Childbirth

Physiological data

Duration of the childbirth

The duration of the work varies enormously, but reached a 13 hours average in a medicalized environment of active Gestion of work, for the women giving birth to their first child ( primiparous ) and 8 hours for those having already given the life. Without management (before the years 1970) the intermediate duration of a first calf cow childbirth activates was estimated at 48 hours.

Such values are however extremely variable and depend on many factors, of which:

Tonicity of the Uterus
fetal Diameter in process of engagement
Dimensions and opening of the maternal basin
Great multiparity
psychological Gémellité
State of the woman in labor
Position of childbirth and mobility of the Parturient
Stimulation by artificial Oxytocin

Hormonal balance

The physiological process of the childbirth is influenced by a delicate hormonal balance:

the Adrénaline is on a minimum level,
the Ocytocine is slackened consequently by pituitary gland closest to the needs (generating the secretion of endomorphines and prolactin later on),
catecholamines are released in a way adapted to each phase of work.

To support this balance, and more particularly the production of Oxytocin, in the absence of medical intervention, the following conditions are optimal for the parturient:

To be in an intimate place, accessible, known,
To have hot, and to be able to maintain this temperature, that it is in the movement or the immobility,
Être free to move, go, to change the least possible position,
Être requested on the level of the cortex, silence or soft music, of questions, filtered light,
Être surrounded by few people, known and appreciated, of intervention except so not required imperative.

Contrary:

unknown environment, little reassuring,
the temperature of the part unsuited to the needs for a motionless parturient,
many interventions on the body of the woman (vaginal examinations, perfusion, survey, shaving) often little or clarified, and not practiced by different people,
immobility and the unsuited position imposed, the technical
noises of machines, conversations around and on the woman in labor, violent and believed lighting,

can cause a massive secretion of antagonistic Adrénaline of the Ocytocine, blocking the secretion of Endomorphine S and Prolactine, disturbing the release of Catécholamine S (whose anarchistic rate plays a role proven on the Hémorragie of the delivery), slowing down work, making the contractions less effective and more painful, kind with a perfusion the oxytocic artificial ones and lowering the tolerance level to the pain. The childbirth becomes unbearably long and painful, and the Péridurale is posed, generating other iatrogenic disturbances.

Normal unfolding

First stage of work

A human birth typical starts with the first stage of work: contractions of the Uterus, initially all 10 to 30 minutes and lasting approximately 40 seconds each one. From time to time work begins with the rupture of the amniotic pocket or Poche of water (made of two twin membranes, the Chorion and the Amnios). The contractions will accelerate until occurring every two minutes although it is not systematically the case. The duration of the contractions also will increase until at the end of the first phase they last from 70 to 90 seconds.

The mechanism of the uterine contractions

During a contraction the long muscles of the Utérus contract, while starting with the top of the uterus and while progressing to the buttocks. At the end of the contraction, the muscles are slackened but remained shorter than at the beginning of the contraction. This traction draws the Cervix over the head of the baby. Each contraction dilates the collar until it reaches approximately 10 cm diameter.

Positions and mobility in the course of work

Many epidemiological studies compared the advantages and disadvantages of various positions in the course of work and in phase of expulsion (see below, second stage of work ). The experimental protocols required for a good level of scientific proof do not make it possible however to study the effects of mobility in the course of work. Indeed, the designation of a position starting from a random pulling excludes a priori the parturients who did not preserve this position for the assigned length of time. The conclusions thus relate mainly to the positions:

In décubitus dorsal: slept on the back, most frequent in the medicalized units
In décubitus side: to see below, second stage of work .
Squatted or sat on the “Dutch seat”

Work on the mechanics of parturition and testimonys of many women, midwives and obstetricians, suggests that mobility (total freedom of position) can play a big role in the reduction of the labor pain and the prevention of the dystocies. This freedom of movement has been of rule for several decades in Swedish maternities. In other countries, associations of users distribute posters or cards of information on the positions recommended in the course of work.

Second stage of work

In the second phase of work, the baby is expelled of the belly through the genital ways at the same time by the uterine contractions and of powerful abdominal contractions. These abdominal contractions are traditionally induced by the medical staff which invites the parturient with " pousser". Out of this context and when nothing comes to disturb the intimacy of the mother-to-be, a reflex of ejection of the fetus occurs which does not require any voluntary effort. The imminence of this second stage can be estimated by the Score of Malinas.

Presentations

The baby is born generally the head the first. In certain cases, the baby presents himself by the seat , which means that the feet or the buttocks are presented in first. With a personnel well trained and if the circumstances lend themselves to it, even a baby in incipient by the seat can leave by the vagina.

There are several types of breech presentations. Most common is that where the buttocks of the baby arrive in first and the legs are folded up against its body with the knees as a tailor and the feet close to the buttocks ( complete seat ). Other possibilities are the seat décomplété in mode of the buttocks , which resembles the complete seat much but the legs of the baby are lengthened to the ears, and the seat décomplété in mode of the feet , in which one or two legs is tended and the feet are presented in first. Another rare presentation is that of transverse lengthening. It is the case where the baby is transversely in the belly and an arm or an elbow was introduced in first into the vaginal channel. A birth by low way is then contra-indicated, although in rare cases the arm can be pushed back inside and the baby can be brought back in the correct position.

Positions in phase of explusion

(To be supplemented with complete references)

Dorsal Décubitus

(To be supplemented with complete references)

Side Décubitus

The parturient is lying on the side (left in the majority of the cases). This position is sometimes indicated as “with English” although it is not more frequent in the United Kingdom. She was popularized in France by Bernadette de Gasquet as a good alternative to the dorsal décubitus when the parturient is under Péridurale.

One of the advantages of the side décubitus on the dorsal décubitus is to allow the parturient of verticaliser at the last time (while passing “to four legs”) if it for of feels the need.

Position semi-base

“Verticalized” positions

A verticalisation of the parturient can occur spontaneously during the phase of expulsion. In the scientific literature, one indicates as “verticalized” all the positions for lesquelle the back of the parturient is close to the vertical:

squatted Position
Position “with four legs”
Sitting position. This position is in particular that of the seats of childbirth used at the time of the childbirth in residence with the Netherlands.
Position upright
Position in dog of rifle. This position, less popular in the Western countries, is very frequently used in Asia. It would seem that it reduces the ano-rectal pains.

The newborn

Immediately after the birth, the sudden child of the physiological modifications important at the same time as it adapts to the air life. Several cardiac structures start to be atrophied immediately after the birth, like the arterial Canal ( ductus arteriosus ) and the Trou of Botal ( foramen oval ).

The medical condition of the child is measured by the Score of Apgar, based on five parameters. A “good departure” corresponds to a raised score, while a child in bad condition will have weak scores which do not improve quickly.

Third stage

The third stage of work generally occurs during the fifteen minutes at one hour which follows the birth of the baby. During this phase, the uterus expels the Placenta ( delivery ). If the woman did not receive a artificial Ocytocine to accelerate work, and particularly during spontaneous childbirth in the absence of medical supervision, it happens that the placenta is separated of the uterine wall but is expelled several hours after the childbirth. It is essential that the totality of the placenta is expelled, this is why the Sage-femme, the companion or the woman itself will examine it to make sure that it is intact. Indeed a piece remaining can cause a Hémorragie of the delivery or an infection, especially if the woman underwent intrusive interventions: vaginal examinations, instrumental extraction etc

Studies show that after first half an hour following the expulsion of the fetus, the risk of bleeding Post-partum increases significantly: in general, the expert makes sure that the Placenta left whole the uterine cavity after this time. This precaution is almost protocolar, to minimize the legal risk.

Clampage of the cord

The umbilical cord can be cramp (tight by tied grips or fasteners) immediately after the birth or later, and that can have effects on the mother and the Nouveau-né. (…) The choice of the moment when the cord is cramp does not seem to have any significant effect on the incidence of the hemorrhage of the delivery or on the transfusion foeto-nursery school. (…) the late clampage (even the absence of clampage) is the physiological means to treat the cord, and the early clampage is an intervention which requires a justification .

Materno-fetal Tranfusion

If, after the birth, the Nouveau-né is placed on the level of the vulva or below this level during three minutes before the clampage of the cord, approximately 80 ml of blood pass from the Placenta to the newborn. The Nouveau-né is thus equipped with a reserve from approximately 50 iron Mg, which reduces the frequency of ferriprive anemia during early childhood. Theoretically, this transfusion of blood of the placenta to the newborn could involve a Hypervolémie, a Polycythémie and a hyperviscosity, as well as a Hyperbilirubinémie. These effects were the subject of a certain number of tests. the babies born after an early clampage of the cord show a rate of Hémoglobine and a weaker Hématocrite. As regards the respiratory disorders of the New-born , no substantial difference was observed between the two practices. The rate of Bilirubine at the newborn was lower after an early clampage cord, but no clinically significant difference was raised between the two practices, nor no difference in the Morbidité néonatale .

One of the reasons of the persistence of the practice of the early clampage is that it makes it possible to collect placental blood for the culture of Original cells. This practice however is disputed. A thesis on the bio-engineering of the original cells concludes: the decision is personal. If the money is not an obstacle, the step can be under consideration like an insurance against possible pathologies. Generally, the doctors will recommend to preserve umbilical blood if the family has strong antecedents of particular diseases.

Cut of the cord

In the medicalized units the most frequent practice consists in cutting the Umbilical cord as soon as possible in order to give immediate care to the Nouveau-né. This practice is called in question by parents who wish that (in the absence of urgency) the cord be cut only after it finished beating, which makes it possible the mother to longer remain in liaison with his/her child, and this one to profit from the materno-fetal transfusion.

Certain parents making the experiment of a childbirth in residence without medical help take as a starting point a practice New Age indicated like birth Lotus in homage to Clair Lotus Day, a woman of California which in made the first experiment in 1974. Jeannine Parvati Baker, midwife self-educated in the North-American mobility of negro spiritual midwifery , was the principal propagator. This practice which wants to be inspired by those of tribal populations in Indonesia consists in not cutting the Umbilical cord to let it dry and be detached from itself, which intervenes in general two to four days after the birth. The Placenta once washed is wrapped in a linen and is preserved by a mixture of salt and medicinal plants. After the rupture of the cord, it is buried with the foot of a tree. Traditionally, the Placenta was regarded as a “psychic double” of the child and was the subject of a ritual to each birthday.

Ritual around the placenta

Souvent the families grant a special place to the placenta, since it was a vital body of the baby during so much of month. Many parents want to see and touch this mysterious body.
In certain cultures, there exists a habit consisting to dig a hole, to bury the placenta there and to plant there a tree with the first Anniversaire of the child.
In other populations, it is prepared then eaten cérémoniellement by the family of the newborn.

After the birth

Usually, the parents give to the newborn its or its Nom S of use shortly after its birth. They can have two sets of ready names, according to whether it is a boy or a girl.

Often the close relations return visit to the mother and with the baby and gifts bring to him. For reasons of Hygiene, the majority of maternities disadvise the Fleur S.

It is of use in many cultures which the arrival with the life is accompanied by ritual monks.

Watery childbirth

The warm water exerts a favorable effect on the progression of work during the phase of dilation of the cervix, and she plays an analgesic part which can be important for certain women. Once reached the complete expansion (end of the first stage of work), two practices can be selected:

the parturient remains in the bath and the third stage (birth of the baby) proceeds in water;
the parturient leaves the bath and the baby is born in the position from expulsion from his choice.

In the first case one can speak about watery birth ('' waterbirth '' in English). This practice is current at the time of the childbirth in residence, in very a small number of French maternities, and in maternities of countries bordering (like that of Ostend).

The second case is frequent in the units obstétricales having “basins of dilation” but not wishing to accompany by the watery births.

(Article to be supplemented. If possible to create a special page on the watery Childbirth.)

Variations

When the Poche of water did not break during work or expulsion, the newborn can come in the world with the intact membranes. One invites that to be born capped . The cap without danger and is easily removed by the doctor or the person who helps with the childbirth. With the the Middle Ages, the cap was regarded as a sign of good fortune for the baby. In certain cultures, one saw a protection against the drowning there, and it cap often tight in paper and was preserved like heritage for the child. To associate chance and the fact d'" to be born coiffé" a share of logic has since the cranium of the child, and thus his brain, undergoes less the pressure due to the contractions: it is the Poche of water which absorbs the shock. The idea that to be born capped chance brings remained in spite of the ages, even if no study never came to support the theory.

With the advent of modern active obstetrics, it became current to practice the early artificial rupture of the membranes and it thus became rare for the Western babies to be born capped. This gesture however should not be taken with the light one. According to WHO, the spontaneous rupture of the membranes should be preferred.

Medical complications and interventions

Complications can occur during the birth; they generally require the intervention of a Obstétricien. In the past, of very many women died during or shortly after the childbirth but the modern medical techniques available in the industrialized countries and the improvement of the sanitary arrangements largely reduced this figure.

Let us note that the Grossesse and the childbirth are physiological processes. If a medical lighting is necessary for good to apprehend of it all the chronology and good progress, it is not less dispensable in the absolute. Strictly speaking, the parturient even in room of childbirth is thus not regarded as Malade.

Term of the pregnancy and postmaturity

One in the long term regards as Grossesse any pregnancy from 37 to 41 weeks of Aménorrhée complete (SA). The theoretical term corresponds to 41 weeks complete, and one speaks about term exceeded as from 42 weeks. These figures have direction only for one date of the theoretical term given to the echography, by crânio-caudal measure of length of the Fœtus, between 11 and 13 weeks. The specialists in fetal Biométrie have statistical tables to various measures which enable them to say if measurements appear coherent with the date of supposed design. It should however be noted that this method makes it possible to detect only the coarse differences.

In addition dispersion over the durations of Grossesse compared to the theoretical term is high. This dispersion is difficult to currently evaluate because of the frequency of releases, but a 7 days value for the standard deviation is an acceptable estimate. This amounts saying that 95% of the women would be confined spontaneously between 39 and 43 weeks of Aménorrhée. Actually, the statistical distribution is not symmetrical, so that it is more frequent to see women being confined front, that beyond the theoretical term. According to the estimate of midwives who practice a total follow-up and certain studies on release, less than 1% of the women would be confined with more than 42 weeks. Certain studies also detected notable differences of the duration of pregnancy according to the ethnicities.

It is important to distinguish the concept of exceeded term, which corresponds to a variation compared to a average statistics, Postmaturité which is a state Pathologique Fœtus caused by a dysfunction of the Placenta not ensuring more its role of exchanges, nutrition and oxygenation. The Postmaturité is difficult to detect but some clinical signs would be the following:

the uterine height and the umbilical perimeter do not progress any more;
the Utérus seems to be moulded around the Fœtus;
the quantity of Amniotic liquid decreases - the fetus does not float any more;
the fetal movements lose amplitude.

The defenders of a practice obstétricale less interventionist suggest an attentive monitoring of the appearance of these clinical signs - before even as the fetal suffering does not become visible on the cardiac rate/rhythm - rather only the very widespread practice which consists in systematically starting the childbirth at 42 weeks of Aménorrhée. The tendency of the obstetricians, however, consists in putting out of balance the risks (for the mother and the child) associated with a particular age gestationnel with the risks of a release of the childbirth. The recommendations of clinical practice aim at indicating reasonable limits according to the scientific literature and of the consensus of the experts. However, the final decision to treat or not to treat belongs to the expectant mother (cf the article L 1111-4 of the Public health code in France).

Release of the childbirth

The artificial release of work is done, either by administration intra- Vagin ale of a gel of prostaglandins, or the perfusion of artificial Ocytocine associated with a rupture of the Poche of water (Amniotomie).

It requires a continuous monitoring of the cardiac rate/rhythm of the baby (who immobilizes the parturient) and generally causes contractions of strong intensity, painful, which involve the installation of a Péridurale, with for consequence a higher rate of instrumental extractions (Forceps or suction cup).

Release for medical reasons

The principal medical indications of release are:

a going beyond of term (with or without suspicion of Postmaturité) beyond 41 weeks + 6 days.
premature rupture of the Pocket of water which involves a infectious risk. The time of expectancy varies, according to the obstétricales teams, typically from 24 to 96 hours.
a Diabetes gestationnel badly balanced
a twin Pregnancy
a stop of growth of the Fetus (which one should not confuse with an intra-uterine delay of growth )
the arterial Hypertension with functional signs, or Pre-eclampsia.

See details on the techniques used.

Release of suitability

The principal nonmedical indications of artificial release in France are:

Suitability of the patient:

Will of the patient: desire to shorten the pregnancy.
organisational Reason: family organization.
psychological Reason: cause psychological related to the anxiety, certainty of the péridurale by the presence of the complete medical team, desired presence midwife or of the obstetrician.

Suitability of the professionals:

Rationalization of the work of the medical team and improvement of the security conditions:
Planning day laborer of the childbirth: temporal distribution of the workload;
Risk management: presence of the complete obstétrico-pediatric team, and greater availability of the ancillary services;
Optimization of the human means and solution with the problem of medical demography: case of the anesthetists in particular but also of the obstetricians and the pediatrists.
Optimization of the capacities of reception.
legal Point of view: limitation of the risks and threats medico-legal.

geographical Cause and medical installation of the territory:

the access to the care: apart from the urban poles, the closing of small maternities reduces the choices of the patients and obliges them to go in a maternity rather distant from their residence.
the extra work of work caused by the surge of new patients following the closing of maternities, and the distance of these last constitute two major reasons in order to justify the programming of the childbirth.

Other reasons:

the company, media: effect of “mode”.
Respect of the free choice of the patient.

The studies show that there exists an important disparity concerning the frequency of the release of principle in terms of nonmedical indications according to the characteristics of the establishments and the area of exercise. The factors of variation are strongly related to the apprehended environmental context from a total point of view:

environmental Context of maternities: area, geographical location of the establishment (rural, perish-urban, urban), many maternities, medical demography (number of gynecologists-obstétriciens, pediatrists and anesthetists per territory of health);
organisational Context of maternities: differences in terms of organization of the care according to maternities (statute of maternity, cuts, level, distribution of competences obstetricians/midwives, mobilization of medical manpower, etc).
Behavior of the health professionals in the area of exercise.

From a medical point of view, the release of suitability should be practiced only as from 39 weeks of Aménhorrée, on a woman who does not have an antecedent of Cesarean, and with a collar of the “favorable” Utérus (softened and a little open), which is quantified by the Score of Bishop. The epidemiological studies agree on a notable increase in the risks (resulting in higher rates of Cesareans) when the Score of Bishop is lower than 5 or 6. Consequently, the current recommendation is to start only for a Score of Bishop equal to or higher than 7. It should be known however that for 290 days of age gestationnel (41 weeks + 3 days) and with a favorable collar, 95 % of the women are confined in the week which follows.

The incidence of this type of release on the rates of Césarienne S calls criticisms of associations of users. These last reproach the health professionals and the public authorities a reserve to call in question a practice of which the first effect would be to minimize the cost of the monitoring, in terms of human resources, competences and financial means, to the detriment of the exercise of the enlightened Consentement. Criticisms of experts relate primarily to two points:

the exploratory studies measure for the majority the incidence of “the intention to treat” ( intention to treat ) and not of the treatment in itself. A big number of women placed by drawing lot in the group “release” (more than 30% in certain cases) can be confined spontaneously during the amount of time (possibly several days) which separates the drawing lot from the intervention. It follows that the results with regard to them should not be associated with those with release.
the management of the childbirth of the women of the group “monitoring” who did not undergo release is far from being non-interventionist; much of them ends up undergoing a release or a Césarienne because of risks more anticipated than real.

Presentation

The Présentation of the top (cephalic) is at the same time most frequent and most favorable to a normal childbirth. In approximately 5 % of the cases, the child arises in a different position:

podalic Presentation or “presentations of the seat”,
transverse Presentation,
Presentation of the face,
Presentations of the face and the bregma.

During dilation

Fetal suffering

The fetal Souffrance is the appearance of signs of discomfort in the child. That includes a high Cardiac rhythm or too low (observed by Cardiotocographie), the diffusion of Méconium in the amniotic liquid, etc

Insufficient dilation or dystocie cervical

The not-progression of work (contractions for periods prolonged without adequate dilation of the collar) is generally treated with a gel containing Prostaglandine applied locally, or of the synthetic Ocytocine by intravenous Voie. If that proves to be ineffective, the use of the Forceps, or a Césarienne can appear essential. It is increasingly frequent today in the rooms of birth where one imposes to the women under Péridurale a lithotomic Position (flat back) contrary with the physiology of the Parturition. Several studies show that it would be preferable to support the freedom of position and ambulation, a protocol adopted in Sweden with excellent perinatal results. Moreover, forced with the passivity in a climate anxiogene (intense light, absence of intimacy, etc), the Parturiente does not produce enough any more of natural Ocytocine and tends to rest on a medical help rather than to request its own resources.

Uterine rupture

Hyperthermia

With complete dilation

One speaks about dilation supplements when the collar is entirely erased, which commonly implies a dilation to 10 cm.

Not engagement of the presentation

One speaks about Non engagement of the presentation when the part of the fetus which presses directly on the collar (also called dilating Cône) does not manage to cross the higher Détroit maternal basin. The causes can be multiple, corrigeables spontaneously or not, temporary or final.

At the instant of the failure of the pocket of water

Hemorrhage of Benkiser

Latérocidence of the cord

Procidence of the cord

At the time of expulsion

The not-progression of the expulsion (the head or the part of the body which arises in first does not advance in spite of the presence of adequate contractions): it requires an intervention such as the Vacuum extractor (or “suction cups”), the extraction with the Forceps or the Césarienne. The Dystocie of the shoulders in is a particular cause, where the newborn remains blocked by the belt scapular.

Episiotomy

Associations of users deplore that the practice of the “preventive” episiotomy remains frequent in France in spite of published in 2005 by the national College of the gynecologists and French obstetricians (). They recommend to the expectant mothers to specify well their possible refusal within the framework of the development of the Projet of birth with the obstétricale team.

Abdominal expression

The abdominal expression refers to the application of a pressure on the bottom of the uterus, with the specific intention to shorten the duration of the 2nd phase of the childbirth.

A dossier of sasine was submitted in May 2005 to the High health official (HAS) by the interassociatif Collective around birth (CIANE). The heading of the request was: “Evaluation of the risks and coding of the practice of the abdominal expression (phases 2 and 3 of the childbirth)”.

The recommendations of clinical practice of the work group of HAS are the following ones:

It does not have there indications médicalement validated to carry out an abdominal expression.
the lived traumatic one of the patients and their entourage and the existence of complications, rare but serious, justify the abandonment of this use.
In the situations which require to curtail the 2^e phase of the childbirth, the recourse, according to the clinical context, with an instrumental extraction (forceps, suction cup obstétricale, spatulas) or to a Cesarean is recommended.
If an abdominal expression is practiced in spite of the preceding recommendations, it must be noted in the medical file of the patient by the person in load of the childbirth, by specifying the context, the methods of realization and the difficulties possibly encountered.

Enclavement

Dystocie of the shoulders

Accidents of the seat

After the birth

Hemorrhage of the delivery

It is normal to observe a hemorrhage limited during a childbirth. However, a Hemorrhage unforeseen and important (Hemorrhage of the delivery or “postpartum”) during or after the birth is potentially mortal in the places without immediate access to emergency care. The important heavy bleeding leads to the state of Choc hypovolemic, an insufficient irrigation of the vital bodies and death if they are not quickly treated by blocking the heavy bleeding and as a practitioner a blood Transfusion. The hypophyseal Insuffisance after a shock hypovolemic obstétrical is called the Syndrome of Sheehan.

The hemorrhage of the postpartum is in France the leading cause of maternal death, with a rate significantly higher than the European average.

The hemorrhage occurs of 11 with 25 % of the cases during a childbirth medicalized in the absence of technique of prevention. In half of the detected hemorrhages, it is “the uterine Atonie” which would be in question. The principal technique of prevention thus consists in managing with the mother of the artificial Ocytocine (or the Misoprostol) after the birth of the baby, insofar as it is not any more able spontaneously to produce enough Ocytocine to start again the contractions of the Utérus. Some epidemiological studies showed that the release of work (Amniotomie/oxytocins) and the use of Forceps constituted risk factors for the hemorrhage of the postpartum, but the majority of work did not include the measurement of these variables to their experimental protocol.

A study relating to more than 9000 cases was carried out by the INSERM (Unit 149) to determine the risk factors of occurred and aggravation of this hemorrhage. With the request express of the collective of associations of users (CIANE) the factors related to the practices obstétricales (acceleration of the childbirth by injection of artificial Oxytocin, episiotomy, Release of the childbirth etc) were taken into account. (Results being analyzed, summer 2007.)

Infections

Among the infectious complications, the Fièvre puerpérale is most dangerous, but is not observed any more in the developed countries. It is about a Septicémie with Streptocoque S, caused by handling under bad conditions of asepsis.

Psychological aspects

During the first part of work, the future mother passes typically by several emotional phases. Initially agitated, it concentrates when the contractions intensify and are regularized.

When the collar finished its dilation, the majority of the mothers test a certain confusion or accesses of doubt: this reaction is perfectly normal, and falls under the continuity of what one could call pregnancy the mourning , and fear of the unknown.

Social aspects

Participation of the father

Today, the participation of the father in the childbirth is the standard in Occident. However, before the years 1960, one prohibited with the father as with the other men (except for the medical personnel) the access in room of birth.

The exception to this rule are the inhabitants of Polésie. In this culture the woman is confined sitted on the knees of her husband.

Some consider that the hospital practice of exclusion of the father of the room of childbirth contributed to the development of the Circoncision for medical reason in the United States. However, in this country, recent social progresses consisting to require written assents, to let the father attend the childbirth and to reduce the use of drugs and the constraints physical on the mother, allowed a considerable increase in parental control on all the aspects of the course of the birth. These changes occurred in the United States these last years allowed there a reduction of the rates of circumcision like those of other interventions like the episiotomy.

Resistance to the surmedicalisation

The epidemiological studies showed that the perinatal results (especially concerning death rates) are comparable whatever the place chosen for the childbirth, under medical good conditions, for a pregnancy at the weak risk followed by a personnel médicalement qualified.

In the poor rural areas of country, one notes a persistence of traditional forms of childbirth with results which depend mainly on the standard of living and the sanitary arrangements. In the industrialized countries, associations or collectives of users preach freedom of choice, for the pregnancies with bottom risks, between medicalized childbirth “traditional” and several modes of assumption of responsibility médicalisés indicated like “physiological dies”:

the childbirth in a “natural room” (or “physiological pole”).
the access to the technical Plate of a hospital with a liberal Midwife in total Accompaniment.
the Childbirth in residence. After a Net decline in the middle of the 20^e century, this practice is again in rise in several countries of Western Europe: France (a little less than 1% of the births), but especially the United Kingdom (2%) and the Netherlands (30%).
the childbirth in House of birth on the Québécois model.

The participation of the users

In France, the representatives of associations of users take part in the work groups on the perinatality of the High health official (HAS) and other authorities of the health system, in accordance with the practices encouraged by the Plan perinatality.

Legal aspects

In certain jurisdictions, the birthplace determines the Nationalité of a child (under the doctrines of the Droit of the ground or juice soli ), in opposition to the Droit of blood.

In many countries, the birth must be declared near an organization of civil statue (Certificat of birth). See also the article Childbirth under X .

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