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Hospital procedures

What happens when you go to hospital in labour? What are some of the procedures that might be proposed when you first arrive? What about later on in labour or at the time of the birth?

Informed consent 

Under the Belgian Law of 22 August 2002 on Patients' Rights, midwives and physicians must have your free and informed consent (i.e. agreement) before beginning any intervention or procedure. They should therefore be explaining the purpose and urgency of any intervention or procedure, what is involved, as well as any potential risks or side-effects.

For examples of questions you may like to ask your care provider about procedures during labour and birth, see Pregnancy > Birth preparation > Writing a birth plan.


In this section we'll look at procedures that might be suggested or carried out:

 

 

 

 


When you first arrive at hospital

Have you thought about attending an antenatal class?

Antenatal classes provide an opportunity to discuss labour and birth in a safe and supportive environment, so that you can explore your own feelings and wishes, feel more confident about making informed decisions and feel better able to communicate with your care provider(s).

'Spontaneous' labour (i.e. labour begins naturally)
When you first arrive at the labour ward, a hospital midwife carries out an initial assessment to try to establish how your labour is progressing. She may ask for the 'feuille de liaison' (or 'carnet de la mère') your gynaecologist gives you towards the end of your pregnancy - this provides the midwife with a summary of your health and your pregnancy, and contains any information that may be important for your care.

She will ask you about the labour signs you are having (e.g. contractions, waters breaking) and will check:

    • your weight, blood pressure, temperature and heart rate
    • a urine sample, to check for protein, glucose
    • your baby's position (e.g. head-down, breech - she can tell this by palpating your abdomen) and heart rate (using a fetal monitor that is strapped around your belly or a Doppler)

She may also ask if she can perform an vaginal exam to check:

    • the dilation of your cervix
    • whether or not your waters have broken
    • your baby's presentation (e.g. which part of the head is coming first) and engagement (i.e. how far down your baby has moved through your pelvis)

Based on her assessment, she may suggest admitting you to the labour ward, or - if she feels that you are not yet in true labour - may ask you to go home and come back when labour is more advanced.



Induced labour
If you have come to hospital to have your labour induced, on your arrival the midwife carries out the same checks mentioned above before admitting you to the labour ward. 

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Once you're admitted to the labour ward

Have you thought about attending an antenatal class?

Antenatal classes provide an opportunity to discuss labour and birth in a safe and supportive environment, so that you can explore your own feelings and wishes, feel more confident about making informed decisions and feel better able to communicate with your care provider(s).

If you are admitted to the labour ward, the midwife will ask you to change into a hospital gown or your own nightshirt/t-shirt, and will probably monitor your baby's heart rate for around 30 minutes, using a cardiotocograph (CTG). To do this, you will have two electronic discs (transducers) held to your abdomen by stretchy bands - one measures your contractions, the other, your baby's heart rate. Reading these two sets of results together helps the midwife see how your baby is responding to your contractions. Read more about monitoring during labour (external link).

Some hospitals have wireless CTG machines, so you may still be free to move around. If a wireless machine is not available, rather than lying in bed you might feel more comfortable sitting on a birth ball, or standing and leaning forward on the bed. Being able to be sway or rock may help you manage contractions. See this handy poster for some ideas of positions that can make your labour easier.

    • If you have not been tested for group B strep, the midwife will offer to perform this test by taking a swab during an internal exam - this swab is then tested quickly in the hospital laboratory, and if you test positive, you will be recommended to have IV antibiotics during labour and birth.

    • If you are being induced or need IV antiobiotics during labour (due to a group B strep infection) you will need an IV line in your hand/arm. While being attached to an IV pole may reduce your field of movement, it is still possible to remain active and upright during labour.

Your midwife may also suggest the following:

    • placing an IV line - even if you are not being induced or need IV antibiotics, some hospitals like to place an IV line in your hand/arm so that staff have access to a vein if required later in labour (e.g. syntocinon to accelerate labour, for additional fluids should you have an epidural). Ask your care provider about practices in his/her hospital.

      Instead of being connected to an IV pole, the midwife may offer to place a saline lock. This means the catheter in your hand/arm is 'locked', and not attached to anything, therefore not restricting your movement.

    • shaving your pubic/perinneal area - unlike in many other countries where this practice is now rare, it is still often proposed in Belgium. It was previously thought that shaving the pubic/perinneal area reduced the chance of infection following a tear or episiotomy, but research shows no benefit in such shaving

    • self-administered enema - another procedure that is becoming less common, this can reduce the risk of you passing faeces during the birth. The midwife will provide you with a small plastic vial which is inserted in the anus, and which, after about 5 minutes helps you clear your colon.

If you do not feel comfortable with any of these procedures, discuss the need for them with the midwife. 

Your midwife will usually then take you to your own labour room - in Belgium, labour rooms are not shared. In some hospitals you can stay in the same room for labour and birth, while in others, you may have to move room when the birth is imminent. This may also depend on how busy the labour ward is. 

The hospital midwife contacts your gynaecologist to let him/her know that you have been admitted and how your labour is progressing.


Induced labour
If your labour is being induced via syntocinon (artificial oxytocin - the hormone that causes the uterus to contract), the midwife will probably start the syntocinon drip (via the IV line in your hand/arm) within an hour or so of your arrival at hospital. It can then take some time to find the right dosage to have efficient contractions. 

As syntocinon can lead to stronger contractions than you might have naturally, your baby should be monitored continuously during labour to make sure that he/she is coping well - CTG monitoring checks how your baby's heart rate responds to each contraction. Many hospitals have wireless machines, in which case you should still be able to move around.

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During labour 

Have you thought about attending an antenatal class?

Antenatal classes provide an opportunity to discuss labour and birth in a safe and supportive environment, so that you can explore your own feelings and wishes, feel more confident about making informed decisions and feel better able to communicate with your care provider(s).

During labour you will be looked after by hospital midwives who undertake any of the standard care, procedures and general monitoring. Hospital midwives typically liaise with your own gynaecologist e.g. via telephone, during this time to discuss how your labour is progressing. Any suggestions to e.g. artificially break your waters or accelerate your labour using syntocinon would be discussed with you and your gynaecologist, and you would be asked for your agreement.

Fetal monitoring
The Belgian KCE guidelines (1) recommend that - if your labour is progressing as normal, and you have not been administered any syntocinon to induce or speed up labour - your baby's heart rate can be monitored intermittently (i.e. not continuously).

In Belgium, this is usually done with with a CTG machine (2, 3, 4). Many hospitals have wireless machines, in which case your movement need not be limited. 

If a wireless machine is not available, rather than lying in bed you might feel more comfortable sitting on a birth ball, standing and leaning forward on the bed or in another position where you can sway or rock to help you manage contractions. See this handy poster for some ideas of positions that can make your labour easier.


Artificially breaking the waters
If your midwife feels that labour is progressing too slowly, she may suggest artificially breaking the bag of waters that surrounds your baby. With your agreement, she will then discuss this with your gynaecologist before proceeding.

During a vaginal exam, the midwife inserts a sterile 'hook' that she uses to gently break the bag of waters. Doing this usually makes contractions become more frequent and more intense.

Accelerating labour using syntocinon
If breaking your waters has not have the desired effect, your midwife may - again, with your agreement and after discussion with your gynaecologist - suggest accelerating your labour using syntocinon. 

This is given through an IV line in your hand/arm. The dosage can be increased or lowered depending on how you and your baby react.

As syntocinon can lead to stronger contractions than you might have naturally, your baby will probably be monitored continuously during the rest of your labour to make sure that he/she is coping well - continuous CTG monitoring (i.e. stretchy belts around your belly that hold two electronic discs in place) will be done to monitor how your baby's heart rate reacts to each contraction.

Eating and drinking
Whether or not you are 'allowed' to eat and drink during labour may depend on your choice of hospital. The Belgian KCE guidelines (1) recommend that labouring women are allowed "to drink clear liquids (possibly with sugar) as long as there is no medical counter-indication". Some hospitals impose no limitations on food or drink, while others may try to limit your intake.

Ask your gynaecologist about this in advance, or ask the question during a hospital visit.

Reluctance to allow eating and drinking in labour stems from the small risk of inhaling stomach contents should a general anaesthetic be necessary. However, most caesarean births are now performed under epidural and anaesthetists can take extra precautions if they know you have eaten prior to a general anaesthetic. Read evidence-based information about eating and drinking in labour (external link).

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During birth

Have you thought about attending an antenatal class?

Antenatal classes provide an opportunity to discuss labour and birth in a safe and supportive environment, so that you can explore your own feelings and wishes, feel more confident about making informed decisions and feel better able to communicate with your care provider(s).

Episiotomy
An episiotomy is a cut from the lower side of the vaginal opening, which may be necessary if your perineum (the are between the vagina and anus) is not stretching enough for your baby to pass through. Although this is not a routine procedure in Belgium, episiotomy rates during hospital births are quite high - in 2010, over 35% of all vaginal births in Brussels involved an episiotomy. For first-time mums, the rate is over 54%For comparison, in planned homebirths, the episiotomy rate in 2010 was 0.8% (3).

When an episiotomy is needed, the Belgian KCE guidelines (1) recommend a diagonal cut from the vaginal opening (called a 'mediolateral' cut), rather than straight down. An episiotomy is performed when the tissues are already stretched, so it is unlikely you will feel much pain. However, a local anaesthetic may be given before the episiotomy is performed. Ask your care provider about this. After the birth, a local anaesthetic is usually administered while your care provider stitches the cut.


How can I reduce the chance of needing an episiotomy?

There are various ways to try to avoid needing an episiotomy.

Read more about episiotomy, including recovering from an episiotomy (external link). 

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References

  1. Belgian Health Care Knowledge Centre (KCE) Guideline to low risk birth (in English). 
  2. Cammu, H., Martens, E., Van Mol, C., Jacquemyn, Y. (2013) Perinatale activiteiten in Vlaanderen 2012. Brussels: Studiecentrum voor Perinatale Epidemiologie (SPE)
  3. Leroy, C., Van Leeuw, V., Minsart, A-F., Englert, Y. (2012) Données périnatales en Région bruxelloise – Année 2010. Brussels: Centre d’Épidémiologie Périnatale
  4. Leroy, C., Van Leeuw, V., Minsart, A-F., Englert, Y. (2012) Données périnatales en Wallonie – Année 2010. Brussels: Centre d’Épidémiologie Périnatale  

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