A normal birth

A “normal” birth, also referred to as a spontaneous delivery, is a birth where a child is born naturally by means of a vaginal birth. This is a natural process that is, in principle, possible without medical assistance. This is how people were born for millennia.

However, in the past, the rates of infant and maternal death associated with childbirth were very high. This is sadly still the case in some developing countries. In Germany, modern medicine has vastly reduced the rate of maternal death. In 2017, 7 out of 100,000 women died during pregnancy or in the 42 days following the birth.

The WHO estimates that a cesarean section is medically necessary in around 10% to 15% of births. However, around 30% of children are born by cesarean section in Germany. In some cases, an “elective” cesarean section can be performed following careful consideration of the benefits and risks. 

There’s almost no such thing as a “normal” birth because all people and all births are unique. In many cases, the birth doesn’t go as expected. This article describes what to expect in the case of a standard birth in Germany.

Deciding where to give birth to a baby is a very personal choice. If the pregnancy has been free of complications, the expectant mother is free to choose between giving birth in hospital on an inpatient or outpatient basis, at a birthing center, or at home.

If she wants to be certain that medical care is available to her at all times, then the best choice for her is to have the baby delivered in a hospital. However, if it’s important to her that medication or medical intervention won’t be part of the birth unless absolutely necessary, then a home birth or a birthing center may suit her better. Delivering a baby at home or in a birthing center means that the mother will receive individual, one-to-one care from a midwife in a pleasant, homely atmosphere. Many hospitals and birthing centers host very helpful information evenings and visits.

The precise signals that trigger labor remain unknown to this day. It is likely that several chemical messengers are produced by the mother, by the baby, and by the placenta, which links the two.

The normal term of a pregnancy is around 40 weeks. Most children are born within the period beginning 14 days before and ending 14 days after their calculated due date. Only about 4% of births happen on the precise due date.

How will I know when it’s time?

There are various signs that indicate that a woman is going into labor:

• The waters break and amniotic fluid gushes or trickles out.
• Labor pains (contractions) occur at intervals of 5 to 10 minutes.

If you notice at least one of these signs, you should contact your midwife or go to the hospital. The midwife will perform a vaginal examination to determine whether the cervix has in fact begun to dilate and the birth is actually underway.

Not every painful contraction of the womb indicates the start of labor. There are several types of contractions, some of which may occur long before the birth:

• Early contractions and Braxton Hicks contractions (false contractions): If the womb can be felt to contract without any pain, this is due to early contractions, which have no effect on the cervix.
• Lightening or dropping pains and training contractions: These can occur in the final 4 weeks of pregnancy and serve to move the baby’s head down into the pelvis. They can sometimes be painful but have no effect on the cervix.
• Dilating pains (first-stage labor pains): These are initially irregular but later become regular, painful contractions occurring at intervals of 3 to 5 minutes or less. These serve to dilate the cervix and mark the start of labor.
• Second-stage labor pains: These are strong, painful contractions occurring 2 to 5 minutes apart and serve to help the baby make its way through the birth canal.
• Pushing contractions: These also occur during the second stage of labor, when the woman feels a strong urge to push with the abdominal muscles.
• Third-stage labor pains: Once the baby is born, the womb contracts and expels the afterbirth (placenta). These contractions reduce post-partum bleeding from the internal wound in the location where the placenta was attached to the womb.
• Afterbirth contractions/post-partum contractions: These help the womb recover and return to its normal size. They also promote the return of the woman’s menstrual cycle. These contractions often occur during breastfeeding because the hormone oxytocin, which triggers milk production, also causes contractions of the womb.

A normal birth, also known as a spontaneous delivery, lasts around 4 to 18 hours. For first-time mothers, labor usually lasts somewhat longer. There are four stages of labor:

First-stage labor

During the first stage of labor, the cervix slowly opens until it is fully dilated. This allows the baby to move from the womb through the cervix and into the vagina (birth canal). Hormones ensure that the tissue in the area becomes soft and stretchy.

Second-stage labor

The second stage of labor begins when the cervix is fully dilated, i.e. approximately 10 centimeters dilated. The bony pelvis is shaped like a basin, which has an inlet that is ovoid in shape and an outlet that is an elongated oval. The funnel shape of the pelvis guides the baby’s head to gently turn by 90 degrees in order to fit through the pelvic outlet and into the birth canal. The contractions during this stage help the baby on its way.

Pushing phase

Shortly before the baby’s head emerges through the vaginal opening, the mother will experience pushing contractions. She will feel a strong urge to push with her abdominal muscles during each contraction. Most babies are born head first and facing towards the mother’s back. If the baby is born face up, this is known as the stargazer position. Once the head is delivered, the shoulders will follow with the next few contractions. The rest of the body is quickly delivered soon after. Babies in a breech position can also be born by means of a vaginal birth. In this case, the baby is pushed bottom first through the birth canal.

Third-stage labor

Once babies have been delivered, they take their first breath. Their lungs unfold and they often cry as they exhale. The midwife cuts the umbilical cord and cleans and examines the baby. Once this is done, the baby is placed on the mother’s chest. Contractions during the third stage of labor help deliver the placenta (afterbirth), which is checked to ensure that it is complete. If the baby suckles at the mother’s breast, this stimulates her body to expel the placenta.

Labor may be delayed or become stalled during each stage. If this happens, various aids can be used to help labor progress in a natural way:

Oxytocin infusion

If labor is slow to progress, synthetic oxytocin can be given intravenously to make the contractions stronger. 

Ventouse (suction cup)

If labor becomes stalled during the second stage, the baby is already in the birth canal. In this case, the doctor may use a ventouse to deliver the baby. With a ventouse-assisted/vacuum assisted delivery, the midwife will continue to coach the mother. A cap made of metal or plastic is placed on the baby’s head and attached by suction. No injury is caused to the baby as a result. Marks will be visible on the skin after birth where the cap was attached but these don’t take long to disappear.

Women can have widely differing experiences of pain during labor. As a rule, fear and tension make the pain more difficult to bear. That’s why many approaches used in preparation for and during labor are aimed at creating a relaxing atmosphere.

There are various ways to successfully manage labor pains. It’s best for the expectant mother to discuss these with her midwife before the birth. No-one should have to endure unbearable pain. The following methods of pain relief can be used during labor:

Non-medical pain relief

During the first stage of labor in particular, changing positions or taking relaxing baths can help make the pain more bearable. Other options include taking short walks, sitting on a gym ball, and using relaxation and breathing exercises. Alternative methods such as acupuncture may also help.

Anti-spasmotics

Anti-spasmotic medication can be administered during the first stage of labor and help the cervix to dilate. 

Medical pain relief

Mild painkillers can provide relief during the first stage of labor. Stronger medication, such as opiates, can be used as labor progresses but can no longer be used as the end of labor approaches. If opiates are administered shortly before the baby is delivered, they can affect the baby’s breathing after the birth. Laughing gas can also be used as pain relief during labor. 

Peridural (epidural) anesthesia

Effective relief for painful contractions can be provided by means of a pain catheter inserted into the lower back close to the spinal cord, which delivers pain relief as required or continuously. A soft, narrow rubber tube is inserted into the space between the main parts of the spinal vertebrae and the spinal cord to deliver pain-relieving medication. This blocks the transmission of pain signals from the pelvis.

The decision as to whether to administer an epidural should be made before the contractions become too strong but after the cervix has begun to dilate. An epidural delivers reliable pain relief, and can also be used if a C-section is required. However, the drawback of an epidural is that it often makes labor slower and contractions weaker. For this reason, an oxytocin infusion is often also used. The desire to push is often somewhat weaker with an epidural. Other possible side-effects are a drop in blood pressure and difficulty passing urine.

Spinal anesthesia (spinal block)

With spinal anesthesia, pain-relieving medication is injected directly into the fluid around the spinal cord. This provides very rapid pain relief. Spinal blocks are used in particular if a C-section is required. The advantages of this method over a general anesthetic are that the mother can remain conscious to experience the birth of her baby and that the baby can be placed in her arms immediately after the birth.

Pudendal nerve block

If pain relief is required during late labor, the transmission of pain signals to the external sex organs and the area between the vagina and anus (perineum) can be blocked by means of an injection through the vaginal wall. However, use of this method has become extremely rare.

Although the tissue in the area is made soft and stretchy, the baby’s delivery through the birth canal can still cause injuries to the membranes lining the vagina, for example. Small tears will heal on their own. Larger tears can be stitched back together shortly after the birth.

Injuries to the perineum

The perineum is the area of soft tissue and muscle between the vagina and anus. Midwives protect the perineum during the pushing stage of labor using specific hands-on techniques (manual perineal protection). However, if strong pushing contractions accelerate the delivery, tears may still occur in the perineal area.

In particular when delivery instruments such as a ventouse are used, it may be necessary to cut the perineum to widen the opening of the birth canal. Injuries to the perineum are treated shortly after the delivery.

Partial retention of placental tissue in the womb

It is important to check that the placenta is complete after it has been delivered. If parts of the placenta remain in the womb, this can have very serious consequences. If the placenta is incomplete, the doctor will remove any remaining parts from the womb by hand. This procedure is done under anesthesia. If some of the placenta is retained, this also increases the risk of the womb not contracting sufficiently, leading to severe hemorrhaging.

Post-partum hemorrhage (severe bleeding after the birth)

Hemorrhaging may occur after a normal delivery or a C-section. The main cause of severe and potentially life-threatening hemorrhaging after the birth is uterine atony, i.e. failure of the womb to contract following delivery.

To avoid this risk, a woman who has given birth is kept under observation for 2 to 4 hours. If the baby suckles at the mother’s breast, this stimulates production of the hormone oxytocin, which promotes the contraction of the womb. 

Towards the end of pregnancy, most babies are positioned in a longitudinal lie, with their spine running in the same direction as (parallel with) the mother’s spine. A normal delivery isn’t possible if the baby is in a transverse lie or an oblique lie. The position of the placenta and the health of the mother or the unborn baby are other reasons why a C-section may be necessary. Today, the cesarean section is a routine procedure that saves lives and prevents birth complications.

Many C-sections can be planned in advance (planned C-section). If a C-section is not planned but becomes necessary during labor, this is referred to as an unplanned C-section. In some cases, an emergency C-section may need to be performed as a matter of urgency to allow the baby to be delivered as soon as possible. This is always the case if the life of the mother or child is at acute risk.

Reasons that always make a C-section necessary

• The baby’s lie or presentation in the womb means that a normal delivery isn’t possible.
• The position of the placenta in the womb means that the baby cannot enter the birth canal.
• The mother has previously had a C-section that required a vertical incision, which means that there is now a risk of the womb rupturing during labor.
• The baby is too big for the mother’s pelvis. 
• Labor has stalled and there is no other way to help it progress.
• The mother is experiencing high blood pressure and convulsions (indicating eclampsia or HELLP syndrome).

Reasons that may make a C-section necessary

• The mother has had a C-section previously.
• The baby’s lie or presentation in the womb could make labor more difficult.
• The mother is carrying multiples (twins, triplets, etc.).
• Labor has stalled.
• There are indications of growth abnormalities, diseases, or deformities in the unborn baby.
• The stress of labor is threatening the health of the mother.
• Labor has been especially long and the mother is exhausted.

Urgent reasons for an emergency C-section

• The placenta has prematurely separated from the wall of the womb, which, in most cases, leads to severe bleeding.
• The umbilical cord has dropped through the open cervix into the birth canal ahead of the baby and is caught between the baby and the birth canal (umbilical cord prolapse).
• A uterine rupture (rupture of the womb) has occurred.
• The baby’s heart rate has slowed down and the baby is no longer getting enough oxygen.

Elective cesarean section

An elective C-section is one that is performed without a medical reason to do so and exclusively at the request of the expectant mother. Elective C-sections are pretty rare in Germany (representing just 2% to 3% of deliveries) and have to be paid for privately. The benefits and risks of undergoing the operation must be weighed up in advance in consultation with a doctor.

First, the doctor ensures that the mother is not experiencing any pain. This is usually done by means of spinal anesthesia, which allows the mother to remain conscious during the delivery. It also means that the baby can be placed in the mother’s arms immediately after the birth. General anesthesia has a faster effect and may be used for emergency C-sections in particular.

The surgeon first makes a horizontal incision about two fingers wide in the abdomen above the pubic bone. The muscles of the abdominal wall are then separated from the peritoneum (the lining of the abdominal cavity). Next, a horizontal incision is made in the womb. The doctor lifts the baby out by hand and cuts the umbilical cord. The placenta is also removed manually. Finally, all layers are stitched back together. It usually only takes a few minutes between the first abdominal incision and the delivery of the baby.

After a C-section, mother and baby usually stay in hospital for 3 to 4 days. Although this is a routine procedure, complications such as infections or hemorrhage may still occur. However, severe complications are rare (less than 1%).

A vaginal birth is the natural way for a child to be born. The advantage to the baby of being born this way is that the narrow birth canal squeezes all of the amniotic fluid out of the lungs during birth so that the lungs are better prepared to breathe. This means fewer breathing difficulties after delivery. It is also thought that the baby’s contact with the healthy bacteria in the mother’s vagina has a positive health benefit, although this hasn’t been scientifically proven.

Drawbacks of a C-section

For the mother:

• increased risk of thrombosis and pulmonary embolism 
• increased risk of painful adhesions or tears in the uterine scar during subsequent pregnancies
• milk production is delayed by about one day
• the wound may be painful 
• if the C-section was unplanned, the mother may take some time to mentally process what has happened 

For the baby:

• more frequent breathing difficulties in newborns
• slightly elevated risk of allergies, asthma, and diabetes later in life

Benefits of a C-section

• no birth injuries in the perineal area
• fewer pelvic floor issues