IN THIS CHAPTER
Recognizing the signs of labor
Being admitted to the hospital
Keeping an eye on your baby
Being induced
Looking at the three stages of labor
Managing the pain of childbirth
Despite the incredible advances that have been made in science and medicine, no one really knows what causes labor to begin. Labor may be triggered by a combination of stimuli generated by the mother, the baby, and the placenta. Or labor may begin because of rising levels of steroid-like substances in the mother or other biochemical substances produced by the baby. Because no one knows exactly how labor starts, no one can pinpoint exactly when it will occur.
This chapter helps you recognize the signs of labor and tells you what to expect at each of the three stages of labor. It also addresses such important issues as labor induction, pain management, how your baby’s health is monitored, and alternative birthing methods.
Knowing When Labor Is Real — and When It Isn’t
Being unsure whether you’re really in labor is actually fairly common. Even a woman expecting her third or fourth child doesn’t always know when she’s genuinely in labor. This section helps you better identify your own labor (but you still may find yourself calling your practitioner several times or even making many trips to the hospital or birthing center, only to find out that what you think is labor really isn’t).
You may experience some of the early symptoms of labor before labor actually begins. Instead of indicating that you’re in labor, these symptoms suggest that labor may occur fairly soon. Some women experience these labor-like symptoms for days or weeks, and others experience them only for several hours. Most of the time, going into labor isn’t as dramatic as it’s portrayed on sitcoms, and women very rarely lack the time they need to get to the hospital before they deliver.
If you think you’re in active labor, don’t run to the hospital right away. Instead, telephone your practitioner first.
Noticing changes before labor begins
As you near the end of your pregnancy, you may recognize certain changes as your body prepares for the big event. You may notice all these symptoms, or you may not notice any of them. Sometimes the changes begin weeks before labor starts, and sometimes they begin only days before:
· Bloody show: As changes in your cervix take place, you may expel some mucous discharge mixed with blood from your vagina. The blood comes from small, broken capillaries in your cervix.
· Diarrhea: Usually a few days before labor, your body releases prostaglandins, which are substances that help the uterus contract and may cause diarrhea.
· Dropping and engagement: Especially in women who are giving birth for the first time, the fetus often drops into the pelvis several weeks before labor (see Book 2, Chapter 3). You may feel increased pressure on your vagina and sharp pains radiating to your vagina. You also may notice that your whole uterus is lower in your belly and that you’re suddenly more comfortable and can breathe more easily.
· Increase in Braxton-Hicks contractions: You may notice an increase in the frequency and strength of Braxton-Hicks contractions (see Book 2, Chapter 3). These contractions may become somewhat uncomfortable, even if they don’t grow any stronger or more frequent. Some women experience strong Braxton-Hicks contractions for weeks before labor begins.
· Mucous discharge: You may secrete a thick mucous discharge known as the mucous plug. During your pregnancy, this substance plugs your cervix, protecting your uterus from infection. As your cervix starts to thin out (efface) and dilate in preparation for delivery, the plug may wash out. Don’t worry; losing your plug doesn’t mean you’re prone to infection.
CONTRACTION OR NOT?
A contraction occurs when your uterus’s muscle tightens and pushes the baby toward the cervix. Usually, contractions are uncomfortable and therefore unmistakable. But many women worry that they won’t know they’re having contractions. You can tell whether you’re experiencing contractions by using a quick and easy trick.
With your fingertips, touch your cheek and then your forehead. Finally, touch the top part of your abdomen, through which you can feel the top part of your uterus (the fundus). A relaxed uterus feels soft, like your cheek, and a contracting uterus feels hard, like your forehead. This exercise is also good to try if you think you may be in preterm labor (see Book 6, Chapter 2 for more information).
Discerning false labor from true labor
Distinguishing true labor from false labor isn’t always easy. But a few general characteristics can help you determine whether the symptoms you’re experiencing mean you’re in labor.
In general, you’re in false labor if your contractions
· Are irregular and don’t increase in frequency
· Disappear for any reason but especially when you change position, walk, or rest
· Are not particularly uncomfortable
· Occur only in your lower abdomen
· Don’t become increasingly uncomfortable
On the other hand, you’re more likely to be in actual labor if your contractions
· Grow steadily more frequent, intense, and uncomfortable
· Last approximately 40 to 60 seconds
· Don’t go away when you change position, walk, or rest
· Occur along with leakage of fluid (due to rupture of the membranes)
· Make normal talking difficult or impossible
· Stretch across your upper abdomen or are located in your back, radiating to your front
Sometimes the only way you can know for sure whether you’re in labor is by seeing your practitioner or going to the hospital. When you arrive at the hospital, your doctor, a nurse, a midwife, or a resident physician performs a pelvic exam to determine whether you’re in labor. The practitioner also may hook you up to a monitor to see how often you’re contracting and to see how the fetal heart responds. Sometimes you find out right away whether you’re truly in labor. But the practitioner may need to keep you under observation for several hours to see whether the situation is changing.
You’re considered to be in labor if you’re having regular contractions and your cervix is changing fairly rapidly — effacing, dilating, or both. Sometimes women walk around for weeks with a partially dilated or effaced cervix but aren’t considered to be in labor because these changes are occurring over weeks instead of hours.
Deciding when to call your practitioner
If you think you’re in labor, call your practitioner. Don’t be embarrassed if he tells you you’re probably not in labor — it happens to many women. Timing your contractions for several hours before you call (to see whether they’re getting closer together) is a good idea because your practitioner can use this information to help determine whether you’re in true labor. If your contractions are occurring every five to ten minutes and they’re uncomfortable, definitely call. If you’re less than 37 weeks along and feeling persistent contractions, don’t sit for hours counting their frequency — call your practitioner immediately.
Call your practitioner if any of the following apply to you:
· Your contractions are coming closer together, and they’re becoming increasingly uncomfortable.
· You have ruptured membranes. When your water breaks, a small amount of watery fluid may leak out, or it may be a big gush. If the fluid is green, brown, or red, let your practitioner know right away.
Meconium (your baby’s first bowel movement) usually happens after the baby is born, but 2 to 20 percent of babies pass meconium during labor, most commonly if they’re born past their due date. Passing meconium doesn’t necessarily indicate anything is wrong, but it can be associated with fetal stress.
· You have bright red heavy bleeding (more than a heavy menstrual period) or are passing clots, in which case you should go to the hospital immediately (after calling your practitioner).
· You’re not feeling an adequate amount of fetal movement (see Book 2, Chapter 3 for more information).
· You have constant, severe abdominal pain with no relief between contractions.
· You feel a fetal part or umbilical cord in your vagina. In this case, go to the hospital right away!
Checking for labor with an internal exam
When a practitioner is trying to determine whether you’re in labor, he performs an internal exam to look for several things:
· Dilation: Your cervix is closed for most of your pregnancy but may gradually start to dilate during the last couple of weeks, especially if you’ve had a baby before. After active labor begins, the rate of cervical dilation speeds up, and the cervix dilates to 10 centimeters by the end of the first stage of labor. Often, you’re considered to be in active labor when your cervix is about 4 centimeters dilated or 100 percent effaced.
· Effacement:Effacement is a thinning out or shortening of the cervix, which happens during labor. Your cervix goes from being thick (uneffaced) to 100 percent effaced (see Figure 4-1).
· Station: When you’re in labor, the practitioner uses the term station to describe how far your baby’s head (or other presenting part) has descended in the birth canal in relation to the ischial spines, a bony landmark in your pelvis (see Book 2, Chapter 3 for more information).
· Position: When labor begins, the baby typically starts out facing to the left or right side. As labor progresses, he rotates until his head is face-down, and he comes out looking at the floor. Occasionally, the baby rotates to the opposite position and comes out sunny-side up, looking at the ceiling.
Illustration by Kathryn Born, MA
FIGURE 4-1: During cervical effacement, the cervix progresses from an uneffaced state to 100 percent effaced and partially dilated.
Getting Admitted to the Hospital
Whether you’re in labor, being induced, or having a cesarean delivery, you need to be admitted to the hospital’s labor floor. If you’re preregistered (ask your practitioner about the process), your records are already on the labor floor when you arrive, and a hospital unit number is assigned to you. When you arrive at the hospital or birthing center, you go through an admission process and are assigned to a room.
Settling into your hospital room
Although each hospital or birthing center has its own system, getting settled in usually follows this routine after you get to your room:
· A nurse asks you to change into a gown.
· A nurse asks you questions about your pregnancy, your general health, your obstetrical history, and when you last ate. If you think your water has broken or you’re leaking fluid, let your nurse know.
· A nurse, midwife, resident, or other practitioner performs an internal exam to see how far along in labor you are.
· Your contractions and the fetal heart rate are monitored.
· A nurse may draw your blood and start an IV (intravenous) line in your arm (for delivering fluids and, possibly, medications).
· You’re asked to sign a consent form for routine hospital care, delivery, and possibly cesarean section. (You sign the consent form when you’re admitted in case you need an emergency cesarean during labor and you don’t have time to sign consent forms.) Signing a consent form doesn’t mean you’re limiting your care options.
You may want to hand over any valuables you have with you to your partner or another family member (or simply leave them at home).
SUPPORTING YOUR PARTNER DURING LABOR
Women in labor need lots of support. Your partner needs to hear that she’s doing well, that things are progressing as they should, and that she really can do this. Even if her mother, sister, doula, and five of her dearest friends are with her, she needs you. Support means different things to different women, though, and your job is to figure out what your partner needs while in labor and do it.
Your partner may not be in a talkative mood during labor, so asking her what she wants you to do may get you kicked out of the room. This is one time in her life when she wants you to think for yourself and take action. Take the lead by offering choices. Ask her whether she wants
· A back rub
· A massage
· A hand to hold
· You to sit behind her and support her back
· An epidural
· You to kick her mom out of the room
· Ice chips
· To get in the tub
· Any of the other labor options you discussed before today
Checking out the accommodations
Some women go through labor in the same room in which they deliver the baby, and others are moved to a different room for delivery. Most hospital rooms include some standard features, so the room you’re placed in probably includes the following:
· Bed: In a room used for both labor and delivery (also known as a birthing room), the bed is specially designed to come apart and be turned into a delivery table. Some hospitals have rooms where you labor, deliver, and even remain for your postpartum recovery. These rooms are called LDR (labor, delivery, and recovery) rooms or LDRP rooms (the p stands for postpartum).
· Doppler/stethoscope: Your practitioner or nurse uses these portable tools to listen periodically to the fetal heartbeat instead of using the continuous fetal monitor.
· Fetal monitor: This machine has two attachments, one to monitor the baby’s heart rate and one to monitor your contractions. The fetal monitor generates a fetal heart tracing, which is a paper record of how the baby’s heart rate rises and falls in relation to your contractions.
· Infant warmer: This device has a heat lamp to keep the newborn’s body temperature from dropping.
· IV line: This tube is connected to a bag of saline (salt water) containing a glucose mixture to keep you properly hydrated. It also provides access for medications in case you need pain control or have an emergency.
· Rocking chair or recliner: The extra chair is for your partner, your coach, or another family member.
Monitoring Your Baby
While you’re in labor, your practitioner keeps an eye on your baby in a number of ways to make sure he’s tolerating the whole process well. Most hospitals and most practitioners advise monitoring the baby’s heart rate during labor. Although some low-risk patients may require only intermittent monitoring, other patients are better off with continuous monitoring. Sometimes knowing whether continuous monitoring makes sense isn’t possible until you’re in labor and your practitioner can see how the baby is responding. This section outlines how your practitioner may monitor your baby.
Fetal heart monitoring
Labor puts stress on both you and the baby. Fetal heart monitoring provides a way to make sure that the baby is handling the stress. Monitoring can be done in several ways.
External monitoring
Electronic fetal heart monitoring uses either two belts or a wide elastic band placed around the abdomen. A device attached to the belt or under the band uses an ultrasound-Doppler technique to pick up the fetal heartbeat. A second device uses a gauge to pick up the contractions. An external contraction monitor can show the frequency and duration of contractions, but it can’t provide information about how strong they are. An external fetal heart monitor gives information about the fetus’s response to contractions and records variability — that is, periodic changes in heart rate that help determine how the baby is tolerating the labor process.
You may hear your practitioner use the following terms to describe the fetal heartbeat:
· Normal baseline heart rate: About 110 to 160 beats per minute.
· Bradycardia: A decrease in the fetal heart rate from baseline to below 110 beats per minute that lasts for more than ten minutes.
· Tachycardia: An increase in the fetal heart rate to above 160 beats per minute for more than ten minutes.
· Accelerations: Brief increases above baseline in the fetal heart rate, often after a fetal movement. Accelerations are a reassuring sign.
· Decelerations: These are intermittent decreases below the baseline fetal heart rate. The significance of decelerations depends on their frequency, how far the heart rate drops, and when they occur in relation to contractions. Decelerations are classified as early, variable, or late, according to when they occur in relation to contractions.
There tends to be a large variability in the interpretation of fetal heart rate tracings. For this reason, the National Institute of Child Health and Human Development created a three-tier system for interpreting fetal heart rate tracings:
· Category 1: Normal tracing — predicting normal fetal acid-base status
You can take heart when fetal heart monitoring indicates the following:
· A normal baseline heart rate of 110 to 160 beats per minute
· An absence of late or variable decelerations
· Moderate fetal heart rate variability (fluctuations of the fetal heart rate) of about 6 to 25 beats per minute above and below baseline
· Category 2: Indeterminate tracing — requires closer observation and possible treatment (fluids, oxygen, change in position, and so forth)
· Category 3: Abnormal tracing — predicting abnormal fetal acid-base status at the moment
Internal monitoring
Your practitioner uses an internal fetal heart monitor when your baby needs closer observation than is possible with external monitoring. Your practitioner may be concerned about how your baby is tolerating labor, or she may simply be having difficulty picking up the heart rate externally — if, for example, you’re having more than one baby. The monitor is placed during an internal exam. It’s passed through the cervix via a flexible plastic tube. This procedure is no more uncomfortable than a pelvic exam. The tiny electrode is then attached to the baby’s scalp.
An internal monitor for contractions (called an internal pressure transducer, or IPT) is sometimes used to better assess how strong the contractions are. The monitor consists of thin, flexible, fluid-filled tubing, which is inserted between the fetal head and the uterine wall during an internal exam. Sometimes, this same device is used to infuse saline into the uterus — if very little amniotic fluid is present or if the fetal heart tracing indicates the umbilical cord is being compressed.
Other tests of fetal health
If the information from the fetal monitor raises concerns or is ambiguous, your practitioner can perform other tests to help determine how to proceed with your labor.
Some practitioners, and some mothers, prefer not to monitor. But most doctors believe that monitoring is very useful and that the benefits of monitoring outweigh the risk that monitoring will lead to an unnecessary cesarean delivery.
Labor admission test
This test involves performing electronic fetal heart rate monitoring for about 20 to 30 minutes upon admission to the labor and delivery floor. It’s a good way of initially assessing fetal well-being and may be helpful in quickly identifying those rare occasions where the fetus needs quick delivery.
Scalp pH
If your practitioner is concerned about how well the baby is tolerating labor, she may want to perform a scalp pH test. This involves sampling a small amount of the baby’s blood through a little prick of his scalp and measuring the pH, which reflects how well the baby is doing during labor. This test requires that the cervix be dilated enough to access the fetal scalp. Many labor floors no longer have the machinery to perform this test because the machines require a lot of maintenance and quality control.
Scalp stimulation
Scalp stimulation is an easy test to see how the fetus is doing. The practitioner simply tickles the baby’s scalp during an internal exam. If this touch causes the fetal heart rate to increase, the baby is usually doing fine.
Fetal pulse oximetry
Another potential way of assessing fetal well-being is by measuring fetal oxygen saturation. This can be measured in a variety of ways, including using a device that attaches to the fetal scalp or a probe that sits inside the mother’s vagina. However, at this time, there isn’t good data to clarify whether fetal pulse oximetry improves newborn outcome beyond regular fetal heart rate monitoring.
Nudging Things Along: Labor Induction
To induce labor means to cause it to begin before it starts on its own. Induction may be a necessity (due to some obstetric, medical, or fetal complications) or elective (performed for the convenience of the patient or her practitioner).
Medically indicated induction
An induction is indicated (is a medical necessity) when the risks of continuing the pregnancy are greater — for the mother or the baby — than the risks of early delivery.
Problems with the mother’s health that may warrant induction include
· Preeclampsia (see Book 6, Chapter 2 for information)
· The presence of certain diseases, such as diabetes (see Book 6, Chapter 3) or cholestasis (see Book 2, Chapter 3), which may improve after delivery
· An infection in the amniotic fluid, such as chorioamnionitis
Potential risks to the baby’s health that may warrant induction include
· Pregnancy well past the due date; because this can increase the risk of certain complications, most practitioners induce labor after the 41st or 42nd week
· Ruptured membranes before labor has started, a situation that may place the baby at risk for developing an infection
· Intrauterine growth restriction (see Book 6, Chapter 2)
· Suspected macrosomia (fetus weighing more than 8 pounds, 13 ounces)
· Rh incompatibility with complications (see Book 6, Chapter 2)
· Decreased amniotic fluid (oligohydramnios)
· Tests of fetal well-being indicating the fetus may not be thriving in the uterus
Elective induction
Although some women like the idea of a planned delivery, others prefer labor to occur spontaneously. Some practitioners gladly perform elective inductions, and others are opposed to the whole concept of it. A woman may choose to undergo an elective induction for several reasons, including the following:
· To enable her to make arrangements for her other children, her work, or her partner’s work; or for the convenience of other family members, who will know exactly which day she’s going into labor
· To ensure that a particular physician in a group practice, with whom she’s developed a special relationship, delivers her baby
· To deliver when the maximum number of labor floor personnel or other specialists are present if she’s at risk for certain neonatal or labor complications
· To reduce anxiety after a history of poor pregnancy outcomes (such as a previous full-term fetal death) by delivering earlier than she naturally would
· To make sure she’ll get to the hospital on time if she lives far away and has a history of rapid deliveries
Some studies in medical literature suggest elective induction of labor may lead to an increase in cesarean deliveries. If the cervix is neither dilated nor effaced, or if the fetal head isn’t engaged in the pelvis, the risk of a cesarean delivery is probably higher. But if all conditions are favorable for induction, the risk of cesarean may not be increased at all. However, the length of time the patient spends in the hospital is likely to increase slightly when labor is induced.
If an elected induction of labor is planned, it should not be performed at less than 39 weeks along in the pregnancy. Delivery before this time should be medically indicated. If you’re considering elective induction of labor, you and your partner should fully understand that you may stand a slightly increased risk of needing a cesarean delivery. If both the expectant parents and the practitioner involved understand these risks, elective induction of labor can be appropriate for personal, medical, geographical, or psychological reasons.
Inducing labor
The way in which labor is induced depends on the condition of the cervix. If your cervix isn’t favorable, or ripe (thinned out, soft, and dilated), your practitioner may use various medications and techniques to ripen it. Occasionally, ripening alone may put you right into labor.
One of the most common agents used for cervical ripening is a form of prostaglandin that helps to soften the cervix and may cause contractions, too. A commonly used ripening agent is misoprostol, which is a prostaglandin E1 analog. It comes as a small tablet that’s inserted into the vagina. An alternative is a prostaglandin E2, which comes as a vaginal insert (Cervidil). Other devices that can mechanically dilate the cervix are also used. Laminaria are small sticks that, when inserted into the cervix, absorb water and expand the cervix. Another good alternative is a catheter, or small tube with an inflatable balloon on the end that is also inserted into the cervix and inflated. Typically once the cervix is dilated, the balloon catheter falls out.
Some recent information in medical literature indicates that the risk of uterine rupture is higher in women who have had a cesarean section in the past and are having labor induced. The risk of this potentially serious complication seems to be highest if the patient is given a prostaglandin for induction. For this reason, many practitioners prefer not to induce with prostaglandins and instead prefer to use a balloon catheter.
If your cervix isn’t yet ripe and you require induction, you’re likely to be admitted to the hospital in the evening and given medications to ripen the cervix at bedtime. Then your practitioner can administer oxytocin (a synthetic hormone similar to one that your body naturally releases during labor) to induce labor in the morning.
If your cervix is already ripe, you’re likely to be admitted in the morning. Labor is then induced either by administering oxytocin intravenously or by rupturing your membranes (often called breaking your water). The doctor performs an amniotomy, or rupturing of the membranes, with a small plastic hook during an internal examination. This procedure usually isn’t painful.
Your practitioner then instructs your nurse to administer oxytocin (usually known by its brand name, Pitocin) through an IV, and a special pump carefully adjusts and controls the dosage. Oxytocin is a hormone that causes the uterus to contract. It can be used to start labor for induction or speed up labor that started on its own. You begin with very little medication, and the level of medication increases at regular intervals until you have adequate contractions. Sometimes labor starts within a few hours after the induction is started, but it may take much longer. Occasionally, it may take as long as two days to really get things going.
A common misconception is that oxytocin makes labor more painful. It doesn’t. Oxytocin is similar to the hormone that your body naturally releases during labor, and it’s administered in about the same doses that your body would produce to cause normal labor.
Augmenting labor
Doctors can use oxytocin to augment labor that is already happening. If your contractions are inadequate or if labor is taking an unusually long time, your practitioner may use oxytocin to help move things along. Again, the contractions produced as a result of this augmentation are no stronger and no more painful than contractions occurring during a spontaneous labor.
Getting the Big Picture: Stages and Characteristics of Labor
Each woman’s labor is, in some ways, unique. An individual woman’s experience may even vary from pregnancy to pregnancy. Anyone who delivers babies knows all too well that labor can always surprise you. A doctor may expect one woman to deliver quickly and find that her labor takes a long time, while another woman, whom he thinks will take forever, may deliver very rapidly. Still, in the vast majority of pregnant women, labor progresses in a predictable pattern. It passes through easily discernible stages at a fairly standard rate.
If you’re going through your first delivery, the entire labor process is likely to last between 12 and 14 hours. For deliveries after the first one, labor is usually shorter (about 8 hours). Labor is divided into three stages, described in this chapter and in Book 2, Chapter 5.
Tracking your progress through labor
Your practitioner can track your progress through labor by performing internal exams every few hours. How easily you progress through labor is measured by how quickly your cervix dilates and how smoothly the fetus descends downward through the pelvis and birth canal. By plotting cervical dilation and fetal station along a graph (see the earlier section “Discerning false labor from true labor” for more information), practitioners can measure the progress of labor objectively. Doctors become concerned over the progress of labor if it’s too slow or if the cervix stops dilating and the fetus doesn’t descend. They have a shorthand system for describing the variables that determine how easily a woman makes her way through labor: the three Ps (passenger, pelvis, and power):
· Passenger — the baby’s size and position
· Pelvis — the pelvis’s size
· Power — the contractions’ strength
Your practitioner must pay attention to all these factors, because if labor doesn’t progress normally, it may be a sign that the baby would be better off delivered with assistance — with forceps or vacuum, or by cesarean delivery.
The first stage
The first stage of labor occurs from the onset of true labor to full dilation of the cervix. This stage is by far the longest (taking an average of 11 hours for a first child and 7 hours for subsequent births). It is divided into three phases: the early (latent) phase, the active phase, and the transition phase. Each phase has its own unique characteristics.
Early or latent phase
During the early phase of the first stage of labor, contractions occur every 5 to 20 minutes in the beginning and then increase in frequency until they’re less than 5 minutes apart. The contractions last between 30 and 45 seconds at first, but as this phase continues, they work up to 60 to 90 seconds in length. During the early phase, your cervix gradually dilates to about 5 to 6 centimeters and becomes 100 percent effaced.
The entire early phase of the first stage of labor lasts an average of 6 to 7 hours in a first birth and 4 to 5 hours for subsequent births, although recent data shows that this may in fact be longer. Often, the exact length of labor is unpredictable because knowing when labor actually begins is difficult.
In the beginning of the early phase, your contractions may feel like menstrual cramps, with or without back pain. Your membranes may rupture, and you may have a bloody show (see the earlier section “Noticing changes before labor begins”). If you’ve been admitted to the hospital, your doctor may use a small plastic hook to rupture your membranes in order to help things along.
Early on in this phase, you may be most comfortable at home. You can try resting or sleeping, or you may want to stay active. Some women find they have an overwhelming desire to clean or perform some other household chores. If you’re hungry, eat a light meal (soup, juice, or toast, for example), not a heavy one — in case you later need anesthesia to deal with labor complications. You may want to time your contractions, but you don’t need to obsess about it.
If you start to become more uncomfortable, the contractions occur with more frequency or intensity, your membranes rupture (your water breaks), or you have vaginal bleeding, call your practitioner or go to your hospital.
Many women find walking around makes them more comfortable and distracts them from the pain during the early part of labor. Others prefer to rest in bed. Ask your practitioner whether your hospital has any restrictions on walking during labor.
Active phase
The active phase of the first stage of labor is usually shorter and more predictable than the early phase. For a first child, it usually lasts about 2 to 3 hours, on average. For subsequent babies, it lasts about 1½ to 2 or more hours. Contractions occur every 3 to 5 minutes in this phase, and they last about 45 to 60 seconds. Your cervix dilates from 5 or 6 centimeters to a full 10 centimeters.
You may feel increasing discomfort or pain during this phase and maybe a backache as well. Some women experience more pain in the back than in the front, a condition known as back labor. This may be a sign that the baby is facing toward your front rather than toward your spine.
By this time, you’re likely already in the hospital or birthing center. Some patients prefer to rest in bed; others would rather walk around. Do whatever makes you comfortable, unless your practitioner asks that you stay in bed to be monitored closely. Now is the time to practice the breathing and relaxation techniques you may have learned in childbirth classes.
If you need pain relief, let your practitioner know (for more information, see the later section “Handling Labor Pain”). Your partner may help ease your pain by massaging your back, perhaps by using a tennis ball or rolling pin.
LABOR CURVES
Until recently, practitioners relied on something called a Friedman Curve to assess a woman’s progress in labor. This was based on now-historic data from the 1950s, when Dr. Friedman evaluated the course of labor of 500 women having their first child. Based on this original information, active labor occurred when a woman dilated to 3 to 4 centimeters, and the minimum rate of cervical dilation during the active phase was 1.2 cm/hour for first births and 1.5 cm/hour for subsequent births. It now seems that labor actually takes longer.
Dr. Zhang and his co-researchers evaluated data from a comprehensive study called the Consortium of Safe Labor. They looked at information on more than 60,000 women with singleton pregnancies in spontaneous labor who delivered vaginally with normal newborn outcomes. This study was sponsored by the National Institute of Child Health and Development (NICHD). Zhang’s labor curve shows that more than half the women did not dilate at greater than 1 cm/hour until reaching 5 to 6 centimeters. It seems that the normal rate of cervical change from 3 to 6 centimeters is much slower than previously thought. After reaching 6 centimeters, cervical dilation is more rapid.
Seeing an end in sight!
In addition to intense contractions, you may notice an increase in bloody show and increased pressure, especially on your rectum, as the baby’s head descends. During this last part of the first stage of labor, you may feel as if you have to have a bowel movement. Don’t worry; this sensation is a good sign and indicates that the fetus is heading in the right direction.
If you feel the urge to push, let your practitioner know. You may be fully dilated, but try not to push until your practitioner tells you to do so. Pushing before you’re fully dilated can slow the labor process or tear your cervix.
Try to practice breathing exercises and relaxation techniques, if they work for you. When you want pain medication or an epidural anesthetic, let your practitioner know. She decides what pain relief options are best for you based on how far along in labor you are and other factors related to you and your baby’s health.
Partners, women aren’t responsible for anything they say during labor, but you are, so don’t get upset over any suggestions your partner makes about your anatomy or her comments on your ancestry. And she doesn’t really mean what she said about your mother, either. And because pain makes people say things they don’t mean and may not even remember, don’t file away her remarks for another day. Vocalizing the pain in this way is both healthy and normal. Because you’re not in pain, you don’t get the same privileges, so save the snappy retorts for another time.
Potential problems during labor’s first stage
Most women experience labor’s first stage without any problems. But if a problem arises, the following info will prepare you to handle it with a clear, focused mind:
· Prolonged latent phase: The latent or early phase of labor is considered prolonged if it lasts more than 20 hours in a woman having her first child or more than 14 hours in someone who has delivered a previous child. Your practitioner may not be able to determine when labor actually starts, so knowing for sure when labor becomes prolonged isn’t always easy, either.
When a practitioner determines that labor is taking too long, he responds in one of two ways.
· One approach is to use medication, such as a sedative, to help you relax. Labor may then subside (which means that it was false labor all along), or active labor may begin.
· The other approach is to try to move labor along by performing an amniotomy (rupturing the membranes or breaking your water) or by administering oxytocin (Pitocin). Both procedures are covered in more detail earlier in this chapter.
· Protraction disorders: Protraction disorders can occur if the cervix dilates too slowly or if the baby’s head doesn’t descend at a normal rate. If you’re having your first baby, the upper limit of time to dilate, according to this recent data, means than it can take up to 6 hours to progress from 4 to 5 centimeters and more than 3 hours to progress from 5 to 6 centimeters, regardless of parity. After that, the average and upper limit to dilate 1 cm/hour is shown in Table 4-1.
Protraction disorders may be caused by cephalopelvic disproportion, or CPD, which is the term for a poor fit between the baby’s head and the mother’s birth canal. Protraction disorders may also occur because the baby’s head is in an unfavorable position or because the number or intensity of contractions is inadequate. In both cases, many practitioners try administering oxytocin to improve labor progress.
· Arrest disorders: Arrest disorders occur if the cervix stops dilating or if the baby’s head stops descending for more than two hours during active labor. Arrest disorders are often associated with CPD, but an infusion of oxytocin may solve the problem. If oxytocin doesn’t alleviate the arrest disorder, you may need a cesarean section. Typically, arrest of labor is diagnosed when the cervix is at least 6 centimeters dilated and membranes are ruptured and when no cervical change occurs for at least four hours with adequate contractions and six hours with inadequate contractions.
Table 4-1 Average and 95th Percentile (Extreme Upper End of Normal) for Patients in Active Labor, Based on Zhang Labor Curves
|
Change in Cervix |
First Birth Average Hours and (95th%) |
Subsequent Births Average Hours and (95th%) |
|
From 6 to 7 cm |
0.6 (2.2) |
0.5 (1.9) |
|
From 7 to 8 cm |
0.5 (1.6) |
0.4 (1.3) |
|
From 8 to 9 cm |
0.5 (1.4) |
0.3 (1.0) |
|
From 9 to 10 cm |
0.5 (1.8) |
0.3 (0.9) |
The second stage
Labor’s second stage begins when you’re fully dilated (at 10 centimeters) and ends with your baby’s delivery. This part is the “pushing” stage and takes about one hour for a first child and 30 to 40 minutes for subsequent births. The second stage may be longer if you have an epidural. Book 2, Chapter 5 describes the second stage in detail.
The third stage
The third stage occurs from the time of delivery of the baby to delivery of the placenta — usually less than 20 minutes for all deliveries. For details on this stage, go to Book 2, Chapter 5.
Handling Labor Pain
During labor’s first stage, pain is caused by contractions of the uterus and dilation of the cervix. The pain may feel like severe menstrual cramps at first. But in labor’s second stage, the stretching of the birth canal as the baby passes through it adds a different kind of pain — often a feeling of great pressure on the lower pelvis or rectum. But none of this pain needs to be excruciating, thanks to well-practiced breathing and relaxation exercises and, in many cases, modern anesthesia.
Most practitioners acknowledge that even for women who have diligently attended childbirth classes, labor is inherently painful. The degree of pain — and the willingness and ability to tolerate it — varies from woman to woman. Some women choose to deal with the pain on their own or with the help of breathing and distraction techniques mastered in childbirth classes — and that’s a perfectly acceptable choice. Many other women want medication to help them deal with the pain, no matter how well prepared they are.
Don’t feel that you’re in any way falling short of being a perfect mother or that your pregnancy isn’t “natural” if you need medication to help with labor pain. Everyone responds to pain differently, both emotionally and physiologically, so even if your best friend, your sister, or your mother got through labor with little or no pain medication, you aren’t weak if you choose to use it. Look at it this way: Women who are in excruciating pain usually don’t breathe regularly. They also tense their muscles, and, by doing so, they may only prolong labor.
Today doctors generally administer medication in two different ways to help you deal with labor pain: systemically — that is, by injection either into a blood vessel (intravenously) or into a muscle (intramuscularly) — or regionally, with the use of an epidural or other local anesthesia.
Systemic medications
The most common medications used systemically are relatives of the narcotic morphine — drugs such as meperidine (brand name Demerol), fentanyl (Sublimaze), butorphanal (Stadol), and nalbuphine (Nubain). These medications can be given every two to four hours as needed, either intravenously or intramuscularly.
Any medication you take (even when you’re not pregnant) has side effects, and pain relievers used during labor are no exception, although your doctor will do what he can to reduce these side effects, often by combining medications. Nausea, vomiting, drowsiness, and a drop in your blood pressure are the main side effects for the mother. The degree to which the fetus or newborn is also affected depends on how close to the time of delivery the medication is given. If a large dose is given within two hours prior to delivery, the newborn may be sleepy or groggy. In rare cases, his breathing may be weak. If this problem is significant, your doctor or the baby’s doctor can give a medication that immediately reverses or counteracts the pain medication. No evidence suggests that these medications, when given in appropriate doses and with proper monitoring, have any effect on the progress of labor or on the rate of cesarean deliveries.
Regional anesthetics
Systemic medications are distributed via the bloodstream to all parts of the body. Yet most of the pain of labor and delivery is concentrated in the uterus, vagina, and rectum, so regional anesthesia is sometimes used to deliver pain medication to those specific areas. Medications used in regional anesthesia can be a local anesthetic (like lidocaine), a narcotic (such as those in the preceding section), or a combination of the two. Commonly used techniques for administering regional pain relief include epidural and spinal anesthesia and caudal, saddle, and pudendal blocks. The following sections go into more detail on these techniques.
Epidural anesthesia
When it comes to relieving labor pain, there is nothing like an epidural. Epidural anesthesia is perhaps the most popular form of labor pain relief. Almost universally, women who’ve had it say, “Why didn’t I get this earlier?” or “Why was I hesitant about this?” An anesthesiologist with special training in epidural catheter placement must administer an epidural, so epidurals may not be available in every hospital. This is definitely something you want to find out ahead of time so there are no surprises on the day (or night) of the big event!
With an epidural, a tiny, flexible, plastic catheter is inserted through a needle into your lower back and threaded into the space above the membrane covering the spinal cord. Before inserting the needle, the anesthesiologist numbs your skin with a local anesthetic. While the needle is going in, you may feel a brief tingling sensation in your legs, but the process really isn’t painful for most women. After the catheter is in place, medication can be sent through it to numb the nerves coming from the lower part of the spine — nerves that go to the uterus, vagina, and perineum (the area between the vagina and anus). The catheter (not the needle) stays in place throughout labor in case you need what’s called a top-up dose of the anesthetic to get you through the rest of labor and delivery.
A major advantage of epidural anesthesia is that it uses smaller doses of pain medication. However, because your sensory nerves run very close to your motor nerves, large doses of anesthetic can temporarily affect your ability to move your legs during labor.
The amount and type of medication you need can be adjusted according to the stage of labor you’re in. During the first stage, pain relief focuses on uterine contractions, but during the second (pushing) stage, pain relief focuses on the vagina and perineum, which are distended by the baby passing through. Epidurals can also make repairing a tear, or episiotomy, much more tolerable.
Years ago, anesthesiologists wouldn’t give epidurals during early labor because it confined patients to their beds for the remainder of their labor. Recently, however, walking epidurals — the kind that allow you to walk around, because they use medications that have little or no effect on motor function — have become more popular for this often painful stage of labor. Some anesthesiologists, however, question the effectiveness of this type of epidural in relieving pain.
Epidurals can also relieve pain in cesarean deliveries, although different medications in different doses are used. In fact, epidurals are very popular for cesareans because they enable the mother to be awake during delivery and to experience her child’s birth. In cases in which cesarean delivery is an emergency or when the mother has blood-clotting problems, however, an epidural may not be possible.
Doctors once thought epidurals, especially if placed too early, prolonged labor and increased the need for forceps, vacuum-assisted, or cesarean delivery. For this reason, many practitioners were reluctant to recommend epidurals to their patients. Most doctors today accept that these problems are negligible when an experienced anesthesiologist places the epidural after labor is well-established and that the benefit outweighs the risk.
Sometimes the epidural takes away the sensation you feel when your bladder is full, so you may need a catheter to empty your bladder. In some cases, the epidural may block motor nerves to the point where you have difficulty pushing. You also may experience a rapid drop in blood pressure that can lead to a temporary drop in the baby’s heart rate.
Overall, pain control simply makes the whole experience of labor and delivery much more enjoyable for the mother and her partner (and the person doing the delivery, too!).
A MENU OF EPIDURAL TECHNIQUES
The method used to administer an epidural is usually determined by the anesthesiologist, based on his expertise, his individual preferences, and your specific situation (such as how far along you are in labor or any medical conditions you may have). The various techniques by which an epidural can be administered include the following:
· Intermittent epidural bolus dosing was the standard way of administering epidural anesthesia for many years. With this technique, intermittent doses of local anesthesia are given through the catheter. Injections are either timed to the woman’s complaints of pain or set at specific intervals. The disadvantage of this method is that often pain is felt as the medication wears off, and more intervention by the anesthesiologist is required.
· Continuous epidural infusions provide continuous infusion of pain medicine, which provides a smooth and constant relief from pain. If needed, the dosing can be changed, and extra medication can be given.
· Patient-controlled epidural analgesia (PCEA) differs from the continuous infusion method in that you’re the one who controls the amount of medication given. Some anesthesiologists use this technique alone, whereas others prefer a combination of continuous infusion with the patient-controlled method.
· Combined spinal-epidural analgesia gives a dose in the spinal area for immediate pain relief (within five to ten minutes) and, at the same time, places a catheter in the epidural space for continuous infusion.
· Walking epidural describes a technique of administering pain relief that doesn’t interfere with motor function. The truth is that, for various reasons, 40 to 80 percent of women don’t actually walk during labor, anyway!
Spinal anesthesia
Spinal anesthesia is similar to an epidural except that the medication is injected into the space under the membrane covering the spinal cord rather than above it. This technique is often used for cesarean delivery, especially when a cesarean is needed suddenly and no epidural was placed during labor. The information in the preceding section about epidurals (regarding the amount of medication needed and the risks involved) applies to spinal anesthesia, too.
Caudal and saddle blocks
Caudal and saddle blocks involve placing the medications very low in the spinal canal, so they affect only those pain nerves going to the vagina and perineum. These methods have a more rapid onset of pain relief, but the medication wears off sooner.
Pudendal block
Your doctor can place a pudendal block by injecting an anesthetic inside the vagina, in the area next to the pudendal nerves. This technique numbs part of the vagina and the perineum, but it does nothing to relieve the pain from contractions.
General anesthesia
When you have general anesthesia, you’re made fully unconscious by an anesthesiologist using a variety of medications. Doctors almost never use this technique for labor anymore, and this technique is only rarely used for cesarean deliveries because it’s associated with a higher risk of complications. General anesthesia obviously also causes you to sleep through your baby’s delivery. But if, in a cesarean delivery, you have a clotting problem that rules out placing a needle into your spinal column or if the cesarean is an emergency and there isn’t enough time to place an epidural, general anesthesia should be used.
Considering alternative forms of labor-pain management
Whereas systemic medications or various anesthetic techniques are aimed at eliminating the physical sensation of pain, alternative or nonpharmacologic methods are directed toward preventing the suffering associated with labor pain. These approaches to pain management emphasize labor pain as a normal side effect of the normal process of labor. Women are given reassurance, encouragement, and guidance to help them build self-confidence and maintain a sense of control and well-being. Many hospitals offer some of these techniques, although other techniques require special training and may not be available in all birthing facilities:
· Continuous labor support: This refers to nonmedical care given to a laboring woman, often by a doula or trained professional (see Book 2, Chapter 3 for information).
· Maternal movement and positioning: Sometimes walking or changing positions can alleviate some of the pain associated with labor. Your caregiver or nurse may suggest different positions to try.
· The Birth Ball: The Birth Ball is a large inflated exercise ball used to help in movement and relaxation during labor. During labor, you can sit or lean against the ball, which provides stability and soft support. The ball also increases the number of positions you can find for comfort.
· Touch and massage: These techniques provide encouragement, reassurance, and a sense of love, and they may be used to enhance relaxation and decrease pain.
· Acupuncture and acupressure: Acupuncture involves the placement of needles at various points on the body, whereas acupressure (or Shiatsu) refers to the placement of pressure with fingers or small beads at acupuncture points. In some studies, acupuncture use during labor was associated with more relaxation but no difference in pain intensity.
· Hypnosis: Usually hypnosis during labor involves self-hypnosis, where the woman herself is taught to induce the hypnotic state. Studies have shown that the use of hypnosis does lead to less use of pain medication and epidural anesthesia.
· Transcutaneous Electrical Nerve Stimulation (TENS): This technique involves the transmission of electrical impulses from a hand-held generator to the skin through surface electrodes. During labor, the electrodes are placed near the spine, and the woman controls the intensity of the current through a dial. TENS causes a buzzing sensation that may reduce awareness of contraction pain. Most studies have not shown a real reduction in pain, but some do suggest less use of pain medication and increased satisfaction.
· Intradermal water injections: This technique involves injecting a small amount of sterile water into four locations on the lower back. This has been shown to reduce severe back pain for 45 to 90 minutes, but it doesn’t seem to help the abdominal pain associated with labor.
· Application of heat and cold: Often this is a matter of personal preference, as no scientific data suggests that one is better for pain relief than the other.
· Music and audioanalgesia: The idea behind this method is that music, white noise, or environmental sounds may help to decrease the perception of pain. Although not clearly beneficial for pain relief, it may help to increase pain tolerance via mood elevation or help the woman to breathe more rhythmically (heavy metal is probably not the best choice, though!).
· Aromatherapy: The use of aromatherapy appears to be on the rise. In one study, about half of the women felt it was helpful in reducing pain, anxiety, and nausea while improving their sense of well-being.