Complications during pregnancy can affect the kind of labour and birth you have. Our obstetrician answers your questions so you know what to expect…
Posted: 5 December 2011
by Jonathan Scott – Consultant obstetrician and gynaecologist
Q: A friend of mine was diagnosed with GBS in the late stages of her pregnancy. It sounds scary – how does it affect the birth?
A: Group B Streptococci are found in the vaginas and rectums of about 28% of pregnant women from time to time and usually cause no symptoms. However, the foetus may be affected if membranes have ruptured for a long time, or during it’s descent through the vagina.
An infected baby does not usually show evidence of the problem (lethargy, poor feeding, temperature) until several hours after the birth, and may suffer from pneumonia and even meningitis.
Although GBS sepsis is the commonest cause of serious infection in newborns in the UK, it probably only occurs once in about 2,000 births (although some authorities claim more).
Current management in the UK is to administer antibiotics to women in labour who have been found to have urinary GBS or other maternal infection, are in preterm labour or have had prolonged membrane rupture, to observe the baby and administer antibiotics at the first sign of any trouble.
If you are still particularly worried, ask to be tested a month before you’re due.
Q: I recently had a bleed, and after an examination I was told that I have a low-lying placenta. Does this mean I won’t be able to have a normal birth?
A: It all depends on how pregnant you are and how low the placenta is lying. If the finding was made before about 28 weeks, during the last trimester the lower uterine segment will develop below where the placenta is implanted and there may well be no problem with a vaginal delivery. Another ultrasound scan at 34 weeks should clarify the situation. In later pregnancy, especially if the placenta is extensively attached near the internal opening of the neck of the womb (the condition is called placenta praevia), a vaginal delivery would be out of the question. Heavy bleeding during labour would be inevitable and a Caesarean is the only safe option for mother and baby.
Q: Can you be too slim to have a natural birth? I am very narrow-hipped, and friends have questioned whether I’ll be able to give birth.
A: Slimness is a very poor predictor of the size of the inside of the pelvis. Decades ago, elaborate callipers were used to measure the distance between the outer parts of the hipbones, and these instruments can now be found gathering dust on a box marked ‘Obsolete Equipment’! Even x-rays, which really can measure the size and shape of the pelvic cavity, are seldom, if ever, used because they cannot assess the functional capacity of the pelvis.
Remember, the pelvis moulds and alters its shape in labour just as the baby’s head does. Height can sometimes give an idea of pelvic size but really the best way to measure a pelvis is with a baby’s head in labour. I would not suggest that the management of your delivery should be modified, no matter how slim you are!
Q: My midwife assumes I will be have a c-section for the birth of my second child as I had an assisted delivery (episiotomy, forceps and ventouse) in April 2003, which resulted in me undergoing a procedure to remove scar tissue. I don’t really want a caesarean but should I follow her advice?
A: Even though your first delivery wasn’t straightforward, I would not have thought a caesarean was mandatory this time around. I hesitate to disagree with your midwife, who obviously knows your history and the state of your perineum better than I do, but the chances are that you will deliver unassisted this time and that any tears, or an episiotomy should it be necessary, will heal satisfactorily. It is very rare that a vaginal delivery is so traumatic that it is considered unwise to attempt that route a second time and from what you say, I don’t think you fall in that category. Obviously one can never be certain how things will turn out, but if you are keen to avoid a caesarean, I should aim for a vaginal delivery with a degree of optimism that this time matters will take a smoother course.
Q: Are there any disadvantages to having an injection to speed up delivery of the placenta after birth? Does everyone just opt for this?
A: The injection contains ergometrine, which gives the womb a squeeze to separate the placenta from its bed, and oxytocin (also known as Syntocinon) to keep the womb contracted and reduce bleeding from where the placenta has been attached. The use of this injection, known as Syntometrine, has greatly reduced the number of women who bleed heavily, even fatally after the birth.
For women with high blood pressure, ergometrine may briefly cause BP to go up more, and so usually just oxytocin is given. Ergometrine has also been blamed for a slight increase in that least romantic aspect of childbirth – vomiting afterwards. Unfortunately, however, this is quite common anyway.
If Syntometrine is unacceptable or unavailable, putting the baby to the breast or just rubbing the nipples will cause the pituitary gland to release oxytocin, but this takes longer to work and, in the vast majority of cases, Syntometrine is by far the best bet.
Q: I have just found out I am pregnant again – so am all excited, but also scared! My first baby was a whopping 9lbs 13oz, requiring forceps and an episiotomy. I have heard that the second is always bigger and I am terrified! Is there anything I can do to help control the birth weight, or at least prepare myself?
A: Second babies are often – but not always – larger than the first and nothing can or should be done to restrict foetal growth, such as diet (or gin!). It would be worth checking you don’t have a tendency to diabetes. If you do, the management of this condition would be very important and reduce the odds of another whopper.
Early induction a few days before term in the hopes of a smaller baby should only be considered if the cervix is really ripe – you don’t want to risk a long labour or even not going into labour at all.
Unless your first delivery was really traumatic – for instance with bowel or bladder damage – very few obstetricians would recommend a caesarean, which is not the easy option it is often thought to be.
Your worries are shared by many women who have had a large baby. My experience is that most of these worries turn out to have no foundation. Some more good news is that second deliveries do tend to be more straightforward.
Q: My mother was diagnosed with Group B Streptococcus in the late stages of her pregnancy with my younger brother. I am concerned that this might happen to me (I’m 10 weeks pregnant). What is the procedure for dealing with this condition during the birth?
A: Group B Streptococcus (GBS) is the most frequent cause of severe infection in newborn babies and is usually caught by passing through an infected vagina. 25% of women carry GBS vaginally and most have no symptoms. As most babies exposed to GBS suffer no harm, there’s no routine screening and antenatal treatment of carriers is not helpful. Babies born by caesarean can still acquire GBS infections.
Women especially at risk are those who labour before 37 weeks, where the waters break 18 – 24 hours before delivery, where for whatever reason GBS has been found in the vagina or urine during the present pregnancy, or when a previous baby developed this infection. The treatment for women at risk of transmitting the infection is intravenous penicillin (or clindamycin) while they are in labour.
The question of routine screening is shortly to be reviewed, and test sites may start offering vaginal and rectal swabbing for all pregnant women at about 37 weeks. If you request a screening, many hospitals would agree on an individual basis, but the fact that your mother had a GBS infection does not increase your risk.
Q: I want an active labour so I can try and get through it without pain relief. I’m 36 weeks pregnant now and am putting together my birth plan. I know how long labour can last, so how can I be active without getting tired out?
A: Strenuous exercise during labour is out of the question but walking, taking frequent pauses to lean on something, is helpful. The weightlessness of a deep bath meanwhile is not only comforting but also allows easy movement from one position to another so that limbs can be flexed without difficulty. Keep your birth plan simple. Remember that labour can be unpredictable – so try and go with the flow.
