in length [ 19 ] [ 20 ]  is left attached to the newborn.


The remaining umbilical stub remains for up to ten days as it dries and then falls off.


A  Cochrane review  in 2013 came to the conclusion that delayed cord clamping (between one and three minutes after birth) is "likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available". [ 21 ]  In this review delayed clamping, as contrasted to early, resulted in no difference in risk of severe maternal  postpartum hemorrhage  or neonatal mortality, and a low  Apgar score . On the other hand, delayed clamping resulted in an increased birth weight of on average about 100 g, and an increased  hemoglobin  concentration of on average 1.5 g/dL with half the risk of being iron deficient at three and six months, but an increased risk of jaundice requiring  phototherapy . [ 21 ]


In 2012, the American College of Obstetricians and Gynecologists officially endorsed delaying clamping of the umbilical cord for 30–60 seconds with the newborn held below the level of the placenta in all cases of preterm delivery based largely on evidence that it reduces the risk of intraventricular hemorrhage in these children by 50%. [ 22 ] [ obsolete source ]  In the same committee statement, ACOG also recognize several other likely benefits for preterm infants, including "improved transitional circulation, better establishment of red blood cell volume, and decreased need for blood transfusion". In January 2017, a revised Committee Opinion extended the recommendation to term infants, citing data that term infants benefit from increased hemoglobin levels in the newborn period and improved iron stores in the first months of life, which may result in improved developmental outcomes. ACOG recognized a small increase in the incidence of jaundice in term infants with delayed cord clamping, and recommended policies be in place to monitor for  and treat neonatal jaundice. ACOG also noted that delayed cord clamping is not associated with increased risk of postpartum hemorrhage. [ 23 ]


Several studies have shown benefits of delayed cord clamping: A meta-analysis [ 24 ]  showed that delaying clamping of the umbilical cord in full-term neonates for a minimum of two minutes following birth is beneficial to the newborn in giving improved  hematocrit , iron status as measured by  ferritin  concentration and stored iron, as well as a reduction in the risk of anemia ( relative risk , 0.53; 95% CI, 0.40–0.70). [ 24 ]  A decrease was also found in a study from 2008. [ 25 ]  Although there is higher hemoglobin level at 2 months, this effect did not persist beyond 6 months of age. [ 26 ]  Not clamping the cord for three minutes following the birth of a baby improved outcomes at four years of age. [ 27 ]  A delay of three minutes or more in umbilical cord clamping after birth reduce the prevalence of anemia in infants. [ 28 ]


Negative effects of delayed cord clamping include an increased risk of  polycythemia . Still, this condition appeared to be benign in studies. [ 24 ]  Infants whose cord clamping occurred later than 60 seconds after birth had a higher rate of  neonatal jaundice  requiring  phototherapy . [ 26 ]


Delayed clamping is not recommended as a response to cases where the newborn is not breathing well and needs resuscitation. Rather, the recommendation is instead to immediately clamp and cut the cord and perform  cardiopulmonary resuscitation . [ 29 ]  The umbilical cord pulsating is not a guarantee that the baby is receiving enough oxygen. [ 30 ]


Some parents choose to omit cord severance entirely, a practice called " lotus birth " or umbilical nonseverance.  The entire intact umbilical cord is allowed to dry and separates on its own (typically on the 3rd day after birth), falling off and leaving a healed umbilicus. [ 31 ]  The  Royal College of Obstetricians and Gynaecologists  has warned about the risks of infection as the decomposing placenta tissue becomes a nest for infectious bacteria such as  Staphylococcus . [ 32 ]  In one such case, a 20-hour old baby whose parents chose UCNS was brought to the hospital in an agonal state, was diagnosed with  sepsis  and required an antibiotic treatment for six weeks. [ 33 ] [ 34 ]


As the umbilical vein is directly connected to the central circulation, it can be used as a route for placement of a venous catheter for infusion and medication. The umbilical vein catheter is a reliable alternative to percutaneous peripheral or central venous catheters or intraosseous canulas and may be employed in resuscitation or intensive care of the newborn.


From 24 to 34 weeks of gestation, when the fetus is typically viable, blood can be taken from the cord in order to test for abnormalities (particularly for  hereditary  conditions). This diagnostic  genetic test  procedure is known as  percutaneous umbilical cord blood sampling . [ 35 ]


The blood within the umbilical cord, known as  cord blood , is a rich and readily available source of primitive,  undifferentiated   stem cells  (of type  CD34 -positive and  CD38 -negative). These cord blood cells can be used for  bone marrow transplant .


Some parents choose to have this blood diverted from the baby's umbilical blood transfer through early cord clamping and cutting, to freeze for long-term storage at a  cord blood bank  should the child ever require the cord blood stem cells (for example, to replace  bone marrow  destroyed when treating  leukemia ). This practice is controversial, with critics asserting that early cord blood withdrawal at the time of birth actually increases the likelihood of childhood disease, due to the high volume of blood taken (an average of 108ml) in relation to the baby's total supply (typically 300ml). [ 25 ]   The  Royal College of Obstetricians and Gynaecologists  stated in 2006 that "there is still insufficient evidence to recommend directed commercial cord blood collection and stem-cell storage in low-risk families". [ 36 ]


The  American Academy of Pediatrics  has stated that cord blood banking for self-use should be discouraged (as most conditions requiring the use of stem cells will already exist in the cord blood), while banking for general use should be encouraged. [ 37 ]   In the future, cord blood-derived embryonic-like stem cells (CBEs) may be banked and matched with other patients, much like blood and transplanted tissues. The use of CBEs could potentially eliminate the ethical difficulties associated with  embryonic stem cells  (ESCs). [ 38 ]


While the American Academy of Pediatrics discourages private banking except in the case of existing medical need, it also says that information about the potential benefits and limitations of cord blood banking and transplantation should be provided so that parents can make an informed decision.


In the United States, cord blood education has been supported by legislators at the federal and state levels. In 2005, the National Academy of Sciences published an  Institute of Medicine (IoM) report  which recommended that expectant parents be given a balanced perspective on their options for cord blood banking. In response to their constituents, state legislators across the country are introducing legislation intended to help inform physicians and expectant parents on the options for donating, discarding or banking lifesaving newborn stem cells. Currently 17 states, representing two-thirds of U.S. births, have enacted legislation recommended by the IoM guidelines.


The use of cord blood stem cells in treating conditions such as brain injury [ 39 ]   and Type 1 Diabetes [ 40 ]   is already being studied in humans, and earlier stage research is being conducted for treatments of stroke, [ 41 ] [ 42 ]  and hearing loss. [ 43 ]


Cord blood stored with private banks is typically reserved for use of the donor child only. In contrast, cord blood stored in public banks is accessible to anyone with a closely matching tissue type and demonstrated need. [ 44 ]  The use of cord blood from public banks is increasing. Currently it is used in place of a bone marrow transplant in the treatment of blood disorders such as leukemia, with donations released for transplant through one registry, Netcord.org, [ 45 ]  passing 1,000,000 as of January 2013. Cord blood is used when the patient cannot find a matching bone marrow donor; this "extension" of the donor pool has driven the expansion of public banks.


The umbilical cord in some mammals, including cattle and sheep, contains two distinct umbilical veins. There is only one umbilical vein in the human umbilical cord. [ 46 ]


In some animals, the mother will gnaw through the cord, thus separating the placenta from the offspring.  The cord along with the placenta is often eaten by the mother, to provide nourishment and to dispose of tissues that would otherwise attract scavengers or predators. [ citation needed ]  In  chimpanzees , the mother leaves the cord in place and nurses her young with the cord and placenta attached until the cord dries out and separates naturally, within a day of birth, at which time the cord is discarded.  (This was first documented by zoologists in the wild in 1974. [ 47 ] )


Some species of  shark — hammerheads ,  requiems  and  smooth-hounds —are  viviparous  and have an umbilical cord attached to their placenta. [ 48 ]


The term "umbilical cord" or just "umbilical" has also come to be used for other cords with similar functions, such as the hose connecting  surface-supplied divers  to their surface supply of air and/or heating, or  space-suited   astronauts  to their spacecraft. Engineers sometimes use the term to describe a complex or critical cable connecting a component, especially when composed of bundles of conductors of different colors, thickness and types, terminating in a single multi-contact disconnect.


In multiple American and international studies,  cancer-causing  chemicals have been found in the blood of umbilical cords. These originate from certain plastics, computer circuit boards, fumes and synthetic fragrances among others. Over 300  chemical   toxicants  have been found, including  bisphenol A  (BPA),  tetrabromobisphenol A  (TBBPA),  Teflon -related  perfluorooctanoic acid ,  galaxolide  and  synthetic musks  among others. [ 49 ]  The studies in America showed higher levels in  African Americans ,  Hispanic Americans  and  Asian Americans  due, it is thought, to living in areas of higher pollution. [ 50 ]


Unassisted childbirth  ( UC ) refers to the process of intentionally giving  birth  without the assistance of a  medical   birth attendant . It may also be known as  freebirth , [ 1 ]   DIY  (do-it-yourself)  birth , [ 2 ]   unhindered birth , [ 3 ]  and  unassisted home birth . [ 4 ]  Unassisted childbirth is by definition a planned process, and is thus distinct from unassisted birth due to reasons of emergency, lack of access to a skilled birth attendant, or other. It is also different from  homebirth , although most UCs also happen within the home.


Vital Statistics Canada defines an "unassisted/unattended" birth as one that takes place without a registered medical attendant, regardless of what other birth professionals may have been in attendance (doulas, non-medical or traditional birth attendants, etc.). Many "unassisted" births involve the attendance of a non-medical birth attendant, though the definition of unassisted birth sometimes means there is only family or peers in attendance and no professional support whatsoever. Approximately 0.25% of births in the United States are unassisted. [ 5 ]


Unassisted childbirth comes with risks. Numerous national medical societies, as well as midwives' associations, have cautioned against unassisted childbirth. Twenty percent of all previously normal pregnancies turn into complications and high-risk situations during labor, which could necessitate assistance from trained medical professionals. [ 6 ]  OB-GYNs do not recommend home births, even when attended by a medical professional, if the mother has  hypertension  or when a  breech birth  is expected. [ 5 ]  A 2010 meta-analysis of existing research concluded that planned home births had a three times higher mortality rate for babies. [ 7 ] [ 8 ]


While unassisted childbirth does not include the use of medical personnel or birth attendants in a professional capacity, the birthing woman may still wish to have other people present at her birth. This might include her partner, close friends of the mother, the grandparents-to-be, or other family members. These people may take on various roles such as minding the other children in the family, preparing food, making sure the mother remains undisturbed by phone calls, etc. [ citation needed ]


A woman giving birth and her partner may wish to be alone together for the birth of their child. Some couples who choose unassisted childbirth consider the birth to be a consummation or extension of their married life. [ citation needed ]  In terms of wanting to have an ecstatic or  orgasmic birth , a high degree of privacy is desired. Others may simply consider birth to be an intimate bonding time between the spouses and their newborn child. [ citation needed ]


Some women choose to give birth completely alone. They may retreat to a room alone at the time of the birth and then bring their partner in afterward; or they may remain entirely alone in their home or another location. Women who choose a solo unassisted birth may see birthing as an intensely private process, or may feel they have all the resources they need through their intuition. [ 9 ]


Giving birth without any health care provider supervision. [ 10 ]  Sometimes used synonymously with "unassisted birth", and sometimes used to describe any birth without medically licensed professionals present, regardless of who else may or not be in attendance in a supportive role.


With respect to medical prenatal care, two broad categories are recognized by unassisted childbirth proponents:


Many women who are planning an unassisted birth choose to have professional prenatal care as part of their birth preparation. This may include regular prenatal visits with a doctor or monitoring by a midwife. Seeking the assistance of a  doctor  or  midwife  may allow for discovering risk factors that might make an unassisted birth inadvisable, such as  placenta praevia . Professional prenatal care may also help identify risk factors that could be managed so that the unassisted birth can continue as planned. Rather than keep to a traditional prenatal care schedule, some women may also selectively choose prenatal care.


Some women who choose UC also choose to have a medically unassisted pregnancy; i.e. they do not visit a doctor or other birth professional for prenatal care. There are potentially life-threatening consequences of having no medical follow-up in case there are complications. [ 11 ]


The  National Center for Health Statistics  reports that of the 4.1 million babies born in the  United States  in 2004, more than 7,000 were born at home without a midwife or physician attending. [ 2 ]  It is unknown what portion of these births, roughly equivalent to a sixth of 1% of the nation's annual total, occurred by choice.


It is not currently known how many women in  Australia  give birth at home by choice without medical assistance. Home births in Australia represent 0.25 percent of all births, with the majority of these done with the assistance of a midwife. [ 12 ]


A 2021 qualitative study conducted in Poland [ 13 ]  examined women’s pathways to freebirth using semi-structured interviews, with the goal of understanding why women were choosing to give birth completely unassisted. The authors note there was “great diversity of pathways to freebirth” seen from the participants. [ 13 ]  However, all participants reported negative prior experience with maternity care where the women had felt there was a mismatch between their needs and the care they received. Women were more likely to report traumatic experiences about hospital births than midwife-attended home births, but there were negative experiences reported with both. Two themes identified were “persistent and unnecessary use of medical technology” and “rudeness and lack of respect” from providers. [ 13 ]  All the women interviewed in this study believed that medical intervention had complicated their previous birth experience. Additionally, all interviewed described their freebirth as “positive and empowering” due to an increased feeling of autonomy and the participation of support people. [ 13 ]


In response to the recent growth in interest over unassisted childbirth, several national medical societies, including the  Society of Obstetricians and Gynaecologists of Canada , [ 14 ]  the  American College of Obstetricians and Gynecologists , [ 15 ]  and the  Royal Australian and New Zealand College of Obstetricians and Gynaecologists , [ 16 ]  have issued strongly worded public statements warning against the practice. Professional midwives' associations, including the  Royal College of Midwives [ 17 ]  and the  American College of Nurse-Midwives [ 2 ]  also caution against UC.


Unassisted childbirth has been linked to substantially elevated rates of both maternal and neonatal mortality. One of the few, and perhaps the only, formal investigation of the mortality rates associated with the practice was conducted by the  Indiana  State Board of Health in 1984, among members of a religious community in Indiana.  The investigation found a perinatal mortality rate 2.7 times higher, and a maternal mortality rate 97 times higher than the state average.  In this community, pregnant women receive no prenatal medical care and deliver at home without medical assistance.  This community avoids not only prenatal medical care but all medical care. [ 18 ]


Unassisted childbirth comes with serious risks. If something comes wrong during labor, the mother and child might need assistance from trained medical staff. [ 19 ]  According to the president of the  American College of Obstetricians and Gynecologists , Thomas Purdon, twenty percent of all previously normal pregnancies turn into complications and high-risk situations during the course of labor that could result in serious adverse outcome to mother and baby, including death. [ 6 ]


OB-GYNs do not recommend home births, even when attended by a medical professional, if the mother has hypertension or when a  breech birth  is expected. [ 5 ]  A 2010 meta-analysis of existing research concluded that planned homebirths had a three times higher mortality rate for babies. [ 7 ] [ 8 ]


The UC movement grew out of, and is an extension of the  natural childbirth  movement, pioneers of which include  Grantly Dick-Read ,  Robert A. Bradley , and  Fernand Lamaze . Influential proponents of UC include  Marilyn A. Moran , [ 20 ]   Jeannine Parvati Baker , and  Laura K. Shanley . The Free Birth Society is one influential freebirth advocacy group; it sells online courses and private consultations. [ 19 ] [ 5 ]  The founder of the Free Birth Society and the organization's instructors do not have medical training. [ 19 ]


Parvati Baker, a  yogini , writer, poet,  herbalist , and "spiritual midwife", coined the term  freebirth  to describe UC. [ citation needed ]


Shanley, a writer, poet, and self-styled birth consultant, is the author of the book  Unassisted Childbirth  (1993), which helped popularize the practice. Inspired by the writings of Dick-Read, Shanley, who has no formal training in gynecology or obstetrics, [ 15 ]  gave birth to all five of her own children unassisted and with no prenatal care. [ 21 ]  Four of them survived; Shanley's fourth child, born four weeks  premature  in her bathroom, died a few hours later of a  heart defect ,  pneumonia , and  sepsis . [ 2 ]


Reasons and motivations for choosing to give birth unassisted range greatly from mother to mother; those most frequently cited in unassisted childbirth literature and advocacy sites include [ citation needed ]  the belief that birth is a normal function of the female body and therefore not a medical emergency. [ 22 ]  Other beliefs are that most interventions commonly used by the medical profession during birth cause more harm than good in a normal birth, that the mother will be more apt to follow the natural flow of her individual birth in an undisturbed birth setting, thus enabling her to find the optimum positions or techniques to birth her child safely, and the view that birth is an intimate, sexual, and potentially orgasmic experience, [ citation needed ]  and the belief that privacy is essential for enabling this erotic dimension.


Advocates believe that unassisted birth gives rise to a significant increase in maternal feelings and the mother's ability to  bond  with and take responsibility for the welfare of her child. Some followers are unable to find a birth practitioner willing to attend their desired home birth. In many areas of the United States, there are no midwives or physicians available to assist at home births. Likewise, the woman may find her specific case presents difficulty in finding a willing practitioner, as is usually the case with a  vaginal birth after caesarean  section (VBAC).


Controversy over the practice of UC has largely centered over whether it is, as claimed by proponents, a safe method of childbirth. Critics of UC, such as the  Society of Obstetricians and Gynaecologists of Canada  (SOGC), claim that unassisted childbirth is quite unsafe, [ 11 ]  and that those who engage in it are "courting danger". [ 14 ]  A spokesperson for the  American College of Obstetricians and Gynecologists  issued a one-word assessment of freebirth: "dangerous". [ 15 ]  The SOGC notes that more than 500,000 women worldwide die annually from complications during childbirth, [ 14 ]  and that even in developed countries, in which expectant mothers generally receive complete prenatal care, as many as 15% of all births involve potentially fatal complications. [ 14 ]  In poor countries in which there are conditions of malnutrition and taboos surrounding childbirth or there is a lack of qualified birth attendants, rates of  maternal [ 23 ]  and  infant mortality [ 24 ]  and complications such as  fistula  are much higher, with disparities in death rates from childbirth between developed and developing countries approaching two orders of magnitude. [ 25 ]  Critics also point out the high rates of complication and death arising from childbirth that existed before the development of modern medicine: between 10 and 15 deaths per 1000 births. [ 26 ]


UC proponents have responded to these criticisms by emphasizing that childbirth is not a disease,  but rather a natural, physiological process requiring proper nutrition, hygiene, prenatal self-care, and psychological preparation. [ 27 ]  They claim that both throughout history and in the impoverished regions of today's world it has not been the lack of medical assistance, but rather conditions of poverty and nutritional ignorance which cause maternal mortality to be a major health issue. [ citation needed ]   Rickets , for example, is prevalent in daughters of malnourished women, resulting in deformation of the  pelvis  and an increased chance of  hemorrhage  in scenarios of  anemia . [ 28 ]  Proponents assert that the women who plan unassisted childbirth today (many of whom are giving birth to their second or third child, with a 'proven' pelvis), do so with a wealth of information and self-care, and are better prepared than most women who depend on care providers to deliver their child.


Some proponents have also claimed that modern  maternal mortality rates in American hospitals  are often obscured by being statistically tracked under 'anesthesiology'. [ citation needed ]  However, evidence suggests that if this is in fact the case, the practice is unlikely to account for more than a small fraction of maternal deaths: one study of maternal mortality records lists the  total  share of maternal mortality deaths recorded as stemming from anesthesia-related complications as just 5.2%. [ 29 ]  A study of anesthesia-related maternal mortality in the United States between 1979 and 2002 found the share of maternal mortality deaths caused by anesthesia to be just 1.6%, and that the share had dropped 59% between the time periods examined. [ 30 ]


Other aspects of this response have also been called into question by scientific research. First, an analysis of historical data from Europe and the United States concluded that in developed countries, the main determinant of maternal mortality before 1937, and its decline since the 1930s, was  not  levels of poverty and associated malnutrition, but rather the overall standard of maternal care provided by birth attendants. [ 31 ]


Second, with respect to UC proponents' claim that unassisted childbirth is a natural process, researchers in the field of paleoanthropology have asserted that  assisted  childbirth is, in fact, a central evolutionary aspect of humanity, and may date back as far as five million years to when humanity's ancestors first began walking upright. [ 32 ]


On 27 March 2009, Janet Fraser, a leading advocate of UC and national convener of the highly popular  Joyous Birth  website, lost her child [ 33 ]  during a birth assisted only by her partner and a female friend. [ 34 ]  In an interview five days earlier with  The Sunday Age , Fraser, in the early stages of labor at the time, stated that she had at no point during her pregnancy consulted with a health professional, and that she intended to deliver the baby at her home without an attending midwife. [ 33 ]  The cause of death was reported to be  cardiac arrest . [ 33 ] [ 35 ]  A coronial  inquest  concluded in 2012 that Roisin Fraser's death was the result of a complication resulting from  cord entanglement , was almost certainly preventable if the birth had proceeded in a maternity unit, and was probably preventable if the birth at home had been attended by a registered midwife. It also found that Fraser's claim of "birthrape" during her first birth followed a planned homebirth attended by a midwife, where Fraser herself requested transfer to a hospital for epidural anaesthesia, and then subsequently requested a  caesarean birth  without medical indications and against medical advice. [ 36 ]


Vacuum extraction  ( VE ), also known as  ventouse , is a method to assist delivery of a baby using a  vacuum  device. It is used in the second stage of  labor  if it has not progressed adequately. It may be an alternative to a  forceps delivery  and  caesarean section .  It cannot be used when the baby is in the  breech position  or for  premature births .  The use of VE is generally safe, but it can occasionally have negative effects on either the mother or the child. [ 1 ]  The term  ventouse  comes from the French word for "suction cup".


There are several indications to use a vacuum extraction to aid delivery:


The woman is placed in the  lithotomy position  and assists throughout the process by pushing. A  suction cup  is placed onto the head of the baby and the suction draws the skin from the scalp into the cup. Correct placement of the cup directly over the  flexion point , about 3 cm anterior from the occipital (posterior)  fontanelle , is critical to the success of a vacuum extraction. [ 2 ]  Ventouse devices have handles to allow for traction.  When the baby's head is delivered, the device is detached, allowing the birthing attendant and the mother to complete the delivery of the baby.


For proper use of the ventouse, the maternal  cervix  has to be fully dilated, the head engaged in the birth canal, and the head position known. Preferably the operator of the vacuum extractor needs to be experienced in order to safely perform the procedure. The baby should not be  preterm , previously exposed to  scalp sampling  or failed  forceps delivery . [ 1 ]  If the ventouse attempt fails, it may be necessary to deliver the infant by forceps or  caesarean section .


In 1849 the  Edinburgh  professor of obstetrics  James Young Simpson , subsequently known for pioneering the use of  chloroform  in childbirth, designed the Air Tractor which consisted of a metal syringe attached to a soft rubber cup. [ 1 ]   This was the earliest known vacuum extractor to assist childbirth but it did not become popular. [ 3 ]  Swedish professor Tage Malmstrom developed the ventouse, or Malmstrom extractor in the 1950s. Originally made with a metal cap, new materials such as plastics and siliconised rubber have improved the design so that it is now used more than forceps. [ 3 ] [ 4 ]


Vacuum delivery as a percentage of vaginal births vary depending on location. In the USA they comprise about 10% to 15% of vaginal births while in Italy 4.8% of vaginal births were delivered via vacuum in 2013. [ 5 ]


In case of a previous  caesarean section  a subsequent  pregnancy  can be planned beforehand to be  delivered  by either of the following two main methods:


Both have higher risks than a vaginal birth with no previous caesarean section. There are many issues which affect the decision for planned vaginal or planned abdominal delivery. There is a slightly higher risk for uterine rupture and  perinatal death  of the child with VBAC than ERCS, but the absolute increased risk of these complications is small, especially with only one previous low transverse caesarean section. [ 1 ]  A large majority of women planning VBAC will achieve a successful vaginal delivery, although there are more risks to the mother and baby from an unplanned caesarean section than from an ERCS. [ 2 ] [ 3 ]  Successful VBAC also reduces the risk of complications in future pregnancies more than ERCS. [ 4 ]


In 2010, the National Institutes of Health, U.S. Department of Health and Human Services, and American Congress of Obstetrics and Gynecology all released statements in support of increasing VBAC access and rates. [ 5 ] [ 6 ] [ 4 ] [ 7 ]  Recently, it is recognized that as the number of cesarean sections a patient undergoes increases so does the risk of significant obstetrical complications [ 8 ]  It is still suggested to try VBAC over ERCS even with its slightly higher risk of uterine rupture.
Both VBAC and ERCS have risks, it is always better to decide delivery based on birthing person's body condition and preferred birthing experience, and advice from health professionals.


TOLAC  (trial of labor after caesarean) is an attempt at vaginal delivery to see whether it can succeed in resulting in a VBAC. If it turns out not to progress acceptably, then a caesarean is performed.


Where the woman is labouring with a previous section scar (i.e. a planned VBAC in labour), depending on the provider, special precautions may be recommended. These include intravenous access (a cannula into the vein) and continuous fetal monitoring (cardiotocography or CTG monitoring of the fetal heart rate with transducers on the mother's abdomen). Most women in the UK should be counselled to avoid induction of labour if there are no medical reasons for it, as the risks of uterine rupture of the previous scar are increased if the labour is induced. Other intrapartum management options, including analgesia/anesthesia, are identical to those of any labour and vaginal delivery. [ 9 ]


For ERCS, the choice of skin incision should be determined by what seems to be most beneficial for the present operation, regardless of the choice of the previous location as seen by its scar, although the vast majority of surgeons will incise through the previous scar to optimise the cosmetic result. Hypertrophic (very thick or unsightly) scars are best excised because it gives a better cosmetic result and is associated with improved  wound healing . On the other hand, keloid scars should have their margins left without any incision because of risk of tissue reaction in the subsequent scar. [ 10 ]


The choice of VBAC or ERCS depends on many issues: medical and obstetric indications, maternal choice and availability of provider and birth setting ( hospital ,  birthing center , or home). Some commonly employed criteria include: [ 3 ]


According to ACOG guidelines, the following criteria may reduce the likelihood of VBAC success but should NOT preclude a trial of labour: having two prior caesarean sections, suspected  fetal macrosomia  at term (fetus greater than 4000-4500 grams in weight), gestation beyond 40 weeks, twin gestation, and previous low vertical or unknown previous incision type, provided a classical uterine incision is not suspected. [ 4 ]


The presence of any of the following practically always mean that ERCS will be performed – but this decision should always be discussed with a senior obstetrician: [ 12 ]


VBAC and ERCS differ in outcomes on many end-points.


The  American Congress of Obstetricians and Gynecologists  (ACOG) states that VBAC is associated with decreased  maternal morbidity  and a decreased risk of complications in future pregnancies than ERCS. [ 4 ]


A caesarean section leaves a scar in the wall of the  uterus  which is considered weaker than the normal uterine wall. A VBAC carries a risk of  uterine rupture  of 22–74/10,000. Slightly lower risk of uterine rupture in women undergoing ERCS (i.e. a section before the onset of labour). [ 1 ]  Mothers with a previous lower uterine segment cesarean are considered the best candidates for VBAC, as that region of the uterus is under less physical stress during labor and delivery. Although there is higher risk of uterine rupture in VBAC than ERCS, both rates happen to be very low. Sometimes no significant difference in uterine rupture rates is found between the groups of VBAC and ERCS. [ 13 ]  If a uterine rupture does occur, the risk of perinatal death is approximately 6%. [ 14 ]
Even it happens, most birthing parents and babies will recover completely after uterine rupture. [ 15 ]


A VBAC carries a 2–3/10,000 additional risk of birth-related  perinatal death  when compared with ERCS. [ 1 ]  The absolute risk of such birth-related perinatal loss is comparable to the risk for women having their first birth. [ 1 ]  Planned VBAC carries an 8/10,000 risk of the child developing  hypoxic ischaemic encephalopathy , but the long-term outcome of the infant with HIE is unknown and related to many factors. [ 1 ]


On the other hand, attempting VBAC reduces the risk that the child will have respiratory problems after birth such as  infant respiratory distress syndrome  (IRDS), as rates are estimated at 2–3% with planned VBAC and 3–4% with ERCS. [ 1 ]


Of the women who have previously had a Caesarean, only about 8% of them will opt for a VBAC. However, of the 8% that opt for a VBAC, between 75%–80% will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010. [ 2 ] [ 3 ] [ 16 ]


The chance of having a successful VBAC is decreased by the following factors: [ 1 ]


When the first four factors are present, successful VBAC is achieved in only 40% of cases. In contrast, in women with a previous caesarean section who have had a subsequent vaginal birth, the chance of a successful vaginal birth again is estimated at 87–90%. [ 1 ]


ERCS, as compared to VBAC, further increases the risks of complications in future pregnancies. Complications whose risks significantly increase with increasing number of repeated caesarean sections include: [ 1 ]


Aside from uterine rupture risk, the drawbacks of VBAC are usually minor and identical to those of any vaginal delivery, including the risk of  perineal tearing . Maternal morbidity,  NICU  admissions, length of hospital stay, and medical costs are typically reduced following a VBAC rather than a repeat caesarean delivery. [ citation needed ]


A VBAC, compared with ERCS, carries around 1% additional risk of either  blood transfusion  (mainly because of  antepartum hemorrhage ), postpartum haemorrhage or  endometritis . [ 1 ]