37-42 weeks

• you feel anxious
• feeling your baby move less
• you experience heavy loss of bright red blood, like menstruation
• During contractions: Is this your first baby? Ring us when you’ve been having regular contractions for at least an hour, every 3-5 minutes, lasting approx. 60 seconds. Have you given birth before? In that case please ring us when the contractions are very 5 minutes and last approx. 60 seconds. This is merely an estimate, each body and each pregnancy is different. Please know you can always check with us if labour has really started and you need our help!
• If you are losing amniotic fluid and you are at 37 weeks or more, the following applies: Is your amniotic fluid clear or pink? That is good news! Take your time, get some more sleep and ring us the next day from 8 am. Unless the baby’s head has not lowered yet, in that case ring us immediately, day or night! Is your amniotic fluid green, yellow or brown? Ring us immediately because the baby may have defecated into the amniotic fluid.
• If you are losing amniotic fluid but you are not yet 37 weeks pregnant, always ring us, even if in doubt.

At the end of your pregnancy you may lose a mucus plug. This is usually brown/red in colour and mixed with mucus. Losing the mucus plug does not mean labour has started.  It can still be a while before contractions begin.

Contractions are strong muscle movements in your uterus, making dilation possible. They are usually not very strong in the beginning but when they occur regularly every 3-5 minutes and last approx. 60 seconds, that is a clear sign that labour has started. Pre-contractions (Braxton Hicks) are common during the last few weeks of your pregnancy but do not mean you are in labour. A contraction is usually experienced as pain in a wave- like motion, running through your abdomen and/or back. A characteristic of a contraction is that it starts slowly, tightens up and relaxes again. Apart from the contractions you should not feel pain.

In 10% of cases, labour begins by the waters breaking. You lose amniotic fluid, varying from small amounts to large gushes. Amniotic fluid is cloudy, has the colour of diluted milk or bitter lemon and may contain white flakes. Unlike urine, amniotic fluid has a sweet smell. If you are not sure whether your waters have broken, you can ask us for advice. It is important that once your waters have broken but you are not yet having contractions, you should not have a bath, use tampons or have intercourse.  If your baby's head has not lowered into the birth canal since your most recent check-up but your waters have broken, lie down immediately and ring us, even at night. 

Have your waters broken at night and the amniotic fluid is clear in colour? If the baby’s head has lowered as well, use a thick sanitary pad, and try to get some more sleep (if it is the middle of the night) Most births (80%) start within 24 hours, so have some more rest while you still can.

Your cervix is a ring consisting of strong connective tissue that should remain closed during the nine months of your pregnancy. And that is a good thing; otherwise your baby would be born prematurely. When you go into labour, the contractions cause your cervix to soften, shorten and open a little (up to 3-4cm). This latent stage is the most time consuming and you should experience contractions that are often still "manageable". During this stage, try to find a distraction for as long as possible, such as folding up the laundry, baking a cake, or watching a movie.

Once you are at (approx) 4cm dilation, the active stage begins. You are now "actively" breathing the contractions away. The contractions follow each other quickly every 3 minutes and last on average 80 seconds. This is the time you should ring us. Dilation is now increasing by a 1cm every hour. During this stage you are concentrating on the contractions and trying to get comfortable. We will coach you through this and keep a close eye on how far you are dilated and the condition of the baby. This is also the time to make a definite decision whether you want to give birth in hospital or at home. To relax properly, a warm shower or a hot water bottle can bring comfort. Alternate your position regularly and eat/drink small amounts to keep your energy levels up.

Gradually the dilation contractions turn into a strong urge to push. Previously you had to ‘tolerate’ the contractions but now you can do something about it. Most women are relieved at this point, you can finally start pushing, the baby is on its way! However, the pushing stage can last a while. When it is your first baby, it’s not unusual to push for 1 ½ hours. With a second or third baby it can go a lot quicker. Find a comfortable position, which can be a birthing stool, squatting in the bath or lie on your side. As long as we have a clear view of the baby being born.

The moment has arrived, your baby is here! We dry your baby and put her/him on your chest. The umbilical cord is cut as soon as the blood inside it has drained and then we wait for the placenta to be born. The first hour after the birth, your baby has a very strong sucking reflex and is very alert. If you have chosen to breastfeed, it is important to try and have your baby latch on during this period. After the first hour we will check, weigh and measure your child.

To speed along the birth of the placenta and to limit blood loss, we give you an injection of oxytocin in your leg once the baby is born. This is the same hormone your body produces to induce contractions. Contractions are also needed for the placenta to be born, but these are generally not very strong. Sometimes we need to suture; we do this ourselves and will give you an anaesthetic. If you have given birth as a hospital outpatient and there are no further complications, you can go home after 3 to 4 hours. If you have given birth at home, enjoy the comfort of your own shower and the maternity nurse will get you ‘beschuit met muisjes’ while you rest.

The birth-TENS (Transcutaneous Electrical Nerve Stimulation) or the stimulation of the nerves via / through the skin) is a device with which you give yourself small electrical impulses. They cause a stinging or tingling sensation, like warming up cold hands. This device can bring relief, especially when experiencing back contractions. You can operate the device yourself, which also gives you a sense of control.

The birth TENS can be used both at home and at the hospital and has no adverse effects on the mother or baby. Check with your health insurance provider if they will cover the cost for a birth TENS machine.

If you are giving birth at hospital as an outpatient, we can administer laughing gas once you are in the active stage of labour. The gas will help you relax and has an anaesthetic effect. Laughing gas should not be administered during the pushing stage as your full concentration is needed. 

If a medical indication refers you to hospital to give birth, nitrous oxide gas is unfortunately not an option. Permitted pain relief methods are listed under "pain relief from the obstetrician ". Watch the video for more information.

If your contractions are mainly felt in your lower back, sterile water injections can help manage the pain. We will give you 4 injections into your lower back. They provide relief between 2 and 4 hours and can be repeated as often as needed. There are no known side effects to you or your baby. We carry the injections with us to use at home births but they are also available at hospitals. Sterile water injections can be used anywhere, anytime, even during the pushing stage or on your way to hospital.

The anaesthetist gives you a local anaesthetic and puts a needle into your lower back. Through this needle a thin tube is inserted. The needle is then removed and the tube is secured to your skin. The tube feeds pain relief medication into your spine which should begin to take effect within 15-20 minutes. The tube can remain in place throughout the birth.

Advantages:

• 95% of women are completely pain free during the contractions.
• An epidural has no known side effects for the baby.
• An epidural does not make you drowsy so you are fully awake during the birth.

Disadvantages:

• Occasionally the epidural only works on one side of the body.
• Approx. 5% of women do not feel (much) relief. This may be because the needle has been inserted into the wrong place or the medication dosage is insufficient. Sometimes the epidural will be reattempted. 
• The birth, especially the pushing can take longer.  It will increase the likelihood of a suction cup being needed. 
• Medication is often required to control the contractions.
• It would be unwise to get out of bed because you will have less feeling in your legs. You will regain control over your legs once the pain relief has worn off. A low dosage allows more feeling in your legs and in some cases you can stand up, walk around while in the pushing stage. 
• You will also receive drugs by IV to prevent your blood pressure becoming too low. 
• Every few hours your bladder will be emptied by catheter because the epidural will suppress your urge to urinate. 
• An epidural may cause your body temperature to rise. It may be difficult to determine if your raised temperature is caused by the pain relief or a possible infection.  As a precaution, you will be given antibiotics. After the birth your baby will be monitored for 24 hours to check if he/she does not develop a fever.   
• It may cause itching. This can be treated easily by adjusting the combination of medication. 

Remifentanil is a morphine type drug which is administered by an IV. An IV is a tube inside your arm connected to a pump. You can give yourself the Remifentanil when needed by pressing a button. However it is made sure you cannot overdose yourself. Remifentanil will start to work within 1 minute; it takes the edge of the pain and helps you to relax better in between contractions. It is possible that this drug will affect your breathing, for this reason a nurse will be in the room with you and may need to give you extra oxygen. Remifentanil is only possible when there is sufficient care staff available.

Pethidine is a morphine type drug which causes drowsiness and helps you to relax and provides pain relief.  The drug is administered by injection into your leg or buttocks. It will usually take effect within 30 minutes and last approx. 2 to 4 hours. Pethidine is most commonly used when you are experiencing an increased amount of pre-contractions, which cause fatigue. Pethidine will help you to get a good night’s sleep, recharge your batteries before the birth. 

Advantages Pethidine

• Approx. 50% of women are satisfied with the level of pain relief.
• It might make you drowsy or fall asleep, which can be a good thing if you are exhausted from the contractions. 
• Pethidine can provide relief while waiting for an epidural.

Disadvantages Pethidine

• Pethidine takes approx. 30 minutes to take effect.
• 25 – 50% of women report no change in pain levels.
• It may cause nausea and drowsiness. You may not be fully aware of the birth. For this reason, Pethidine is often administered during the early stages of labour.