indications for induction may include: abruptio placentae chorioamnionitis fetal compromise such as isoimmunisation leading to haemolytic disease of the newborn or oligohydramnios fetal demise gestational hypertension maternal conditions such as gestational diabetes or chronic kidney disease preeclampsia or eclampsia premature rupture of membranes post-term pregnancy induction is also considered for logistical reasons, such as the distance from hospital or psychosocial conditions, but in these instances gestational age confirmation must be done, and the maturity of the fetal lung must be confirmed by testing. the acog also note that contraindications for induced labour are the same as for spontaneous vaginal delivery, including vasa previa, complete placenta praevia, umbilical cord prolapse or active genital herpes simplex infection, in which cases a cesarean section is the safest delivery method. cesarean section the who recommends a c-section rate of between 10 and 15 per cent because c-sections rates higher than 10 per cent are not associated with a decrease in morbidity and mortality. in 2018, a group of medical professionals called the rates of increase around the world "alarming". in a lancet report, c-sections were found to have more than tripled from about 6 per cent of all births to 21 per cent. in a statement by the maternal and child health organisation, the march of dimes, the increase is largely due to an increase of elective c-sections rather than when it is really necessary or indicated. looking at the c-section rates between 1976 and 1996, one large study done in the u.s. found that the proportion of pregnancies delivered by c section increased from 6.7% in 1976 to 14.2% in 1996, with maternal choice the most frequent reason given. by 2018 the rate had climbed to one-third of all births. management share of births attended by skilled health staff obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. supportive care during labour may involve emotional support, comfort measures, and information and advocacy which may promote the physical process of labour as well as women's feelings of control and competence, thus reducing the need for obstetric intervention. the continuous support may be provided either by hospital staff such as nurses or midwives, doulas, or by companions of the woman's choice from her social network. there is increasing evidence to show that the participation of the child's father in the birth leads to a better birth and also post-birth outcomes, providing the father does not exhibit excessive anxiety. continuous labour support may help women to give birth spontaneously, that is, without caesarean or vacuum or forceps, with slightly shorter labours, and to have more positive feelings regarding their experience of giving birth. continuous labour support may also reduce women's use of pain medication during labour and reduce the risk of babies having low five-minute agpar scores. preparation eating or drinking during labour is an area of ongoing debate. while some have argued that eating in labour has no harmful effects on outcomes, others continue to have concern regarding the increased possibility of an aspiration event (choking on recently eaten foods) in the event of an emergency delivery due to the increased relaxation of the oesophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anaesthetic in the event of an emergency cesarean. a 2013 cochrane review found that with good obstetrical anaesthesia there is no change in harms from allowing eating and drinking during labour in those who are unlikely to need surgery. they additionally acknowledge that not eating does not mean there is an empty stomach or that its contents are not as acidic. they therefore conclude that "women should be free to eat and drink in labour, or not, as they wish." at one time shaving of the area around the vagina, was common practice due to the belief that hair removal reduced the risk of infection, made an episiotomy (a surgical cut to enlarge the vaginal entrance) easier, and helped with instrumental deliveries. it is currently less common, though it is still a routine procedure in some countries even though a systematic review found no evidence to recommend shaving. side effects appear later, including irritation, redness, and multiple superficial scratches from the razor. another effort to prevent infection has been the use of the antiseptic chlorhexidine or providone-iodine solution in the vagina. evidence of benefit with chlorhexidine is lacking. a decreased risk is found with providone-iodine when a cesarean section is to be performed. forceps or vacuum assisted delivery main article: obstetrical forceps an assisted delivery is used in about 1 in 8 births, and may be needed if either mother or infant appears to be at risk during a vaginal delivery. the methods used are termed obstetrical forceps extraction and vacuum extraction, also called ventouse extraction. done properly, they are both safe with some preference for forceps rather than vacuum, and both are seen as preferable to an unexpected c-section. while considered safe, some risks for the mother include vaginal tearing, including a higher chance of having a more major vaginal tear that involves the muscle or wall of the anus or rectum. for women undergoing operative vaginal delivery with vacuum extraction or forceps, there is strong evidence that prophylactic antibiotics help to reduce the risk of infection. there is a higher risk of blood clots forming in the legs or pelvis – anti-clot stockings or medication may be ordered to avoid clots. urinary incontinence is not unusual after childbirth but it is more common after an instrument delivery. certain exercises and physiotherapy will help the condition to improve. pain control main article: pain management during childbirth non-pharmaceutical some women prefer to avoid analgesic medication during childbirth. psychological preparation may be beneficial. relaxation techniques, immersion in water, massage, and acupuncture may provide pain relief. acupuncture and relaxation were found to decrease the number of caesarean sections required. immersion in water has been found to relieve pain during the first stage of labour and to reduce the need for anaesthesia and shorten the duration of labour, however the safety and efficacy of immersion during birth, water birth, has not been established or associated with maternal or fetal benefit. most women like to have someone to support them during labour and birth; such as a midwife, nurse, or doula; or a lay person such as the father of the baby, a family member, or a close friend. studies have found that continuous support during labour and delivery reduce the need for medication and a caesarean or operative vaginal delivery, and result in an improved apgar score for the infant. pharmaceutical different measures for pain control have varying degrees of success and side effects to the woman and her baby. in some countries of europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 53% nitrous oxide, 47% oxygen, known as entonox; in the uk, midwives may use this gas without a doctor's prescription. opioids such as fentanyl may be used, but if given too close to birth there is a risk of respiratory depression in the infant. popular medical pain control in hospitals include the regional anaesthetics epidurals (eda), and spinal anaesthesia. epidural analgesia is a generally safe and effective method of relieving pain in labour, but has been associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. however, a more recent (2017) cochrane review suggests that the new epidural techniques have no effect on labour time and the use of instruments or the need for c-section deliveries. generally, pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but rise again later. medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by apgar scores. augmentation oxytocin facilitates labour and will follow a positive feedback loop. augmentation is the process of stimulating the uterus to increase the intensity and duration of contractions after labour has begun. several methods of augmentation are commonly been used to treat slow progress of labour (dystocia) when uterine contractions are assessed to be too weak. oxytocin is the most common method used to increase the rate of vaginal delivery. the world health organization recommends its use either alone or with amniotomy (rupture of the amniotic membrane) but advises that it must be used only after it has been correctly confirmed that labour is not proceeding properly if harm is to be avoided. the who does not recommend the use of antispasmodic agents for prevention of delay in labour. episiotomy further information: episiotomy for years an episiotomy was thought to help prevent more extensive vaginal tears and heal better than a natural tear. perineal tears can occur at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. once common, they are now recognised as generally not needed. when needed, the midwife or obstetrician makes a surgical cut in the perineum to prevent severe tears that can be difficult to repair. a 2017 cochrane review compared episiotomy as needed (restrictive) with routine episiotomy to determine the possible benefits and harms for mother and baby. the review found that restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. multiple births main article: multiple birth in cases of a head first-presenting first twin, twins can often be delivered vaginally. in some cases twin delivery is done in a larger delivery room or in an operating theatre, in the event of complication e.g. both twins born vaginally – this can occur both presented head first or where one comes head first and the other is breech and/or helped by a forceps/ventouse delivery one twin born vaginally and the other by caesarean section. if the twins are joined at any part of the body – called conjoined twins, delivery is mostly by caesarean section. fetal monitoring for external monitoring of the fetus during childbirth, a simple pinard stethoscope or doppler fetal monitor ("doptone") can be used. a method of external (noninvasive) fetal monitoring (efm) during childbirth is cardiotocography (ctg), using a cardiotocograph that consists of two sensors: the heart (cardio) sensor is an ultrasonic sensor, similar to a doppler fetal monitor, that continuously emits ultrasound and detects motion of the fetal heart by the characteristic of the reflected sound. the pressure-sensitive contraction transducer, called a tocodynamometer (toco) has a flat area that is fixated to the skin by a band around the belly. the pressure required to flatten a section of the wall correlates with the internal pressure, thereby providing an estimate of contraction. monitoring with a cardiotocograph can either be intermittent or continuous. the world health organization (who) advises that for healthy women undergoing spontaneous labour continuous cardiotocography is not recommended for assessment of fetal well-being. the who states: "in countries and settings where continuous ctg is used defensively to protect against litigation, all stakeholders should be made aware that this practice is not evidence-based and does not improve birth outcomes." a mother's water has to break before internal (invasive) monitoring can be used. more invasive monitoring can involve a fetal scalp electrode to give an additional measure of fetal heart activity, and/or intrauterine pressure catheter (iupc). it can also involve fetal scalp ph testing. complications