Additional information

CTG

A CTG, (short for: cardiotocogram), is a method by which a device measures the heart rate of your unborn baby (cardio). It can also observe and monitor any activity of your uterus (toco).

A CTG during your pregnancy is usually performed via your abdomen with the aid of an external transducer, but can also be monitored internally during labour. If it’s performed externally you get two straps around your tummy with two devices with sensors. One device, the doppler, measures your baby’s heart rate. The other device, the tocometer, can detect and record activity in your uterus. If your baby’s heart rate is recorded internally, it will be done with an electrode. This is attached via your vagina with a small clip on the head or on the buttocks of your baby.

When using the CTG internally and externally, it is also possible to register the information wirelessly. This gives you more ability to move around.

Birthing positions.

Compilation of photographs of birthing positions from a labour room in OLVG-West

Pain relief

In the case of a breech birth, you have the same possibilities to labour in a position of your choice as you do when you give birth to a baby in head-down position. This can be done with breathing techniques, by adjusting your position, or by taking a shower or bath.

If you want pain relief, you have the choice between an infusion (IV) with a pump containing remifentanil or an epidural. The pros and cons of these options will be discussed with you by the midwife or doctor who will is caring for you.

Remifentanil
Remifentanil is a painkiller that is administered by means of a pump and an infusion. Which has a button that gives you control over its administration. The drug can usually be administered directly and works very, very quickly. The moment you no longer press the button, the drug disappears quickly out of your body. It doesn’t take away all the pain, but makes you a little sleepy, making the pain more bearable.

Disadvantages/side effects/complications

• Some patients become so sleepy that they forget to breathe properly. That’s why we’ll always measure your oxygen levels. If your oxygen level is too low, we’ll give you a lower dosage or turn off the pump.
• If Remifentanil does not provide enough pain relief for you, you can still opt for an epidural.

Epidural analgesia (epidural)

The epidural is placed by the anesthesiologist. You can’t feel the pain of contractions. The epidural has no overall anaesthetizing effect on the mother (only in the target area: the abdomen and has no or anaesthetizing effect for the baby.

Disadvantages/side effects/complications

• Because it is sometimes more difficult to push with an epidural, you have a slightly increased chance of needing help with the birth, but no increased chance of a cesarean section.
• Length of pushing-phase can be longer (16 minutes longer on average).
• Moving and standing on your feet is usually not possible.
• There is a higher risk of low blood pressure (hypotension): an infusion (IV) is always inserted prior to the placing of an epidural in case of the need for the administration of fluid and possibly medication.
• Because you can’t feel when your bladder is full, a catheter tube is inserted into your bladder. After inserting a bladder catheter there is a risk of cystitis or that you cannot urinate properly once the pain relief has worn off.
• When using pain relief, medication to stimulate the contractions is more often required (artificial oxytocin).
• You have a 20% chance of fever. Usually it is not possible to make a distinction whether this is physiological (normal) or fever due to infection. Therefore, you have more chance of being prescribed antibiotics and there is an increased chance that your baby will have to be admitted for observation to the special care baby unit due to suspicion of an infection.
• During to the placement of the epidural, there is a small chance that the needle will end up in the wrong place which can lead to leakage of cerebrospinal fluid. This can give you a severe headache. However, if this happens, this can be remedied by patching the leak after childbirth.

Medication to stimulate the contractions (artificial oxytocin)

Oxytocin is a hormone produced by the pituitary gland (a gland in the brain). It causes the muscles of the uterus to contract rhythmically. It is these contractions, which causes the cervix (the opening of the uterus) to open up (dilation phase) and then to help you to push your baby out of your uterus (pushing phase). If it is necessary to induce or strengthen the contractions during labour, you will be given artificial oxytocin via an infusion (IV). Also after the birth you will get an injection of oxytocin to help the placenta to be delivered, and also to prevent too much blood loss. Artificial oxytocin can sometimes cause nausea, or headaches or palpitations. .

Risks of vaginal breech delivery

The risks for you are the same risks as with a vaginal delivery of a baby in head-down position.

• Hemorrhage, infection of the wound in the event of a tear or episiotomy (cut).
• Approximately 8 out of 100 women suffer from complications (8%).

The risks for your baby are slightly greater after a breech birth than in a head-down position or a caesarean section.

• Each baby born gets a score of 1 to 10: at 1 minute, 5 minutes and 10 minutes after birth. This is called the Apgar Score. This score tells us something about whether the baby is doing well: the higher the score, the better the condition. When born in breech position, the baby can be limp a little longer and sometimes needs longer to breathe properly. This is normal for a baby where the head is born last. In these babies, the Apgar score is usually slightly lower after one minute. After five minutes they have the same Apcar score as a baby born in head-down position.
• 2 out of 100 babies (2%) born in a breech position require admission to the special care baby unit immediately after birth. For example, because the baby needs extra oxygen.
• 2 out of 1000 babies (0.2%) die during or after a vaginal breech delivery.
• If the obstetrician has had to help during the birth of the arms and the baby’s head, then it is possible that the collarbone or bone of the upper arm can break. There is also a chance of nerve damage in this area. This happens to 1.8 out of 100 babies (1.8%) where the obstetrician has had to help.
• Serious problems arise in 1 to 1.5 out of 100 babies born in a breech position (1 to 1.5%).

Delivery of a baby in head-down position

• Hemorrhage, infection of the wound in the presence of a tear or episiotomy. 9 out of 100 women suffer from complications (9%).
• In 20 out of 100 women (20%) the birth ends in a caesarean section.
• Of all vaginal births, with both high risk and low risk of problems, approximately 9 out of 100,000 mothers (0.009%) die.
• Of all babies born after 37+0 weeks both vaginally and by caesarean section, the death rate is 1 in 1000 babies (0.16%).

Chance of a caesarean section in case of a vaginal breech birth

If it’s your first delivery, 55-60 out of 100 women give birth vaginally when the baby is in breech position (55 to 60%).

If you have given birth once before this figure rises to, 75-80 out of 100 women (75 to 80%).

Look at the bottom of this page for the differences between a vaginal breech birth and a caesarean section compared to a head-down delivery.

Risks of caesarean section

For yourself:

• Hemorrhage, infection of the surgical wound or the formation of blood clots that can cause complications (thrombosis). About 9 out of 100 mothers (9.0%).
• A small risk of being cut into your bladder and/or bowel.
• With infection, healing of the wound can be long-lasting.
• Breastfeeding can be more difficult, because you are less mobile and in pain.
• With an unplanned caesarean section, the first contact with your baby can be delayed, because you cannot be directly together in the operating room.
• Before surgery, a catheter tube is inserted into your bladder. After inserting a bladder catheter there is a risk of cystitis or that you cannot urinate properly following its removal.

For your baby:

• About 3 out of 1000 babies (0.3%) require admission to the special care baby unit.
• Less than 0.5 out of 1000 babies (0.05%) die following C-section.
• Skin-to-skin contact is known to be important but sometimes after the caesarean section it is not immediately possible.

Risks to subsequent pregnancies after an earlier caesarean

In approximately10 out of 1000 deliveries (1.0%) there is a problem with the scar on your uterus (uterine rupture). This is means that the scar from the previous C-section can tear during a subsequent delivery. If this happens, the baby must be born by an emergency caesarean section. As a result of a uterine rupture, 5-10 out of 1000 babies (0.5-1%) can die. That’s why we advise you to give birth in the hospital once you’ve had one caesarean section.

After a caesarean section, problems may occur with the growth of the placenta in the case of a subsequent pregnancy. During your discussion with the obstetrician you will get an explanation about this.

Differences between a vaginal delivery and a caesarean section, when a baby is in the breech position.

Warning: real imagery