Labour and Delivery in Singapore

What are the 4 stages of labour?

Most women experience significant pain during labour and delivery. Labour happens in 4 stages: 

  • First stage: The cervix dilates with regular contractions which may last from 8 to 12 hours for first-time mothers. 
  • Second stage: The cervix is fully dilated (10cm) during this phase. The baby descends through the birth canal and is delivered with the mother’s pushing.
  • Third stage: This stage is known as the Afterbirth stage, where the mother pushes out the placenta. 
  • Fourth stage: Recovery

Pains increase in intensity and frequency with the progress of labour. Different women perceive labour pain differently and this may be influenced by the woman’s previous labour experience, duration of the labour and the use of medications to accelerate the progress of labour.

What are my options for labour pain relief in Singapore?

Some options include hypnosis, hydrotherapy, local heat or cold application, and transcutaneous electrical nerve stimulation (also called ‘TENS’). These methods vary in their effectiveness and may be most useful in short labours. 

More common ones include: 

Entonox Inhalation

In this method, the mother inhales a gas mixture of nitrous oxide and oxygen, administered via a facemask. For effective use, the mother should start breathing the gas as soon as contraction begins, so that maximal effect is achieved at the peak of contraction. Entonox inhalation alters the perception of pain but does not remove it completely. The effectiveness of Entonox in the relieving labour pains is variable.

Advantages: readily available, easily administered and short acting.

Disadvantages: causes drowsiness, light-headedness and nausea.

Opioid injections

The most common opioid used for labour pain relief is Pethidine. This is administered via a thigh injection, takes about 15-30 minutes to take effect and lasts for 2-3 hours. However, it cannot be within 4 hours of the anticipated delivery, as it can cause drowsiness and breathing problems in the new-born. If these occur, additional medication may to be administered to the baby.

Pethidine may cause drowsiness, nausea and vomiting in the mother.

Epidural Analgesia (EA)

Epidural analgesia (EA) is the most reliable and effective way to relieve labour pain. This involves injection of local anaesthetic drugs through a small tube inserted into the back and is performed by a trained anaesthetist during active labour. Although EA reduces labour pain to almost completely, most patients will feel some pain and pressure in the second stage and especially while “pushing” the baby.

What are the side effects of epidural after childbirth?

Some side effects may occur but they are usually minor and short lived. These include:

  • Numbness and weakness of the legs and lower half of the body.
  • Temporary absence of bladder sensation requiring urinary catheter to drain urine
  • Nausea and shivering
  • Low blood pressure – requiring additional fluids or medications
  • Mild generalized itch
  • Spinal headache (1%) – This occurs post-delivery and is worsened by the upright posture and in most cases, resolves with time. Medications and/or an epidural “blood patch” can be used for treatment, if severe.

Other myths of epidural include: 

Long term backache

Research has not shown a link between long-term backache and EA. Backache is quite common after childbirth even without the use of EA hence proper back care and supplement use during pregnancy and after childbirth is important.

Epidural harms the baby

EA does not harm the baby even though temporary changes in the baby’s heartbeat may occur due to transient changes in the mother’s blood pressure.

Epidural can cause paralysis

This is extremely rare. Permanent nerve damage occurs 1 in 100,000 patients and the risk of paralysis is 1:1,000,000.

Epidural prolongs labour and increases the risk of a caesarean section

EA has not been shown to increase the risk of needing a caesarean section. There may however be a slightly increased risk of instrumental delivery as the mother as no sensation to push due to the EA.

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What is assisted vaginal delivery? 

Assisted Vaginal Delivery refers to the use of forceps/vacuum after the cervix is fully dilated to assist delivery of the baby. If the baby cannot be delivered safely in this way, an emergency caesarean section will be needed.

With forceps, the doctor performs an episiotomy (vaginal cut) followed by application of forceps blades on either side of the baby’s head. Similarly, with a vacuum, the doctor performs an episiotomy first followed by application of a suction cup to the top of the baby’s head. During contractions, the doctor pulls while the mother pushes, to help deliver the baby together.

What are the risks of an episiotomy? 

An episiotomy carries the following possible risks to the mother: 

  • Long healing period 
  • Small risk of wound infection and scarring 

The use of forceps or vacuum has the following possible risks to the mother: 

  • The vagina, anal sphincter (10% with Forceps, <5% with Vacuum) or bladder may be injured requiring further repairs and resulting in pelvic floor dysfunction.
  • Post-delivery hemorrhage (excessive bleeding) 10%
  • The attempt to deliver the baby may fail and you may need an emergency caesarean section which may be more complicated because your baby’s head is low and may be stuck in the pelvis.
A newborn baby in an incubator

Can forceps harm a baby?

The use of forceps or a vacuum may bring the following possible risks: 

  • The baby’s face/scalp or facial nerve may be bruised (10%). This condition usually improves over a few days.
  • The cup may not attach firmly enough to the baby’s head and need to be reapplied, hence delaying delivery or the need for a caesarean section. 
  • Risk of retinal heamorrhage – resolves spontaneously in a few weeks. 
  • Neonatal jaundice (10%)
  • Blood blister (10%) on one side of the scalp 
  • Uncommonly, there may be bleeding within the brain (0.5-0.01%)

What is a caesarean section? 

A caesarean section is a surgical procedure to facilitate the delivery of your baby. This is performed by making a cut in the mother’s abdomen and the uterus, usually at the lower segment of the uterus.

What are the side effects of caesarean delivery?

Common risks (1-10%)
  • Infection
  • Bleeding and requiring measures to control bleeding or a 1-2% risk of requiring a blood transfusion.
  • In rare cases, a hysterectomy may be needed if bleeding cannot be controlled.
  • Fetal laceration (1.5%)
  • Respiratory (breathing) problems for the baby (1.5%)
Infrequent risks (0.1-1.0%)
  • Increased risks of the uterine scar rupturing should I go into labour normally in future
  • Increased risks of abnormal implantation of the placenta in future, which can lead to heavy bleeding after caesarean delivery and may require a hysterectomy
Rare risks (<0.1%)
  • Blood clots in the veins and lungs
  • Injury to the bladder or ureter
  • Risk of Maternal Death is about 82 / 1,000,000