Childbirth in Isala (EN) Childbirth in Isala (EN)

In the Netherlands, your pregnancy and delivery will be attended by an midwife if no special risks are expected during the pregnancy and delivery. In that case usually you can give birth at home or you can choose to give birth in Isala with your own midwife. This is what we refer to as an outpatient delivery. Depending on your health insurance, you will often have to pay a personal contribution for an outpatient delivery with your own midwife.

If you have an increased risk of problems during pregnancy or the delivery, you will be referred to the gynaecologist. Often the gynaecologist will take over your case. In that case your delivery will automatically take place in hospital. This is known as a clinical delivery for a medical reason or ‘on a medical indication’. With a clinical delivery, your insurance will reimburse the costs of admission and the delivery.

The outpatient clinic

If you have a clinical delivery for a medical reason, then your antenatal check-ups will take place in the Obstetric outpatient clinic. These check-ups will be carried out by:

• your own gynaecologist during his or her consultation hours;
• different gynaecologists during the special pregnancy consulting hours;
• an assistant physician or clinical midwife under the supervision of the gynaecologist.

Your blood pressure will be taken at each check-up. In addition, the growth of your baby and its heart sounds will be assessed. An examination of weight, urine, blood, an echoscopy and/or an ultrasound of the baby's heart (Cardiotocography: CTG) will only be carried out if there is a reason to do so.

If your check-ups are carried out by the gynaecologist, you will be referred by the doctor or clinical midwife for an Obstetric Nursing Consultation (VSO). You will receive information about the delivery and attention will be paid to your personal circumstances. You will also get the chance to ask questions of a non-medical nature. The assistant in the outpatient clinic can make an appointment for you that is coupled to your appointment with the gynaecologist.
Isala also organises information evenings for you and your partner about giving birth in Isala. Midwifes in and around Zwolle have folders with the dates of future meetings and these dates are also published on the Isala website. During an information evening you will see a presentation and you can put questions to a gynaecologist and a nurse.

Arrange in advance

• Obstetric care during childbirth
  If a gynaecologist is attending your pregnancy, it would be wise to make timely agreements with your GP or midwife about check-ups after you have given birth. One of them will start attending you at home after you have been discharged from the hospital. Isala will inform the midwife or GP about you being discharged.
• Maternity care
  It is also a good idea to register with an organisation for maternity care before the 16th week of your pregnancy. Health insurers generally have a contract with various providers of home care. For this reason, you should first ask your health insurer for which type of maternity care you are eligible. You should still register even if (part of) your confinement will be in hospital. This is because you are often still eligible for maternity care after you have returned home.

When should you phone?

Your check-ups take place with fairly large intervals, particularly at the start of your pregnancy. If problems occur in between or if you are concerned, feel free to contact the Obstetric unit, telephone number 088 624  35 55 (in urgent situations you should call the delivery rooms, telephone number 088 624 81 61).

Call the delivery rooms immediately in the event of:

• stomach-ache, contractions;
• vaginal loss of blood: more than a few drops;
• loss of amniotic fluid;
• baby movements are gone or diminished;
• all other complaints you are worried about, e.g., fever, severe headache, seeing stars or sudden severe fluid retention.

The delivery

Contact us if:

• you have a painful, contracted stomach (contractions) every 5 minutes for an hour long;
• you experience loss of amniotic fluid;
• you experience loss of blood;
• you are concerned, for instance, because you have a stomach-ache or you experience that the baby moves less;
• your doctor has agreed otherwise with you.

You can call the outpatient clinic on Monday to Friday inclusive, between 08:00 and 16:30 hours, telephone number 088 624  35 55. Outside these hours you can call the delivery rooms, telephone number 088 624 81 61. This number can be reached 24 hours a day. You must always phone before coming to the hospital. This allows the staff who work in the delivery rooms to prepare for your arrival.

What should you bring?

Make sure you are properly prepared and have a bag ready to take with you to the hospital when your delivery date is drawing near.
For yourself you should bring:

• the midwife's pregnancy card, your insurance documents and proof of your identity;
• nightwear, toiletries, underwear, a T-shirt, socks, a dressing gown and slippers;
• any medication that you use at home;
• a camera/video camera (and chargers).

As your partner is allowed to stay with you when you are in the delivery room, it can be handy to bring items for your partner:

• toiletries;
• nightwear;
• food: there is a refrigerator and a microwave in the delivery room.

For your baby you should bring:

• baby clothes (romper, jumper/trousers/suit, socks, a bonnet, a matinee coat). Your baby can wear clothes you have brought with you while you are staying in the Isala;
• fleece/baby wrap;
• a car seat/Maxi Cosi that complies with the statutory safety requirements.

Where should you report?

Your delivery will take place in the Obstetric/Maternity ward V4.4. You can come to the hospital in your own vehicle or by taxi. Transport by ambulance is only in emergency situations, but always on the instructions of the midwife or GP (or other doctor).
Your car can be parked in the car park or in the parking lot. You will enter through the main entrance or the entrance for invalids. You can walk straight on to the delivery rooms via the central hall; you may want to borrow a wheelchair.

Isala has 35 obstetric delivery rooms where you can give birth in a homely setting. Care for the family comes first for us, so we allow partners to stay overnight if they wish. We do have to ask for a small reimbursement for a number of services, e.g. overnight stay(s) and meal(s) for the partner. The suite is equipped with all medical appliances and has a sanitary facility with a sink, a toilet with a bidet and a shower. The room has a television, a sleeping couch for the partner, a refrigerator and a microwave. You can also make use of our free Wifi network. Coffee and tea are available from the unit's dispenser. For the baby there is a dresser with a changing mat, a bath and a crib.

Attendance during childbirth

A nurse who specialises in - or is training in - obstetrics will admit you to the ward. She fits a plastic bracelet to your wrist, bearing your name, date of birth and patient number. This is for identification purposes and to avoid errors. You should always wear this bracelet during your stay in our hospital.
Once you have gone into labour, you will be taken to your own delivery room. The doctor or clinical midwife will attend to you together with an obstetric nurse. Regular discussions will take place with the gynaecologist. If necessary, the latter will attend the birth. During delivery, CTG equipment will be used to monitor your contractions and the condition your baby is in. This equipment registers contraction activity and the baby's heartbeat. A monitor allows the doctor, midwife and nurse to see the CTG-registration outside the delivery rooms too.
If you like you can draw up a birth plan or delivery plan containing your wishes regarding attendance during delivery. More information about drawing up a birth plan can be found on the Gynaecology and Obstetrics website. You can discuss this birth plan with the doctor, clinical midwife and/or the VSO nurse during a check-up at the outpatient department.

Pain relief during childbirth

Giving birth always involves pain. Differences do exist in the duration and the severity of the pain during childbirth. Respiratory exercises and relaxation exercises can help you to cope with the contractions. However, you may find the pain unbearable and want to be given pain relief. The doctor or clinical midwife will inform you about the various possibilities for pain relief:

Remiphentanyl

This is a pain relief product that patients can self-administer using a pump. It is administered by means of an infusion line. Remiphentanyl has a very fast effect on pain and causes you to relax. In addition to the maintenance dose, you can give yourself a bolus of the medicine once every two minutes. The advantage of this medicine is that its effect dissipates very quickly. This method of pain relief can be used, when indicated, 24 hours a day.

Administration
In order to avoid too much medicine being administered, you will not be administered an unlimited amount of this product. The infusion pump is limited to once per two minutes; this means that you cannot re-administer pain relief immediately. Only you can operate the administration button, not the nurses, the doctors, your partner, nor anyone else who is present.
The doctor or midwife attending your delivery can determine whether you are eligible for this form of pain relief. The method is particularly useful for bridging the last phase of the dilation contractions or if there are reasons for not using an epidural puncture.
Your delivery may have progressed to such a stage that you are no longer eligible for this form of pain relief. Also, dilation may already have progressed to the point that the baby can be born within a short space of time.

Preparation
As preparation you will be given an infusion line in your arm to which the pump is attached. Another infusion line will be placed in your other arm as a precautionary measure. A CTG lasting at least 30 minutes will be made of the baby in advance in order to check that the baby is in a good state of health.
A peg attached to your finger measures the oxygen level of your blood. In addition, your blood pressure and respiration will be checked regularly. Nurses and doctors will take regular readings and ask you whether the pain relief is still adequate.
Side effects of this form of pain relief can include:

• sleepiness;
• nausea;
• itching;
• depressed respiration.

If your respiration is depressed, this may cause changes in the baby's heart rate too. For this reason the baby's heart rate is continually measured using a cardiotocogram or CTG).

Administering pain relief in this way will require some practice on your part. After you have pressed the button it takes 20 to 30 seconds before the pain relief works and a contraction lasts 60 to 90 seconds. You have to learn how to administer the pain relief, which means: choosing the right moment when you need to press the button to achieve maximum effect during the next contraction.

A list of the advantages and disadvantages of using the Remiphentanyl pump

• It gives powerful pain relief during contractions.
• Remiphentanyl will cause you to feel drowsy and like you are shut off from the world; as a result some women do not consciously experience giving birth and may even find it unpleasant. Looking back, they may have the feeling that they 'missed' part of the birth.
• You must remain awake to be able to press the button in time.
• Some preparation time is required to regulate this form of pain relief. Two injections are needed for the two infusion needles.

Epidural pain relief (lumbar puncture)

There are two types of pain relief with a lumbar puncture:

• epidural pain relief;
• spinal anaesthesia (narcosis).

Epidural pain relief is also known as peridural pain relief. Epidural pain relief is often given during childbirth. Spinal anaesthesia is usually used for a caesarean section. This is discussed later.

What is epidural pain relief?
For a lumbar puncture, the anaesthesiologist injects an anaesthetic, via a thin tube (a catheter), into the space in the middle of the spinal vertebrae: the epidural space. This is the location of nerves that transport pain signals from the cervix and the pelvic floor. You no longer feel the pain of contractions if these nerves are disabled.

What are the procedures for a lumbar puncture?
Preparations and check-ups
You are first given extra fluid via an infusion. This is necessary because your blood pressure must not drop too low. Your heart rate and blood pressure are checked regularly using automatic monitoring equipment. The heart sounds of the baby are checked using a CTG (cardiotocogram).

Who gives the injection?
An anaesthesiologist administers epidural pain relief. It takes place in the delivery room.

After the injection
You can start moving around again once the catheter has been introduced. The catheter is connected to a pump that causes the continuous flow of a small amount of anaesthetic. On average it takes between five and fifteen minutes before you really notice the effect.

Further check-ups
During the course of giving birth regular checks will take place of your blood pressure, pulse rate, urine production and sometimes the level of oxygen in your blood. Attention will also be given to whether your pain relief is adequate. The state of your baby's health will also be monitored.

What effect will the epidural pain relief have?
You may experience almost no pain whatsoever with epidural pain relief. It is often the case that you do feel the contractions, but they remain bearable. Sometimes your legs may feel weak or you may feel a tingling sensation on the skin of your stomach and/or legs. These effects disappear when the medicine is no longer administered.
The anaesthesiologist always tries to balance the dose: making your pain bearable while keeping the side effects to a minimum. At the peak of a contraction, this means you may feel some pressure or a little pain. However, due to the epidural puncture, you get more rest and are be able to gather your strength; reducing your pain and anxiety can speed up dilation.

How does delivery progress further with epidural pain relief?
By the time your cervix is fully dilated, you will feel an urge to push: the urge to push during a contraction. This can occur while you are still receiving pain relieving medication. Sometimes the pelvic floor is so sedated that a patient does not experience the urge to push, in which case the doctor or clinical midwife often decides to stop administering the medication via the peridural catheter. The medication has to wear off; it may take a while before you start to feel a spontaneous urge to push. As a result, the pushing phase may take longer. There is a slightly higher chance of a vacuum or forceps delivery due to your reduced awareness of the expulsion contractions. You do not have an increased chance of a caesarean section.

Can epidural pain relief always be given?
It may take a while before the anaesthesiologist can come to your delivery room because he is still busy caring for other patients. If expectations are that the anaesthesiologist will be unable to come within an hour, then a different form of pain relief can be offered to bridge the gap.
In certain situations epidural pain relief is undesirable, e.g. with blood coagulation disorders, infections, some neurological disorders or if there are abnormalities or prior operations on the spinal column.

A list of the advantages and disadvantages of epidural pain relief:

• It is the most effective form of pain relief during childbirth. In principle, can be used continuously, both during dilation and during the pushing phase. During the pushing phase, the pain relief is sometimes stopped in order to promote active participation in pushing. As a result, it is possible that you will feel some pain when you push.
• Extensive monitoring is required for you and your baby. You will in any case receive an infusion, a blood pressure sleeve, a catheter in your back that is connected to the infusion pump, always continuous CTG-monitoring of the state of the baby's health and sometimes a bladder catheter.
• The chance of serious complications is negligible. Annoying side effects can sometimes occur but these are not serious: a drop in blood pressure, headache, loss of strength in your legs, itching, reduced bladder function. These complaints can easily be treated and are temporary.
• You will generally not be able to move around before the delivery; you will have to remain in bed.
• The pain relieving effect is insufficient in about 5% of women.

Caesarean section

The medical term for a C-section is sectio caesarea. There are a number of reasons for a caesarean section. Sometimes it is apparent during a pregnancy that such an operation will be necessary, e.g. if complications can be expected. In other cases it sometimes becomes apparent during the delivery that a caesarean section will be necessary, e.g. because the birth is not progressing.

Planned caesarean section: As with any operation, you will undergo a medical examination prior to a planned caesarean section. This is referred to as preoperatieve screening. This means the anaesthetist will ask questions about your health and you will also often be physically examined, e.g. listening to your heart and lungs. In addition, a blood examination is carried out and the anaesthetist discusses with you the choice of general anaesthesia (narcosis) or a lumbar puncture.

Seven days prior to the caesarean section you are no longer allowed to remove hair from the surgical area using clippers, a razor or a depilatory cream, as this would increase the risk of infections after the operation. If the doctor feels that the surgical area needs to be depilated in your case, then the operation assistant uses special clippers to do this just before the caesarean section.

On the day of the operation you must be in a fasted state, meaning that you may not eat or drink anything from 00:00 hours, and up to two hours before the operation you may only consume clear drinks. If the caesarean section is planned in the afternoon, you will be allowed a biscuit and a cup of tea before 06:00 hours in the morning.

About two hours before the caesarean section you will be given an operating gown to put on and a bladder catheter will be inserted to keep your bladder empty during and after the operation. You will also be given an infusion with extra fluid. Blood will be taken when attaching the infusion.

Your partner may not be present in the operating theatre when the sedation is given (spinal anaesthesia) in connection with hygiene requirements in the operating theatre.

During a caesarean section a baby comes into the world via the abdominal wall. This requires an operation that lasts about 45 minutes, while the baby is generally born fifteen minutes after the start of the operation. You and your partner can look on via a screen. A nurse will receive the baby from the gynaecologist and take it to the paediatrician. The paediatrician examines the baby in the operating theatre or in a room next to the operating theatre. If the baby is in a good state of health, you will have skin to skin contact with your baby shortly afterwards, in the operating theatre. The doctors complete the caesarean section while you and your partner become acquainted with your baby. After the operation - in the recovery room and assuming you can return to the maternity ward - the baby will be with you as much as possible. If all goes well, you will return home on the second to the fifth day after the caesarean section. Naturally, the speed of your recovery and the health of your baby play a role in this. The day after the caesarean section, the ward doctor will visit you to discuss with you whether you can go home the following day.

Your further recovery will take place gradually at home. The time needed for recover after a caesarean section is often longer than after a normal delivery. Not only have you just become a mother (again), but you are also recovering from an operation.

You will notice that you are gradually able to do more after the first few weeks. You can climb stairs, so there is no need for a bed in the living room. Arranging flowers and setting coffee/tea will do no harm as long as you avoid doing too much all at once. For instance, some things can be done sitting down.

You are advised not to life heavy things (no more than 5 kilo) during the first six weeks. If you lift things, bend at the knees and keep what you are lifting close to your body. Make sure you work at the right height
(bath and dresser). Gradually you will be able to extend your activities (light household jobs, small errands). Getting fresh air is a good idea, but do not go alone in the beginning and do not go too far. This is more tiring than you think, as you have to regain your former state of health.

You can take a shower quite soon after the operation. We advise against taking a bath for as long as you still have a bloody discharge (on average two to four weeks). If your wound leaks fluid or a tiny amount of blood, you can clean the wound in the shower, dry it carefully and place a dry dressing on it to protect your clothes. Coughing, pushing (faeces) and laughing may still be painful, but the wound is strong enough to cope. The best way to support your wound is by gently placing a flat hand or a towel against it. In the beginning you may sometimes feel a pulling sensation at the side of your wound due to internal sutures. This is nothing to worry about.

You can start doing stomach muscle training six weeks after the operation. The various layers of the wall of your stomach will have healed well by then.

In principle, you are allowed to drive a car immediately after having had an epidural puncture. However, we advise you not to do this too soon after childbirth, as the speed of your reactions and your ability to concentrate are reduced. You may feel dizzy now and again during the first three weeks after a general anaesthetic (narcosis), so you are also advised not to drive a car. You may experience problems with your balance when cycling, particularly when turning to look behind you. Some insurance companies will not pay for damages if you start driving within six of a caesarean section. It would be wise to check this with your insurance company.

The use of contraceptives is the same as after a normal delivery. If necessary, ask your midwife, GP or gynaecologist for advice. You should in any case avoid intercourse until after the bloody discharge has stopped. Some women find it takes a while before the desire to have sexual intercourse returns.

You will feel a sense of numbness around the scar for some time, as nerves in the wall of your stomach are cut when a bikini section is performed. Above this numb area, an area about halfway up to your umbilical is sometimes extra sensitive. It often takes six to twelve months before the wall of your stomach feels normal again. After surgery, in order to keep the area of the wound as pliable as possible, you can massage the wound lightly with your fingertips, making small rotating movements along and above the wound. This improves the flow of blood, which helps to prevent adhesion between your skin and the underlying fatty tissue.

Will you need a caesarean section again in the future?
If you do want to become pregnant again, the gynaecologist advises that you wait at least one year. Whether you will need another caesarean section depends on the reason for this caesarean section. During your check-up you should discuss the chance of you having a ‘normal’ delivery next time. A caesarean section is often not necessary for your next baby. You will always have a medical indication for a hospital delivery due to the scar in your cervix.

After the delivery

Feeds

If you are breastfeeding, the idea is to start feeding your baby within one hour after the delivery. Your baby can stay next to your bed 24 hours a day. If this is not possible – because the baby has been admitted to the paediatrics ward - you can express the milk in order to encourage your milk production. Personal information about feeds will be recorded on a list. This baby list will be given to you for the maternity assistant. During the first few days after giving birth, it is important to breastfeed your baby eight to twelve times a day. Additional food is only given on medical indication. Lactation specialists who work at Isala can advise you. If you expect problems with breastfeeding even before you have given birth, you can make an appointment with the lactation specialist. The outpatient clinic assistant will organise this for you.
If you choose to bottle-feed your baby, formula for bottle feeds is available on the ward. You can choose to bring your own if you prefer.

Registering the birth

You are statutorily obliged to register the birth of your child with the municipal civil registry within three days. In your case this is Zwolle, because that is the municipality where your child was/will be born. The three-day period includes the weekend. However, if the third day is a Saturday, Sunday or a public holiday, then the registration can be made on the next working day.
To make registration of your baby easier, an official from Zwolle municipality is present on the ward during mornings on Monday to Friday. Contacting the birth registration desk is by appointment only. The nurse who was present at your delivery can make an appointment for you with the birth registration desk. You can contact the birth registration desk at the Obstetrics/Maternity ward for the following documents:

• registering a birth;
• indicating the choice of name;
• drawing up a certificate of recognition of paternity.

Naturally, you can also choose to register the birth at the Municipal Office on Lübeckplein. There too, registration is by appointment only. Appointments can be made via www.zwolle.nl/afspraakmaken.
In order to register the birth you will need:

• valid proof of identity;
• if you are married: your marriage booklet;
• if you are not married: possibly the certificate of recognition of paternity;
• the pink or blue Isala birth card.

N.B. Don't forget to register your baby with your health insurer (within four months after the birth) and for other insurance policies.

Bathing

The maternity assistant or nurse will not bathe your baby immediately after it is born. Your baby does not need to have been bathed before you are discharged. This only takes place 24 hours after the birth, unless there is a reason for doing it earlier, e.g. if your baby had defaecated in the amniotic fluid.

The water should be about 37 degrees Centigrade. You can check this with your elbow or use a bath thermometer. To make sure your baby does not cool off too quickly, dry your baby carefully but quickly, first the head, then the rest of the body. A room temperature between 20 and 22 degrees Centigrade is recommended for bathing the baby.

Taking the baby's temperature

During the first 24 hours, your baby's temperature will be taken once every three hours (before a feed). The temperature is measured anally. The best way to check your baby's temperature is by feeling his/her neck; the baby's hands and feet always feel slightly colder, so this is not a good indicator.
Once your baby is able to maintain his/her temperature, during the first week at home you can check your baby's temperature twice daily, before a feed or a bath, to be sure your baby is maintaining his/her temperature in the new surroundings. The normal temperature is between 36.5 and 37.5 degrees Centigrade.
If your baby is cold you can place a hot-water bottle in the crib. Always place it on top of the blankets and not immediately next to your baby! Your maternity assistant will advise you about this.

Room temperature

The normal temperature for a baby's room is between fifteen and eighteen degrees Centigrade. It is not a good idea to turn up the central heating. It is better to give your baby an extra blanket or a hot water bottle to help him/her maintain his/her temperature. You can open the window slightly, as long as the temperature remains between fifteen and eighteen degrees Centigrade.
If it is cold outside, only open the window now and again for some fresh air, e.g. when your baby is taken out of the room for a feed. Avoid draughts in the baby's room.

Care of the umbilical stump

At each feed you should check the baby's umbilical stump for signs of infection (redness or extremely red colour, dampness, odour). The baby's umbilical stump will automatically dry up and fall off after about a week.

Urinating

A baby normally urinates within the first 24 hours after being born. In principle, your baby will have a wet nappy after every feed. When breastfeeding, this is a sign that the baby is receiving sufficient nourishment. It may be slightly less during the first few days. One or two wet nappies a day is sufficient.

Defaecation

A baby's first stools are black. This is also known as meconium. Your baby should have produced stools for the first time within 48 hours after the delivery. The number of times a breast-fed baby produces stools will vary enormously.

Once your milk production is functioning well (after a few days), the colour and consistency of your baby's stools changes; these are referred to as the transitional stools. The stools are often yellow at this stage and very thin and grainy, and may cause your baby to have colic.

Sleeping position

Your baby's position for sleeping, right from birth, is on his/her back with the head turned alternately to the left or the right. Your maternity assistant will tell you more about this. One of the reasons for the importance of putting your baby to bed properly, is to prevent sudden infant death. For more information about this, see www.wiegedood.nl.

Discharge

If no complications arise, in consultation with the duty doctor, you will go home with your baby a few hours after giving birth. After a caesarean section you will not go home until after at least 48 hours. This can be in the evening or at night, depending on the course of your pregnancy and the situation surrounding delivery. Nowadays a number of maternity centres offer the possibility of maternity care in the evening/night. You can ask the maternity centre where you are registered or the ward nurse whether they offer this possibility.
When you know that you are going home, it is important to inform the maternity centre so that they can plan a maternity assistant for you.
If you had a clinical delivery for a medical reason, then your discharge will be discussed by the doctor/clinical midwife. The idea is to discharge you before 10:00 hours.
The nurse will give you discharge papers for the midwife and a discharge letter will be sent to your GP.

Follow-up examination

A follow-up examination can take place with your own gynaecologist six weeks after giving birth. Sometimes your GP or midwife can carry out the follow-up examination. Before you are discharged from the hospital, an agreement will be made with you about where the follow-up examination will take place.

Contact

If you still have questions after reading this information or if you want to know more, then you can speak to your doctor during surgery hours. It can be a good idea to write down your questions on paper in advance.
You can also contact the hospital by telephone on 088 624 35 55 (Monday to Friday inclusive, between 08:30 and 16:30 hours).

Do you have an appointment soon? The confirmation of your appointment states where and when you are expected.

Telephone numbers and accessibility

• Obstetrics/Maternity ward
  +31 088 624 79 78.

Visiting hours: You can receive visitors as and when you like, but only until 21:30 hours. On the day that you give birth, you are of course welcome to receive visitors, as long as your visitors respect the calm environment that is expected in a hospital. 

• Nursing via home monitoring
  06 10 09 02 08 (daily between 7:30 and 15:30 hours, between 15:30 and 7:30 hours) you will automatically be connected with a nurse from the Obstetrics/Maternity ward
• Obstetrics outpatient clinic
  088 624 35 55 (Monday to Friday inclusive, between 8:30 and 16:30 hours)