Your baby is full term now and completely developed. Keep in mind that you could start labor at any point in time. You should be ready to go armed with your hospital bag.James W. Brann, MD
Your Pregnancy MD
Pregnancy Week Thirty Eight
At 38 weeks pregnant and until you give birth; your belly size is going to stay pretty constant. If your baby has already dropped into your pelvis – which is a sign that labor might be on its way in a few days – you may notice that your belly is lower than it was before.
Pregnancy Symptoms at 38 Weeks
Now the waiting game begins. You must try to be patient and watch out for the signs of labor. Contractions may start; your water may break; you might lose your mucus plug. Pay attention to anything unusual, and make sure that you have your hospital bags packed.
You will feel more frequent bouts of Braxton Hicks contractions now. Unlike earlier in the third trimester, these false labor pains are more intense and might even be painful. They may occur closer together, which can confuse you into thinking you’re in early labor.
However, if your contractions go away when you rest or change positions, then they are Braxton Hicks contractions. True labor pains will continue to plague you despite changes in position, and they will become more painful and more intense as time passes.
The Braxton Hicks contractions work to prepare your body for labor. They soften, thin, and even open your cervix a little bit.
For second-time moms, your cervix will probably dilate a centimeter or two before labor actually begins with the Braxton Hicks contractions. (Remember that you are not in active labor, until you are at least 4 centimeters dilated.)
With cervical changes, you may notice that you have vaginal discharge that is tinged with blood. This is called the “bloody show,” and it’s often a sign that you’re on your way towards labor. However, it may be hours, or even days before you’ll go into true labor.
Swollen feet and ankles is a normal symptom in the final weeks of pregnancy. This symptom is called “edema,” and it occurs when extra fluid collects in the tissues. You can blame physical changes (such as you’re a huge uterus adding pressure to your veins), changes in your blood chemistry (you have more blood pumping in your pregnant body), and poor blood circulation for your swollen feet, ankles, and hands.
Although mild swelling is normal, you’ll want to contact your doctor right away if your symptoms are severe. If your swelling comes with persistent headaches, blurred vision or other strange vision changes, extreme upper abdominal pain or discomfort, or nausea, this may be a sign of preeclampsia – a serious complication that needs to be treated.
Your breasts may leak. What they’re leaking is colostrum – pre-milk that will nourish your newborn baby in the first days of life if you are breastfeeding.
Pelvic Exam at Your 38 Week Visit
At your 38 week prenatal visit, your doctor or healthcare provider will probably do an exam to see if there are any changes in your cervix. Your doctor may use the following terms:
- Effacement: The thinning of your cervix. This is calculated in percentages, such as 50 percent effaced or 100 percent effaced (completely effaced). A thin cervix dilates more easily. First time mothers start effacing in the last month of pregnancy with the help of Braxton Hicks contractions. Your cervix will efface before you start to dilate.
- Dilation: Your cervix starts to open to prepare for childbirth. When you are “fully dilated,” your cervix has opened 10 centimeters and you’re ready to push and give birth.
- Station: This term refers to the location of your baby’s head as he or she moves through your pelvis (a process called “descent”). The station of your baby gives your doctor an idea of how far the baby’s head has descended into the pelvis
Learning what these terms mean will help you understand how close you may be to starting labor.
“How will I know when I am really in labor?”
This is the number one
question that pregnant women ask their doctors. “How can you tell
when labor is really beginning?”
There is no definitive answer to this question. Labor is a complicated process,
and every woman will experience it differently.
Some women feel excruciatingly painful contractions before labor actually begins, while others experience a relatively comfortable tightening of their uterus. Your water may break before you feel any contractions at all.
When labor does begin
you will have regular contractions that will become more frequent and stronger. Each
contraction starts at the top of the uterus and moves in a wave-like motion
down to the bottom. Contractions push your baby downward into your pelvis, and
they place pressure on your cervix. As a result, your cervix effaces (thins
out) and dilates (opens up) to allow the baby to pass through the birth canal
In order to tell whether or not your labor has started, you need to understand the difference between Braxton-Hicks contractions (“false labor”) and true labor contractions. In the early stages of labor, it can be difficult to tell the two apart. Sometimes, early labor contractions start out feeling like Braxton-Hicks contractions.
Braxton-Hicks contractions prepare your body for delivery. These false labor contractions are usually not painful, but some women find them uncomfortable. They occur at irregular intervals, and the intensity level of each contraction varies.
In contrast, true labor contractions occur at regular intervals, getting stronger and more painful as time passes. With each contraction, your cervix undergoes changes to prepare for delivery.
An easy way to tell apart true labor versus false labor is to record the interval between each contraction. If you notice the time gap between each contraction is shortening – i.e. your contractions are getting closer together – you are probably having true labor. If the interval between contractions gets longer, or is irregular in frequency, you may be in false labor.
When you are having false labor contractions, you may get relief by changing positions or walking. When you’re in true labor, nothing you do will give you relief from your discomfort.
The only surefire way to tell if you’re in active labor is to have your doctor do a pelvic exam. Your doctor will examine your cervix to see if it’s effacing or dilating.
If you are a first-time mom, you will probably have several false alarms. To avoid multiple trips to the hospital or your doctor’s office, wait until your contractions are strong, regular, and increasing in frequency.
As a rule of thumb, you will want to wait to go to the hospital until you’re in active labor. Once you are in active labor your contractions will last between 45 and 60 seconds, and they will be between 3 and 4 minutes apart.
Keep in mind that not every woman will have a textbook labor start. You should always contact your doctor, or go to the hospital when you instinctively feel that it’s time. Trust your instinct!
What Causes Labor to Start?
We really don’t
exactly understand what triggers the initiation of labor. Several theories have
suggested that the mother, baby, and placenta all play a role in triggering
What experts do know is that prostaglandins (hormone-like substances) cause the cervix to soften and ripen near the end of pregnancy, as your body prepares itself for labor and delivery.
Once your labor starts, another hormone called oxytocin stimulates the strength of your contractions. In some cases, when labor isn’t progressing, your doctor may augment labor with synthetic oxytocin (a medication called Pitocin).
Vaginal and Rectal Tearing during Childbirth
Perineum stretches during childbirth and can tear.
The perineal area is the skin and muscle between the rectum and vagina. This area stretches during childbirth and can tear.
Perineal tear vs episiotomy
A perineal tear is different from an episiotomy. An episiotomy is an incision made by the physician in the perineum. The incision is made before the baby’s head is delivered out of the birth canal. The cut is stitched up after birth. A perineal tear occurs as the baby coming down the birth canal stretches the vaginal wall resulting in it tearing.
Perineal tear classification
Perineal tears are classified to measure the severity and extent of trauma to the perineum during child birth. Tears arising from vaginal births are categorized into four classifications: first-degree tears, second-degree tears, third-degree tears, and fourth-degree tears. Description of perineal tears, including their management and healing time, is discussed in the succeeding sections.
First-degree or superficial tears involve lacerations of the fourchette, the lower end of the vaginal tissue. Lacerations are limited to the vaginal epithelium, the perineal skin and the fat layer; only a minimum amount or none of the perineal muscles is damaged.
Women with first-degree tears that only involve the perineal skin rather than the muscles may not require stitches. First-degree tears heal quickly, and the extent of discomfort is minimal.
Second-degree tears are generally deeper than first-degree tears. Lacerations of the perineal skin and the superficial muscles, specifically the bulbocavernosus and transverse perineal muscles, are noted. The anal sphincter is not damaged.
Second-degree tears are repaired with stitches, sutured layer by layer. A tear with this classification will bring you some discomfort for a few weeks. Damaged tissues are expected to heal in two to three weeks. Women may have incontinent of flatus years after the trauma. Liquid and solid stool continence is usually maintained.
Third-degree tears involve lacerations in the perineal skin, vaginal wall, perineal muscles, and the anal sphincter muscles, the muscles surrounding the anus. Anal sphincter muscles maintain constriction of the anal orifice and prevent loss of stool. Third-degree tears have been associated with liquid stool incontinence. A third-degree tear is further divided into three types:
- Grade 3a – less than 50% thickness of the external sphincter muscle is lacerated
- Grade 3b – greater than 50% thickness of external sphincter muscle is lacerated
- Grade 3c – the internal anal sphincter muscle is also lacerated, completely lacerating the sphincter muscle.
Fourth-degree tears involve the external and internal anal sphincters and the rectum mucosa. It is often described as a third-degree tear that involves disruption of the mucosa tissue of the rectum.
Third- and fourth-degree tears are serious lacerations; thus, treatments are usually more invasive. First- and second-degree tears are repaired in the labor room under local or pudendal block, whereas third and fourth degree tears are repaired under general or regional anesthesia in an operating theater to achieve relaxation of the torn anal sphincter muscles. It may take a month or even longer to achieve complete pain relief. In the first few days after childbirth, urinating and evacuating the bowel are often difficult.
Fourth-degree perineal tears have been linked to complete fecal incontinence years after trauma.
Perineal care to relieve the pain and promote faster healing
Perineal tears and sutures can be sore and painful. A tear repaired through episiotomy can also cause a considerable amount of discomfort during the postpartum period. Here are some measures that you can do to relieve the pain and promote faster healing of the tissues:
- Apply an ice bag or cold pack to the perineum during the first 24 hours to reduce swelling. Cold applications may also reduce the risk of hematoma formation. After 24 hours, apply dry heat in the area in the form of a perineal hot pack.
- Have a sitz bath. The movement of water enhances blood circulation, decreases inflammation, and soothes the area. Sitz baths use water that has a temperature between 100°F and 105°F. A sitz bath can be used three to four times a day for 20 minutes each time.
- Perform perineal exercises three to four times daily to relieve discomfort. Perineal exercises are performed by contracting and relaxing the perineal muscles 5 to 10 times in succession, as if attempting to stop voiding.
- Maintain good bowel care. Take a shower or a bath daily. Perineal care should be done as a part of your daily bath and after urinating or bowel movement. Keep in mind to wash your hands before caring for your perineum. Always wash from front to back.
- Avoid constipation; bowel movement can be difficult during the first few days. Drink 2 to 3 liters of water a day, and increase your fiber intake. Your physician may prescribe you with a stool softener to prevent constipation.
- Manage pain with medications. Your health care provider will prescribe topical medications with Xylocaine bases, such as sprays and gels, to control and alleviate pain. An oral or parenteral analgesic with a moderate strength is prescribed for the first 24 hours; acetaminophen is then prescribed for the rest of week.
- Rest. Get adequate rest, and do not take on heavy or unnecessary tasks. Schedule your activities, and make sure to have rest periods between activities.
Steps you can take to prevent tearing
It is not uncommon for the perineal area to tear during delivery. There are few steps you can take to prevent the more serious forms of lacerations. Perform perineal massage. Research revealed that perineal massage with Vaseline before labor and during the second stage of labor increased perineal integrity, thereby reducing perineal traumas. It is also recommended to perform perineal exercises or Kegel exercises months before labor to strengthen your pelvic floor muscles.
Vaginal and Cervical Lacerations in Childbirth
Small lacerations are common and may be considered an expected consequence of childbirth. However, larger lacerations involving the vagina and the cervix predispose mothers to postpartum hemorrhage. Excessive bleeding during the postpartum period continues to be one of the leading causes of maternal death worldwide.
Larger or more extensive lacerations are caused by difficult labors, fast and short or precipitate births, and delivery of oversized infants. Women who are about to give birth for the first time and women who go into labor and delivery in lithotomy position are more susceptible to sustain vaginal and cervical lacerations.
What are vaginal lacerations?
Injuries to the vagina occurring due to labor are commonly found at the opening of the birth canal. Lacerations of the vaginal tissue may occur at a 6 o’clock position, the part of vagina nearest to the anus, or at a 12 o’clock position, the part nearest to the clitoris. Vaginal lacerations have also been identified high into the vaginal wall at the level of the ischial spines or in the expanded region of the vaginal canal.
Causes of vaginal lacerations
A vaginal laceration is commonly caused by vaginal birth. As the baby is moves through the birth canal, his or her head stretches the opening of the vagina to facilitate delivery. In most cases, the walls of the vagina can competently stretch without tearing. When the rate of birth proceeds as expected, the tissues in the vagina can sufficiently adapt to the pressure applied by the presenting part, thereby facilitating stretching. When the baby descends too quickly, such as in precipitate labor, the tissues are not provided the time needed to adapt to changes, causing vaginal lacerations. Vaginal lacerations may also involve the vaginal wall with use of forceps in a rotational manner.
Degrees of vaginal lacerations
Similar to perineal tears, vaginal lacerations are graded according to the extent of the damage or severity. Vaginal lacerations are classified into four types:
- First-degree vaginal lacerations – These tears are limited to the lining or mucosa of the vagina. First-degree lacerations are the most common type. Bleeding is minimal. A vaginal repair is usually not necessary.
- Second-degree vaginal lacerations – These tears involve the vaginal mucosa and its underlying tissue; the anal sphincter or rectum is not involved. Majority of second-degree vaginal lacerations occur in midline. A surgical repair is usually indicated.
- Third-degree vaginal lacerations – The vaginal mucosa and its underlying tissue and the anal sphincter are lacerated; the rectal mucosa is not involved.
- Fourth-degree vaginal lacerations – The vaginal mucosa and its underlying tissue, anal sphincter, and the mucosa lining the rectum are lacerated.
Third- and fourth-degree tears are more susceptible to complications, such as excessive bleeding, urinary or fecal incontinence, pain, and infection.
Treatment and management
Vaginal lacerations are difficult to repair because the vagina tissues are more friable. Third- and fourth-degree vaginal lacerations are more challenging to repair. An adequate anesthesia, a skilled surgeon, and assistance with retraction are required to explore and repair these lacerations.
Discharge often follows a repair. The vagina may be packed to maintain pressure on the suture line, thereby controlling the discharge and bleeding. When packing is inserted to the birth canal, it has to be removed in 24 to 48 hours to prevent stasis and infection, which is similar to toxic shock syndrome.
What are cervical lacerations?
The cervix is found on the lower end of the uterus. It is commonly referred to as the neck of the womb. The cervix opens into the uterus superiorly and into the vaginal canal inferiorly.
Lacerations in the cervix are commonly located on the sides of the cervix, next to uterine artery. A torn uterine artery causes excessive blood loss. Bleeding caused by a lacerated cervix occurs immediately after placental delivery.
Complications from cervical lacerations include bright red vaginal bleeding and cervical incompetence or insufficiency.
Signs and symptoms of cervical lacerations
During inspection, cervical lacerations are commonly located at the 3 o’clock and 9 o’clock positions. Any laceration measuring more than 1 ½ to 2 cm or with an active bleeding should be repaired.
Cervical lacerations involve an arterial bleeding; thus, the bleeding associated with cervical tears is bright red in color. Venous blood is lost with uterine atony, a condition where the uterine muscles are not contracted; bleeding is dark red in color.
What causes cervical lacerations?
Cervical lacerations may occur following mechanical dilatation of the cervix. The risk further increases with inappropriate use or administration of prostaglandins. The other causes of cervical lacerations include instrumental deliveries, fast and short labors, pushing before full dilation, and presence of previous scars or lacerations. Women with cervical stenosis or cervical atrophy are more susceptible to tear their uterine arteries. A research suggested that cervical cerclage, a cervical stitch used for the treatment of cervical incompetence, and induction of labor have been associated with cervical lacerations.
The possibility of a cervical laceration is suspected during the first stage of labor when cervical dilation is more rapid than expected and accompanied by vaginal bleeding.
Treatment and management of cervical lacerations
Small cervical lacerations do not bleed; thus, intervention or repair is not usually required. If active bleeding from the lacerations occurs or if an anatomic relationship is altered, repair of lacerations is indicated.
Once the extent of the laceration is determined, suturing is immediately performed. Repair of cervical lacerations is not easy. If the uterine artery is torn, the bleeding may be excessive that it can block direct inspection and visualization of the affected area. A physician will need a sufficient area to work, adequate repair supplies, and a good light source to repair the cervix to make a good repair.
If the cervical laceration is found to be extensive or if repair is more difficult than expected, administration of a regional anesthetic may be necessary. The anesthetic aims to relax the uterine muscle and to relieve or prevent pain.
Vacuum Extraction to Assist Delivery of Baby
In some labors, an operative vaginal delivery is necessary to accelerate the birth of an infant and to shorten a mother’s difficult labor, thereby preventing maternal and fetal complications. Use of vacuum devices has proven to be a reliable technique to assist delivery. Vacuum extraction has a long history. It was first used in deliveries in the 1700s based on the concept of cupping. The modern era of vacuum extractor use began in 1954 when Malstrom introduced the technique of using a metal cup, called the vacuum extractor, to accelerate deliveries that involved dystocia. Vacuum extraction has gone a long way since then. At present, use of vacuum devices has surpassed obstetric forceps as the preferred choice of method to assist vaginal delivery. The FDA reported that 228,354 vacuum deliveries are performed annually.
Why Would You Need Vacuum Extraction?
A mother in labor may need to have a vacuum extraction when a condition warrants an assisted vaginal delivery. The indications for vacuum extraction are similar to those of obstetric forceps delivery. The following are the most common reasons why a physician may order this particular operative vaginal delivery during labor:
- Failure to progress during the second stage of labor. A labor that is progressing slower than expected during the second stage of labor may require a vacuum extraction. The second stage of labor begins when the cervix has fully dilated and thinned out and ends when with the birth of the baby. It must be emphasized that this occurrence is an absolute indication for vacuum extraction. Dysfunction during the second stage of labor is characterized by an arrest of fetal descent down the birth canal. A mother who was previously in labor demonstrates arrest of descent when no descent is noted for 1 hour without anesthesia and 2 hours with anesthesia administration. A first-time mother manifests arrest of descent by the absence of descent for 2 hours without and 3 hours without anesthesia administration. Dysfunction of the second stage of labor occurs when baby’s head has failed to engage or progressed beyond the ischial spine. The most likely cause of dysfunction at the second stage of labor is cephalopelvic disproportion.
- A suspected case of fetal distress in the second stage of labor. If the baby demonstrates non-reassuring tracings on the fetal monitor, fetal compromise must be considered and addressed immediately to avoid putting the baby in jeopardy.
- Elective shortening of the second stage of labor. Presence of a maternal complication or disease can be an indication for a vacuum extraction. A mother with a pre-existing cerebrovascular, neuromuscular, or cardiovascular condition is more susceptible to experience maternal exhaustion during the postpartum period. The second stage of labor is the pushing stage. The mother is required to perform expulsive efforts to push the descending baby out of the birth canal.
Types of Vacuum Extractors
There are mainly two types of vacuum extractors: rigid-cup designs and soft-cup devices. Soft-cup devices are more commonly used in the United States. The rigid-cup extractors include the Malstrom vacuum extractor, a mushroom-shaped stainless steel cup, and the different refinements of the first steel instrument. Soft-cup extractors can be made of plastic or silicone vacuum pumps. These extractors are usually funnel, mushroom, or bell in shape. Research showed that, although soft-cup devices have a higher incidence of failure than rigid-cup designs, these devices cause less fetal scalp injury than the more rigid types.
Procedure Using Vacuum Extractor During Delivery
Before vacuum extraction is performed, an indication must be recognized and verified. The following preconditions must be met before a vacuum device is used for delivery:
- The pregnancy is at term or near term. Vacuum delivery is not indicated in cases where the gestational age is less than 34 weeks.
- The cervix must be fully opened and thinned out. The head of the baby must be well-engaged.
- The head of the fetus must be determined. Breech, face or brow presentations are absolute contraindications for vacuum delivery.
- The bladder must be empty.
After verifying the indication and meeting the preconditions, the physician may proceed with the procedure. The cup is lubricated with a sterile lubricant, and the labial folds are gently moved apart to slip the cup into the birth canal until it reaches the fetal head.
After verifying that the cup is correctly placed, vacuum pressure between 100 and 150 mm Hg is applied to allow palpation around the rim of the cup and detection of any trapped maternal tissue under the cup. This pressure also allows the cup to adhere tightly against the baby’s head. Full vacuum pressure between 450 and 600 mm Hg is applied next. Gentle traction with the cup extractor is started as soon as the contractions are recognized and the mother begins to push. The traction efforts coincide with the contractions of the uterus. The vacuum pressure may be maintained or decreased between the contractions. The descent of the baby is expected during the first pull. If uncertain of the descent, the physician may attempt two additional tractions.
Complications with Vacuum Extraction
Vacuum extraction is the more preferred choice over forceps delivery; however, this technique is not entirely risk-free. Neonatal injuries have been reported with vacuum extraction. As the vacuum extractor draws the scalp of the baby into the cap, swelling of the scalp tissue or an edema may form. Application of traction applies tension to the scalp, which increases the risk for bleeding within the scalp. Two major types of scalp injury have been associated with vacuum delivery: cephalhematoma and subgleal hemorrhages. Cephalhematoma is a collection of blood between the skull and the dense tissue covering the skull. This particular injury is manifested by discoloration of the swollen area without crossing the suture lines. Subgleal hemorrhages can be a life-threatening complication of vacuum extraction. This type of scalp injury is caused by rupture of the emissary veins. However, the advances made in vacuum extraction have significantly decreased the occurrence of subgleal hemorrhages. The most recent research findings revealed that subgleal bleeding was not observed in the large number of vacuum extraction delivery cases. Rarely, vacuum extraction can cause scalp bruising or lacerations.
Maternal injuries, such as perineal lacerations and urinary and anal incontinence, were reported following a vacuum extraction. However, researchers recognized that, overall, vacuum extraction has a lower rate of maternal injury compared with forceps delivery.
Vacuum Extraction vs. Forceps Delivery
In majority of labors, the use of obstetric instruments to facilitate delivery is not necessary. Pregnant mothers are expected to deliver spontaneously and smoothly by the time they reach their 39th week of gestation. However, there are cases when an operative vaginal delivery is indicated and necessary to prevent maternal and fetal complications. In 2004, the total percentage of operative vaginal delivery in the United States is only 5.2%. Obstetric forceps were used to assist delivery in 1.1% of deliveries and 4.1% were delivered through a vacuum extractor. Obstetric forceps and vacuum extraction have the same goal, and that is to accelerate delivery of the infant and shorten a woman’s difficult labor.
Before the eighties, forceps deliveries were more favored over vacuum extractions; however, the most recent findings revealed that the use of forceps has steadily declined from 5.5% in 1989 and 1.1% in 2004, as the frequency of vacuum extraction delivery peaked at 6.2% in 1997 and then decreased to 4.1% in 2004. What explains the gradual decrease of forceps delivery and the increasing number of vacuum extractions performed each year? Is vacuum extraction safer or more effective than forceps delivery? Which obstetrical instrument is best to assist delivery?
Indications for assisted vaginal delivery with a vacuum extractor or forceps
Before considering the factors that favor the use of one obstetric instrument over the other, it is important to emphasize that no absolute indication exists when it comes to instrumental delivery. The physician must thoroughly evaluate the mother’s and the baby’s condition and consider various factors before deciding on the preferred technique for assisted delivery. In general, both vacuum extractors and obstetric forceps are indicated when the second stage of labor is extended or prolonged. If labor is allowed to continue or persist way beyond the expected time period, an instrumental assist through the forceps or vacuum extractors can be considered.
Forceps delivery and vacuum extraction are indicated for mothers who are required to have an elective shortening of the second stage of labor. Mothers who have an underlying cardiovascular, neuromuscular, or cerebrovascular disorder are more likely to suffer from maternal exhaustion when allowed to proceed with the second stage of labor spontaneously. Both methods are also considered when an occurring or a potential fetal comprise is suspected. Non-reassuring tracing on the electronic fetal monitor may suggest a potential fetal compromise.
Forceps delivery and vacuum extraction have the same contraindications; however use of vacuum extractors has more relative contraindications in comparison to obstetric forceps use.
- Forceps delivery is contraindicated after an unsuccessful trial of vacuum extraction or in the absence of anesthesia or analgesia.
- Vacuum extraction is contraindicated when the fetus is less than 34 weeks’ gestation due to the fragility of the vascular structures within the fetal scalp at this stage of gestation. Application of suction against the scalp in premature infants increases the risk of intracranial hemorrhage and cephalhematoma. Premature infants can be delivered through forceps use.
- If scalp sampling was previously performed, vacuum extraction is not considered because the pressure created by the suction may cause severe bleeding.
In general, vacuum extraction deliveries are less uneasy for a woman in labor than a forceps procedure. A report by Johanson indicated that anesthesia is markedly reduced with vacuum extraction operations in comparison to forceps deliveries. Some anesthesia, at least a pudendal block, is necessary for forceps application, whereas an uncomplicated vacuum extraction can be performed with local infiltration, pudendal block, or no anesthetic.
Johanson and Menon reported in 2000 that a successful delivery is significantly more likely to occur with forceps use as opposed to vacuum application. The higher incidence of vacuum extraction failure rate is attributed to a number of factors, including the material of the cup used to apply the suction. Soft or flexible cup extractors have a higher incidence of failure than the rigid vacuum cups or obstetric forceps.
Delivery assisted with either forceps or vacuum extractor is not free from maternal risks, but vacuum extractor has a clear advantage over forceps in the incidence of perineal lacerations. Research showed that maternal complications, such as perineal tears or lacerations, are undoubtedly less severe after a vacuum extraction than after forceps deliveries. In almost all of the trials, maternal injury involving the genital tract is consistently higher in women who went through a forceps delivery. Forceps operations have been associated with anal sphincter injury trauma. Women assisted by a vacuum extractor reported less pain at delivery and 24 hours after birth.
Which obstetric instrument is safer for the baby? In 2001, a group of researchers led by Wen published a study that included 31,105 women delivered by vacuum extraction and 18,277 women delivered by forceps. The group concluded in their report that, although vacuum extraction delivery was associated with less maternal vaginal trauma and perineal tearing, vacuum extractors increase the risk of birth injuries, especially cephalhematoma and intracranial hemorrhage. In rare cases, a life-threatening condition called subgleal hemorrhage may occur following vacuum extraction. The application of traction applies tension to the scalp, consequently rupturing the veins and increasing the risk of bleeding within the scalp. In general, neonatal injuries are more often with vacuum extraction, whereas maternal injuries occur more frequently with forceps delivery.
Advances in has significantly reduced the number of fetal injuries caused by vacuum application. Research findings indicated that subgleal bleeding was not observed in the large number of vacuum extraction delivery cases. The succeeding list includes the fetal injuries and complications associated with operative vaginal delivery:
- Facial nerve palsy occurs in 4.5 per 1,000 in babies delivered with forceps; the rate of facial nerve palsy in babies delivered through vacuum extractors is 0.46 per 1,000.
- The risk for shoulder dystocia increases with vacuum extraction.
- Vacuum extractors are not used to assist breech presentations; however, a vaginal breech delivery may be considered as an indication for forceps application.
The use of vacuum extractors in comparison to forceps application is associated with a higher incidence of failure, more neonatal birth injuries, but less of regional anesthesia requirement or less maternal perineal trauma. However, it must be emphasized that the outcomes in vaginal deliveries assisted by obstetric forceps or vacuum extraction should not be the sole indicator of superiority of one instrument over the other. Each instrument has its own advantages and disadvantages. The choice of instrument to assist vaginal delivery should be based on the assessment of the mother’s health profile and other factors, including the physician’s proficiencies and preference.
Packing Your Hospital Bag
As you come into the final weeks of your pregnancy you might start wondering what to bring to the hospital. It is a good idea to have your hospital bags ready to go from about 35 weeks on; you simply never know when your little one will make a ‘surprise’ entrance. Largely what you bring will depend on your personal preferences and comforts.
Labor and Delivery Must Haves
Here are some general ‘must haves’ and other suggestions from moms who have “been there and done that” on one or more occasions:
- Personal identification and health insurance card.
- List of phone numbers for people you want to contact after the delivery.
- Lip balm or Chap Stick (your lips get dry when pushing!).
- Watch with a second hand to time contractions.
- Tooth brush and toothpaste.
- Something to read in case you will be in for a long delivery.
- Pillow from home with a pillowcase other than white to distinguish your pillow from the hospitals.
- Music or CD’s.
- Camera and/or camcorder with film and batteries.
- Copy of your birth plan.
- Water bottles.
- A going home outfit for mom (You will probably need to select something that fit you when you were about five months pregnant… you will not return to your pre-pregnancy size ‘instantly’ after giving birth).
- A going home outfit for baby.
- Slippers/socks to keep your feet warm.
- Baby book for getting footprints.
- Calling card (most hospitals do not allow cell phones!).
- Nursing bras and nursing pads.
- Blanket for baby.
- Robe or night gown in case you don’t want to wear the hospitals.
- Any personal hygiene items you might want (shampoo, brush etc.).
Some women prefer to
have two bags, one for labor and delivery and one for post partum. The post
partum bag may contain your outfit and your baby’s outfit for leaving the
hospital, some make up and a clean pair of socks as well as camera.
It really depends on what is most convenient for you.
Another non-necessity that many women find enjoyable is some massage oils or lotions. During the labor process, you might feel better if your partner massages the small of your back and feet. Alternatively, a light massage will feel great after you deliver!
Remember that labor and delivery is a messy process. When packing a change of underclothes, do not pack your finest lace underwear, because you will likely ruin them from the voluminous lochia (bleeding) that occurs after birth.
Remember too that it is essential to have a going home outfit that is comfortable. You will not be your pre pregnancy size just after birth, and packing a pair of too tight jeans will only leave you excessively stressed and disheartened at a time when you should be reveling in the amazing feat your body just accomplished.
Preparing your hospital bag can be a fun and encouraging process, reminding you that there is indeed an end in sight. Be sure to remember to put the bag in the vehicle you plan on using for the hospital ahead of time, otherwise you may forget it whilst in the midst of labor.
Your Baby at 38 Weeks of Pregnancy
By 38 weeks pregnant,
you are probably feeling exhausted, heavy, and bloated. You are most likely
impatient for your baby to come. Although you are early term, your baby may not be ready to come out for
another week or two (full term). So you’ll be playing the waiting game for the
next two weeks.
At 38 weeks pregnant, your baby may weigh anywhere between 6 and 7 pounds. The amount of amniotic fluid surrounding your baby continues to steadily decrease as your pregnancy continues. However, your baby still has plenty of amniotic fluid to protect him or her.
Though space is becoming very limited in your womb, your baby may still be trying to move and stay active. (Always call your doctor if you notice a change in your baby’s movements.)
By now, the long bones in your baby’s arms and legs have hardened. This process is called ossification and it has been occurring throughout your pregnancy.
Your baby’s grasp reflex is very strong now. He or she is often grasping the umbilical cord or curling his or her hands into little balls.
What does a Newborn Baby Look Like?
A healthy newborn may look a little strange in the beginning. Before a child is born, it is in the uterus, surrounded by liquid. Your baby is also curled-up because there’s not too much space left to move around anymore. In addition, babies born during vaginal births have to squeeze through a small passage. All of these types of things contribute to a newborn baby’s appearance.
Newborns are born with a thick white substance all over them, as
well as blood and fluid from their mother. This washes away during your child’s
A healthy newborn also normally has pink skin. Occasionally, a baby’s skin may look kind of blue, most commonly around the lips, as well as the feet and hands. All of this is perfectly normal.
Your child may also have some scratches, red spots or bruises after delivery. The scratches and bruises may have been caused by what’s called a fetal probe. This is what doctors use to help monitor your baby during delivery. Some newborn babies also have small bumps or spots similar to acne. These will eventually go away. You may even notice a birthmark, which may fade with time but usually is permanent.
A newborn’s face sometimes has a squished or swollen look right after delivery. However, your child’s face should be even, or rather symmetrical, when you look at both sides. Your baby’s nose and mouth are full of mucus, which the doctor or nurse needs to suction out immediately after birth.
A newborn baby’s head normally looks kind of big in comparison
with the rest of its body. The head may also appear cone-shaped or pointy if
you had a vaginal delivery. Your baby’s head should look normal after a few
days. Newborn babies also normally have a number of soft spots on their heads
where their bones still need to grow together fully.
While some babies don’t have any hair, others have a lot. Many times, a baby’s hair will fall out over the first month and new hair will replace it.
Your newborn’s neck should be lump-free and smooth. Some newborns have their neck twisted to one side because of the position they were in inside the womb. Doctors call this torticollis or wry neck. There are certain treatments to help straighten out a child’s neck when this happens.
A baby’s genitals are often swollen or puffy right after delivery.
Sometimes, girl babies have vaginal discharge that is white or even bloody.
This is caused by the mother’s hormones. It’s normal and goes away.
As for boys, the skin that covers the tip of the penis, or the foreskin, shouldn’t be pulled back, and is normally tight. If you want to have your baby circumcised, surgery will remove this skin.
Belly and Chest
You may see some swelling in your baby’s breasts. You may even
notice some milky fluid. This is due to hormones from the mother. The leaking
or swelling normally goes away over the next few days or even weeks.
A newborn baby’s belly usually sticks out some, and is usually round. Once the umbilical cord is cut, you’ll notice the small stump where your child’s belly button is. Your nurse will tell you how to take care of this. The stump normally falls off over the next week or two.
Legs and Arms
Your newborn may want to keep its legs and arms close to his or her body, and bent as if they were back in your womb. You want to make sure their legs and arms move the same amount on both sides.
Right after your baby is born, your nurse or doctor will check these things:
- Check genitals to see whether baby is a boy or girl.
- Check body’s movement and position.
- Check skin color.
- Measure baby’s length, weight and head.
- Check baby’s body to make sure everything is normal.
- Check baby’s organs to make sure everything is working correctly.
Can the Nurse or Doctor tell if my Baby is Healthy?
It’s difficult to know just by looking at a newborn baby whether the child is healthy. However, your nurse or doctor will check for certain things. These include the size, appearance and position of certain body parts. These things can be signs of other health issues. This makes it extremely important that a nurse or doctor sees your baby after delivery.