The World Health Organisation (WHO) has just published its new recommendations for childbirth and care. Doctors, midwives and obstetricians from around the world have reviewed research to provide evidence-based advice for childbirth. The eCare project is based on these recommendations: everything in eCare is backed by science and the WHO.

There is room for improvement in childbirth care and the World Health Organisation is driving forward change.

The WHO recognises the maltreatment that many women still suffer during childbirth leading to unnecessary interventions that endanger both their health and that of their babies.
Respectful care is the basis of all care in labour and birth and the subjective experience of the woman is very important.

The WHO concludes its recommendations in the following way:

Pregnancy, childbirth and the postnatal period are memorable events in a woman’s life. Implementing these recommendations will enhance this experience for women around the world.

Oxytocin is a chemical substance produced in the brain. For this reason it is called a neurohormone. From the brain it passes into the bloodstream and has effects in other areas of the body. In mothers, oxytocin stimulates contractions of the uterus during childbirth and the release of breast milk during breastfeeding.

But the most interesting effects of oxytocin occur in the brain. It is the hormone that facilitates much of our loving, reproductive and social behaviour. That is why it is called the hormone of love and life.

Throughout pregnancy, oxytocin receptors in the brain multiply. The highest levels of oxytocin in a lifetime occur in the first two hours after birth, in both the mother and the new-born.

Synthetic oxytocin is an identical substance but produced artificially. It is used as an intravenous drug in some deliveries as it helps the labouring woman’s uterus contract. This is why it is sometimes administered when labour stops or after the birth of the baby to contract the uterus and prevent haemorrhage. However synthetic oxytocin does not reach the mother’s brain so it does not produce the feelings of well-being and relaxation. Thus the contractions it produces are much more painful than contractions without artificial oxytocin.

The baby is getting ready to be born. When it is ready to leave the womb, its brain sends a signal to the mother and labour usually begins. The ligaments of the mother’s pelvis soften considerably at the end of pregnancy to allow the pelvis to open as wide as possible for the birth. Each uterine contraction is a small push. As labour progresses, the contractions become stronger and last longer, lasting almost a minute. The cervix slowly opens; this is called “dilation”.

Inside the uterus, the baby is surrounded by a kind of water balloon: the amniotic sac, which makes it easier for the baby to move and turn. As long as the sac is not broken, the baby is able to turn more easily inside the pelvis (it is also more protected from external infections).

As labour progresses, the baby will turn and position itself. Some are very well positioned from the beginning of labour making delivery much easier. Others are in positions that can make labour longer and, above all, more painful. This explains why some women have very painful and intense contractions without even being in labour: the baby is trying to position itself before moving into the birth canal.

Birth is a very dynamic process: a chain of coordinated movements that allow the baby’s head to pass through the narrow birth canal and out.
If the baby is badly positioned or stuck, labour can be very long and difficult. This is where the midwife’s knowledge of how to detect and correct the baby’s malpositioning is key. In such cases, obstetric interventions such as epidural anaesthesia or instrumental delivery may be helpful or even necessary.

In 1974 the French obstetrician Frédérick Leboyer (1918-2017) published a book entitled Birth without Violence. He was the first doctor to put himself in the shoes of a new-born and describe all his sensations on arrival in the delivery room of any modern hospital. He described childbirth as a journey, an adventure for the arriving baby, and explained clearly how painful it can be for the baby to feel cold on arrival, a blinding light, or to be separated from the mother as soon as he or she is born and taken away from her. Leboyer subsequently left obstetrics and devoted the rest of his life to studying and spreading the importance of the emotional connection between mothers and their babies. Since then, and partly thanks to his legacy, things have changed for the better. Newborns are now offered more thoughtful care and the time they take to arrive is more broadly respected.

The midwife or doctor attending the birth can check that the new-born is healthy by observing how the baby is lying on top of the mother. Only when a major problem is detected should the baby be separated from its mother, otherwise it is essential to leave it with her for at least the first two hours of life. These first two hours are called the “sensitive period” because they are deeply engraved on the new-born’s memory.

Childbirth is a very intense experience: probably one of the most important and most memorable moments in a mother’s life. Although each woman will experience childbirth in her own way, we now know that there is a psychological process common to all natural childbirth, partly because the hormones that produce uterine contractions also have effects on the brain.

The onset of labour may be felt as gentle contractions that come and go or as a sensation in the uterus similar to that of menstruation.

As contractions become more frequent and intense, women often feel the need to move to their chosen place of birth. Once there, they “go into” labour. The sensation in the body is so intense or strong that it is difficult to think about anything else or pay attention to what is happening outside.

The intensity of contractions is almost always surprising in its strength and in some cases also in its pain.

Contractions pass through the uterus in waves. The task of giving birth is made easier when contractions are accompanied by appropriate breathing and if the mother visualises them as an embrace that helps the baby to emerge.

At the end of labour, many women say that they have felt that they could not go on any longer, that they were at their limit, or that they thought they could not go on or even that they were going to die. These feelings almost always precede the final contractions of labour and signify that the baby is about to come out. Interestingly, the strong final contractions are often less or not at all painful. The support of the father or companion and healthcare professionals is essential at this time.

Birth, the bringing of a baby into the world, can take time. Once outside and placed on her body the mother will often experience wonderful feelings, intense emotions, a kind of ecstasy of love coupled with the amazement of seeing the baby for the first time.

Who can eat for you? Nobody, obviously
Who can sleep for you? Once again, nobody.
And who can give birth in your place? No one.
Really, no one else but you. You and only you.
Once you embrace this fundamental concept, you will be able to
solve each of your problems and you will stop looking for
a person or a place to give birth.
You will then understand
that there is only one thing to do:
stay close to yourself.
F. Leboyer. Free translation by G. Bianco from Frédérick Leboyer’s book Atmen, singen, gebären, 2008. (“Breathing, singing, giving birth”)

When a woman goes into labour she is influenced by what her relationship with her body has been throughout her life. This is not always an easy relationship. We live in a culture where not all the different kinds of women’s bodies are celebrated. Some studies indicate that already at the age of five or six many girls feel ugly or fat, and how the pressure to have an ideal body (thinner, younger, slimmer, more athletic, etc.) continues throughout life, even into old age. Many women grow up with a complex about their bodies, feeling ashamed at the arrival of their first period, experiencing adolescence as a “shrinking away” in order not to stand out because of their height or a concern about showing their breasts, with eating disorders in an attempt to stay under their natural weight. Most take a long time to enjoy their sexuality and some never manage to do so.
With this kind of past it can be difficult or almost impossible for a woman to go into labour with confidence in her body.

Childbirth is part of sexual life, which is why it is so important to feel safe whilst giving birth, trusting one’s own body and its wise nature. Acknowledging the wonder of each pregnancy, stopping to imagine how the baby is developing, celebrating the birth at full term… all of this helps to improve the relationship with one’s own body during pregnancy.
Pregnancy weight gain in the breasts, hips or belly should be a cause for celebration and pride: the body is preparing to receive and nourish the baby.

For the baby in the womb there is no comparison: its mother’s body will always be the most perfect and beloved, precious home.

More and more fathers want to be present at the birth of their children. For the father’s presence at the birth to be a help rather than a hindrance or obstacle, it is important that the father knows and understands both the birth process for the mother and the needs of the new-born.
With that knowledge a father’s presence can guarantee respect and support for the mother-baby dyad.
Childbirth is part of the sexual and emotional realm; the same hormones drive it. A woman needs to feel secure and confident if she is to give birth well.

The woman should not feel exposed, but rather accompanied by someone discreetly offering love and care. The father’s role can be a true blessing if he offers his partner caresses, trust, complicity and support and reinforces her innate ability to give birth. Sometimes the father will have to act as an intermediary precisely to prevent the labouring woman from being disturbed unnecessarily, in tandem with the midwife or professionals attending the birth.

Once the baby is born, it is vital to give the baby skin-to-skin contact with the mother. Unless a real medical emergency justifies it, for the first two hours after birth nobody should disturb or interrupt this first encounter between mother and baby. The informed father understands and respects this vital time for mother and baby, and knows that facilitating this loving encounter will foster bonding, breastfeeding and nurturing.
If the birth was by caesarean section, the mother can also be offered skin-to-skin baby placement straight after birth and the father can assist with the first encounter.

The father’s role is fundamental if the baby needs to be transferred or admitted to hospital far from the mother. In this case, it is up to him to be at the baby’s side at all times, ensuring that the baby’s right to be accompanied by his parents during hospitalisation is respected.

The word obstetrics comes from the Latin expression “Ob Stare” meaning “to be at the side of”, referring to the role played by those who attend the birth at the side of the woman in labour

The role of obstetricians is vital to women’s health, not only in pregnancy and childbirth but also in the detection and treatment of illness.

In addition, in complicated deliveries when there are major problems obstetricians can save lives.

The art of obstetrics is to know when it is necessary to intervene to get a baby out of the birth canal urgently, or conversely, when to wait. To do this, obstetricians work as a team with midwives and other medical specialists such as anaesthetists and neonatologists.

The history of midwifery is full of light and shadow. There have been many obstetricians who have honoured and helped women in childbirth and continue to do so.

“A healthy woman giving birth naturally is doing something that cannot be improved upon. This task will be carried out optimally if the woman feels self-confident and is able to stay in an environment in which she is the centre, such as her own home”. G.J. Kloosterman was Professor of Obstetrics at the University of Amsterdam, and made this statement in an essay in 1922.

Since the late 1980s, the French obstetrician Michel Odent has worked hard to spread the benefits of natural or non-medicalised childbirth and to promote obstetrics that respects both mothers and babies, where caesarean sections are only performed when truly necessary and in the safest and most gentle way possible.

The above-mentioned obstetricians have proven the advantages of natural childbirth for the mother’s recovery, for the baby’s adjustment to life outside the womb and its long-term health. It is important to note here that natural childbirth is not the same as vaginal or medicalised childbirth.
Natural or physiological birth is a birth in which the woman is not subject to any medical intervention. No drugs or drips are administered, no episiotomy is performed, she is not forced to remain in a certain position, she is not separated from the new-born immediately after giving birth and the birth takes place without any complications.
A medicalised birth is when the woman undergoes medical interventions during labour, such as an intravenous drip, oxytocin, epidural, rupture of the amniotic sac, forceps or vacuum extraction, episiotomy, etc.
A vaginal birth as its name suggests means that the baby has come out of the vagina, but it is not the same as natural childbirth.
Respectful childbirth is an expression used to describe births where the woman is the protagonist, her own process and informed consent are respected at all times, interventions are only made when strictly necessary and are done so in a careful and respectful manner for both mother and baby.

The midwife is the professional expert in assisting normal childbirth.

A midwife can assist a pregnant woman from the beginning of her pregnancy and monitor her pregnancy.

Their job in childbirth is precisely to take care of this normality and to prevent or avoid complications in childbirth. To this end, they carry out a number of essential tasks:
They convey confidence to the woman and support her emotionally.
They observe the progress of labour without hindering it.
They are experts in making it easier for the woman accompanied by her partner to dilate at her own pace and as she wishes. They know when to encourage the woman and how to inspire feelings of trust and safety.
They know how the baby is doing and can observe how the baby is settling right from the onset of labour.
They listen especially to its heartbeat to ensure baby is well at all times.
They inform the mother of the progress of the birth and ask for informed consent if any intervention is required.
Sometimes, if labour is prolonged or halted, or if there is a need for the baby to come out quickly, they may recommend that the mother be placed in various different positions, or perform minor interventions such as an amniotomy or episiotomy.
If there is a complication, they know how to detect it and request the intervention of obstetricians who will then continue the delivery or immediate postpartum care.
As soon as the baby is born, they place it on the mother, check that it is well and assess whether it needs to be seen by a paediatrician.
They are experts in breastfeeding: they know how to assist with breastfeeding at birth and in the months and years that follow.

Doulas are women (almost always mothers) who are experts in accompanying women during pregnancy, childbirth and the postpartum period. They have been trained to provide the emotional support during labour that assists with birth. They understand that childbirth is an intimate moment, which requires the mother to feel cared for and protected from external distractions or discomfort.

They are not healthcare professionals, i.e. they do not assess how the birth is going or give any advice, but they help to make the woman as comfortable and at ease as possible during labour.
The doula is usually an experienced mother who has already given birth and knows what it is like. She forms a bond of trust with the mother before the birth and helps her to achieve a more natural and respected birth. During the birth she supports, sustains, cares for and reinforces the labouring mother at all times.
For mothers without a partner, the doula’s presence at birth can be an even greater help.
A friend of the mother who knows what childbirth is and how to accompany her with calm confidence can also provide this accompanying role. In fact, the doulas take on the role of an expert friend when the mother does not have this support available.

Just as all childbirth, a caesarean section is an act of love that involves a sacrifice by the mother for the love of her baby and the birth of a human being. Every pregnancy may end in a caesarean. The World Health Organisation and the main scientific societies recognise that many more caesarean sections are performed than necessary, and that this carries risks for the lives of both mother and baby, but sometimes a caesarean section really does save both from a situation that seriously, urgently and unexpectedly compromises their health.

Whatever the reason for performing a caesarean section, there is no reason to neglect the other aspects surrounding the birth. In other words, in addition to being a surgical intervention, the caesarean section is still the moment of birth and, as such, should be treated with the utmost respect and humility by the professionals attending it.

Caesarean sections, whether unexpected or planned, can be a rewarding and restorative experience if done respectfully.