Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 13 When Childbirth Becomes Complicated

Most healthy pregnant women will have normal childbirth experiences, in which labor progresses without significant delay and the baby is healthy, tolerates contractions well, and is in a position that’s favorable for birth. For some women, however, complications can arise during labor or birth. In these cases, the well-being of the mother and baby may improve with interventions such as medications, technology, or surgery.

This chapter describes conditions and events that can complicate labor or birth, as well as interventions that may resolve such problems. If your pregnancy is high-risk, you’re more likely than not to require some of these interventions. If your pregnancy is low-risk, it’s still wise to learn about possible complications and available interventions, just in case an unexpected problem arises during your labor or birth. With this knowledge, you can prepare for how you’ll work with your caregiver to have the best birth experience possible.


In this chapter, you’ll learn about:

• Complications in labor that may resolve through the use of non-medical interventions, such as self-help techniques and complementary medicine methods

• Problems that require medical treatment to increase the chances of improving your baby’s well-being as well as your own

• Medical interventions such as induction of labor, augmentation, vacuum extraction, forceps delivery, and episiotomy (See Chapter 14 for information on cesarean sections.)

• Conditions that may cause labor complications, such as a pregnancy with multiples

• Complications that require special treatment, such as a seriously ill newborn or infant death

Labor Complications and Interventions

Although a woman may be having a normal pregnancy, no one can predict whether her labor will be free of complications. Compared to a normal labor, a complicated labor is longer, more painful, or more difficult, and may require medical help to ensure the well-being of the mother and baby.

Most labor complications rarely pose immediate problems that require prompt medical attention. If a potential problem arises in labor, such as slow cervical dilation, it may be resolved simply with time, patience, and self-help techniques. The problem becomes a complication only if these approaches don’t resolve it. To identify, prevent, or treat a complication, caregivers may use interventions such as induction, episiotomy, continuous electronic fetal monitoring, cesarean surgery, and other procedures.

For every complication, there are usually several possible interventions that may resolve it. When deciding which interventions to use, caregivers consider many factors, including:

• The circumstances of the woman’s pregnancy and labor

• The woman’s preferences for interventions

• Current scientific evidence on the effectiveness of interventions, as well as their benefits and risks

• Hospital policies and customs on interventions

• Legal liability issues

• The caregiver’s training and experience

• Professional standards on interventions

• Professional peer pressure to use interventions

• Cost of interventions as well as staff availability to conduct them

The combination of these factors helps explain the wide variation in intervention rates among different caregivers and hospitals across the United States and Canada.

Some labor complications occur more frequently than others. The following are typical problems, numbered in order from most common to least common:

1. The need or wish to start labor

2. Prolonged active labor

3. Concerns about the baby’s well-being

4. Prolonged second stage of labor

5. Preterm labor and premature birth

6. Gestational hypertension

7. Multiples (twins, triplets, or more)

8. Breech and other difficult presentations

9. Complications in the third stage of labor

10. Rapid unattended birth

11. Prolapsed cord

12. Seriously ill newborn or infant death

During your prenatal visits, discuss these potential problems with your caregiver and ask the key questions on page 10 to help you make informed decisions about interventions, so you’ll know what to expect if a complication arises in your labor.

The Need or Wish to Start Labor

For some women, if the need or wish to start labor at a particular time trumps letting labor start spontaneously, they consent to an intervention called induction. The following sections discuss the reasons for induction, describe the medical methods for doing the procedure, and offer alternative non-medical methods to induce labor.



If a caregiver knows or suspects that any of the following conditions have occurred, he or she closely monitors both the mother and baby for signs of distress. The caregiver also may order tests to assess the baby’s maturity and well-being. (See page 144.) If monitoring or test results suggest that the risks of continuing the pregnancy outweigh the risks of induction, the caregiver usually recommends inducing labor.

Post-date pregnancy

post-date, or prolonged, pregnancy is one that has lasted to at least forty-two weeks. (Many caregivers shorten that time frame to 40½ weeks or 41½ weeks.) After forty-two weeks gestation, a baby has about a 5 to 10 percent risk of postmaturity, a condition in which the placenta stops functioning well, the baby’s growth slows or stops, and the risk of stillbirth gradually increases. Tests that assess babies’ well-being can help identify those at risk of postmaturity. If postmaturity is suspected, induction is recommended.

Rupture of membranes

After a woman’s bag of waters breaks, her risk of infection increases. If her labor doesn’t start on its own within twenty-four hours (or sooner if she has tested positive for Group B streptococcus—see page 131), her caregiver may recommend induction.

Lack of growth in the baby

If a caregiver observes signs that the baby is no longer growing or thriving in the uterus, an induction typically is recommended.

Genital herpes

If a woman is having frequent outbreaks of genital herpes in late pregnancy, her caregiver may plan to induce labor between outbreaks to avoid a cesarean birth. (See page 133 for more information on genital herpes.)

Illness in the mother

Particular illnesses, such as gestational hypertension or diabetes, can affect the health of the mother or the pregnancy, especially if the illness intensifies over time. (See Chapter 7.) Induction is recommended if the birth will alleviate or cure the illness.

Fear of macrosomia (big baby)

In some pregnancies, ultrasound scans suggest that the baby is large for his mother’s size and build, or is growing rapidly. Some of these women and their caregivers worry about letting labor begin on its own, because during the wait the baby may grow too big to fit through the pelvis or will experience shoulder dystocia, a rare situation in which the baby’s head is born but the shoulders become stuck within the pelvis. To avoid either complication, these women consent to induction in order to give birth to a baby of manageable size.

Studies on the accuracy of ultrasound scan estimates, however, have found a margin of error of at least 10 percent. This finding means that ultrasound scans often overestimate the baby’s size. In addition, even if a baby is large, his size won’t necessarily cause problems with the birth. In all cases of shoulder dystocia, only 30 percent occur in babies that weigh more than 8½ pounds at birth; this means that 70 percent of cases occur in babies of average or small size. Furthermore, when compared to letting labor begin spontaneously, inducing labor because of a suspected large baby more often causes labor to stop (arrest of labor), increasing the need for a cesarean birth. For these reasons, professional obstetrical and midwifery organizations don’t include macrosomia on their lists of medical reasons to induce labor.2


The reasons for induction often stem from concerns for the mother’s or baby’s well-being during labor. Sometimes, however, women request induction—or their caregivers recommend it—for non-medical reasons. This type of induction is called a social or elective induction.3 Opinions vary among maternity care experts on the wisdom of the following reasons for elective induction:

Convenience for the caregiver’s schedule

If a woman has been seeing a caregiver in a group practice, she may want labor to begin on a day when her caregiver is on call, and avoid having an unknown caregiver attend the birth. Many caregivers prefer inducing their clients’ labors because doing so lets them attend the births. Furthermore, in some (but not all) group practices, the caregiver who attends the birth receives the largest share of the maternity care fee.

Convenience for the family’s schedule, support needs, or circumstances

Many women choose induction so the birth will fit into their family’s schedule or into the schedules of those who can help out after the birth. Induction may especially appeal to women who live far from a hospital, those who need to arrange for the care of other children during the birth, or those who have had a previous rapid birth and want to better control the timing of this birth.

Discomfort in late pregnancy

Induction often appeals to women who are uncomfortable in the late trimester and are impatient for pregnancy to end.

Pregnancy reaches term

A pregnancy reaches term at thirty-seven weeks gestation. Many women request induction at that time, but babies benefit from pregnancies that last closer to forty weeks. Elective induction should not be done before thirty-nine weeks, to allow babies’ lungs to mature fully3a.



Medical advances have made induction methods more reliable than they were in the past, when elective inductions were considered unsafe for babies. Today, elective inductions far outnumber medical inductions in many hospitals; in fact, induced labors outnumber spontaneous labors. Although induction may sound tempting when you’re anxious to get labor started, consider the following facts before consenting to an elective induction:

• Induction leads to a more medicalized birth, with more interventions, such as intravenous (IV) fluids and continuous electronic fetal monitoring (EFM), and fewer options for natural coping techniques, such as the freedom to move around and the use of the bath or shower for pain relief.

• Depending on the method of induction, the intervention may make contractions more painful than normal, which may increase the need for pain medications.

• Elective induction bypasses the baby’s ability to start labor at the optimal time. Babies continue to mature and develop during the last weeks of pregnancy. Even if a pregnancy has reached its due date, the baby may benefit from a few more days in the uterus. (See pages 393–394.) Elective induction can cause a premature birth if done too early, especially for a pregnancy without a clear due date. Elective inductions have contributed significantly to the increasing rate of prematurity in the United States.

• All methods of induction carry possible risks, especially uterine hyperstimulation (contractions that are too strong or too frequent) and the higher likelihood that the baby won’t tolerate labor (as indicated by EFM).

• There’s no guarantee that induction will get labor started. If induction fails, a cesarean section typically is performed. When compared to first-time mothers whose labors began on their own, those who had elective induction (or whose cervixes weren’t ripe before induction) were two to four times more likely to have had a cesarean birth.4

If you’re considering an elective induction, weigh the risks and benefits of the procedure to you and your baby. If your caregiver suggests an induction, ask the key questions on page 10 to determine whether it’s medically indicated or elective. Ask whether there’s a desired time frame for an induction to work, and under what circumstances an induction is considered a failure. Also ask if it’s possible to wait for labor to begin after a failed induction, or if an immediate cesarean is required. Weigh all these factors so you can make an informed decision.

If you’re offered an induction for a non-medical reason and are thoroughly informed of the procedure’s risks and benefits, you may decide to wait for labor to begin on its own or postpone induction until later in pregnancy. Or you may consent to induction after concluding its benefits outweigh the potential risks. Whatever you decide, you’ll have made an informed decision, which is the best one for you.

Medical Conditions That Rule Out Induction

In some cases, induction isn’t possible because a medical condition compromises the procedure’s safety to the mother and baby. Examples of such conditions include a genital herpes outbreak, placenta previa (see page 139), previous surgery to remove uterine fibroids, or a baby with a transverse presentation (lying sideways). If you have any of these conditions, your caregiver won’t induce your labor.


If your caregiver recommends induction, you may have time to try non-medical methods to start or speed up labor on your own. Although most of these methods have had little scientific evaluation, they’re generally simpler and easier to do than medical induction. They also pose milder risks, although some have unpleasant side effects.

Non-medical methods for induction are less likely to start labor than medical methods; however, if successful, they let you avoid the disadvantages of medical induction (see page 277). Even if only partially effective, they may cause enough cervical changes to allow for a successful medical induction.

The following sections briefly describe self-help techniques and complementary medicine methods for inducing labor. Visit our web site,, to learn more information about them. Before trying any of these methods, consult your caregiver! If you think your caregiver might not support your decision to try them, approach the topic carefully in order to avoid receiving an unhelpful response. For example, instead of asking, “Do you think I should try some non-medical induction methods such as walking or acupuncture?” try asking, “Is there any medical reason why I shouldn’t try walking or acupuncture to start labor?” That way, if your caregiver disapproves of a technique, he or can give you specific reasons.

Note: If you don’t have time to try non-medical induction methods, if you don’t wish to try them, or if they’re unsuccessful, your caregiver can offer you various medical methods of induction. See page 279for more information.

Self-help Techniques

The following are activities you can do and actions you can take to try to start labor on your own.


Taking long walks can help start labor; however, walking is more effective at keeping active labor going than it is at starting labor, when extensive walking may just exhaust you.

Intercourse or orgasm

Sexual intercourse and clitoral stimulation (manual or oral) may help start labor. Sexual excitement, particularly orgasm, causes the release of oxytocin and prostaglandins, two hormones that cause uterine contractions and may start labor. Semen also contains prostaglandins. When using this method, frequent sexual activity is more effective than a single act. Try to forget your goal of starting labor and just enjoy the sexual experience.

Note: If your bag of waters has broken, don’t have intercourse or put anything into your vagina, to minimize the risk of infection.

Nipple stimulation

Nipple stimulation causes the release of oxytocin, which in turn causes uterine contractions that may start labor.5 To stimulate your nipples, lightly stroke them, have your partner gently caress or suck on them, or use a breast pump. You may feel contractions within minutes, or you may have to stimulate your nipples for hours (off and on, but perhaps continuously) before experiencing steady contractions.

Caution: Occasionally, nipple stimulation causes contractions that last too long (longer than sixty seconds), occur too frequently (more than two in ten minutes), or are too painful. If this happens to you, stop stimulating your nipples.

Castor oil

Labor may start if the bowels are stimulated to empty. Castor oil is a strong laxative that causes powerful bowel cramps and contractions. It’s thought to increase prostaglandin production, which may start uterine contractions.6 Visit our web site for directions on using castor oil to start labor.

Enemas are also used to stimulate bowel movements; however, current studies have found them to be ineffective at starting labor.7


Firm finger or thumb pressure on particular acupressure points may start or speed up contractions. (See page 214.)

Complementary Medicine Methods

The following non-medical methods are often used along with conventional medicine methods to treat various health-related problems. Because of their potential side effects, these methods require the supervision of a trained professional.

Herbal tea and tinctures

Various herbal teas and tinctures can induce labor; however, these ingredients may also cause undesired side effects. For example, blue cohosh tea causes uterine contractions, but it can also raise blood pressure to unsafe levels.8(Visit our web site for more information.) Use this method only with the guidance of a knowledgeable professional and your caregiver.

Homeopathic remedies

Homeopathy uses diluted derivatives of certain natural substances to stimulate the body to respond in a way that heals or corrects a specific problem, such as a labor that won’t start. Although side effects are unlikely, these remedies are best administered by a trained homeopathic practitioner.


Acupuncture is an ancient Chinese medicine technique that uses needles placed at strategic points along meridians, or energy flow lines, in the body. It has no known risks. There’s been little scientific research on the effectiveness of acupuncture to ripen the cervix or start labor, but the few studies on the subject have found acupuncture to be beneficial for induction.9 (Visit our web site for more information on acupuncture.)

An acupuncturist may also use moxibustion, a version of acupuncture that doesn’t use needles but instead uses burning herbs placed close to the acupuncture point.


Caregivers use a selection of medical methods to start labor. The choice of method depends on the condition of the cervix. Induction is more likely to succeed if the cervix is favorable—that is, it’s ripe, anterior, and partially effaced and dilated. The cervix is unfavorable for induction if it’s firm, posterior, and not effaced. (See page 168 for further explanation of cervical conditions.)

The philosophy and preferences of the caregiver and hospital also influence the choice of method. If you’re scheduled for an induction, ask your caregiver which method will be used so you’ll know what to expect.

Medical Non-drug Methods

The following are brief descriptions of methods for ripening the cervix or inducing labor without the use of medications. Visit our web site to learn more information about them.

Balloon dilators

These devices have been found to speed up the onset of labor by ripening the cervix and causing some dilation.10 A Foley balloon catheter (originally designed to empty the bladder) or a cervical ripening balloon is placed within the cervix, where it remains until it falls out when the cervix begins to open or until up to twelve hours have passed and it’s removed.


Stripping (or sweeping) the membranes

This procedure is quick and relatively noninvasive. The caregiver inserts a finger into the cervix to loosen the bag of waters from the uterine wall in order to prompt the release of hormones that start contractions. Your caregiver may suggest this intervention if you’ve reached or passed your due date and your cervix is very ripe and dilated at least the width of a finger. Although the procedure is painful (it feels like a vigorous vaginal exam) and may cause slight bleeding and cramping, studies have found it to reduce the time until labor begins.11

Artificial rupture of membranes (AROM)

Also called amniotomy, AROM is a procedure in which the caregiver breaks the bag of waters with an amniohook, a long plastic device that resembles a crochet needle. It’s done either alone or with Pitocin to start labor or to speed up progress in active labor. AROM is rarely successful if the cervix is unfavorable (see page 279), in which case the caregiver uses cervical ripening techniques (see page 281) before trying AROM. See below for more information on using AROM to start or speed up labor.


Risks and Benefits of Artificial Rupture of Membranes (AROM)

AROM for Induction

AROM increases the chance of starting labor, especially when used with Pitocin; however, if labor doesn’t start after AROM, the chance of a cesarean birth increases. This is because bacteria can enter your uterus after your membranes are ruptured, which increases the risk of infection to you or your baby over time. If labor doesn’t progress after AROM, a cesarean section is performed.

If you need an induction for medical reasons, remember that your chance of success increases if AROM is used along with Pitocin. If you consent to an elective induction but want to avoid a cesarean birth, consider trying Pitocin without AROM. If Pitocin doesn’t start labor, it can be discontinued and tried again in a day or two. The second attempt may start labor, potentially decreasing the need for a cesarean.

AROM to Speed Up Active Labor

During contractions in active labor, your bag of waters may bulge through your cervix. Performing AROM at this time may cause your baby’s head to press more firmly on your cervix, likely making contractions suddenly more painful and speeding up labor progress. Without AROM, the membranes often remain intact until the second stage of labor, and then break spontaneously.

If your caregiver suggests AROM to speed up labor, ask the key questions on page 10 to help you decide whether to consent to the procedure. If labor is progressing well, you might not need AROM. If labor is progressing slowly, and your caregiver thinks your baby is in a favorable position, then AROM may help speed it up. If labor is progressing slowly because your baby is an unfavorable position such as occiput posterior (facing toward your front) or her head is tilted back or to the side, you may prefer to try other options first to correct your baby’s position and speed up labor (see page 286).

The advantage of not rupturing your membranes is that your bag of waters provides your baby some cushioning and room for moving into a more favorable position. In fact, rupturing your membranes may cause your baby’s head to stay in an unfavorable position, potentially causing a longer or more painful labor.12

Medications to Induce or Augment Labor

Pitocin, commonly referred to as “Pit,” is a synthetic version of oxytocin, the hormone that your body releases to start labor. (Syntocinon is another synthetic version of the hormone.) Pitocin is almost always used for medical induction, and it’s sometimes used to help augment (speed up) a slow labor by increasing the frequency and intensity of contractions. It’s administered intravenously, allowing the dosage to be increased, reduced, or stopped, if necessary.

Although Pitocin causes your uterus to contract, it doesn’t ripen your cervix. If your cervix is unfavorable for induction (see page 279), cervical ripening methods are necessary before receiving Pitocin (see below). Visit our web site,, for more information on Pitocin.


Medications to Ripen the Cervix

Synthetic prostaglandins are medications that mimic prostaglandin, the hormone the body releases to ripen the cervix. They’re used especially when the cervix is unfavorable for induction (See page 279).

One type of synthetic prostaglandin is prostaglandin E2 or dinoprostone, which comes in a gel (Prepidil) that’s placed next to the cervix to speed up ripening. This medication is also available in a tampon-like device (Cervidil). While both are relatively noninvasive, Cervidil may be the more desirable choice, because the medication can be removed entirely if it becomes necessary to stop ripening.

Another type of synthetic prostaglandin is prostaglandin E1 or misoprostol (Cytotec). The use of this medication is more likely than other synthetic prostaglandins to cause contractions along with cervical ripening. It comes either in a pill that’s taken orally or in a gelatin capsule that’s placed next to the cervix. See page 282 for more information on misoprostol.

Two Options If Induction Leads to Slow Labor Progress

Occasionally, labor can take a long time to start with induction. If your labor progress with induction is slow (and your membranes haven’t been ruptured), you have two options.

Option One: Serial Induction

With serial induction, Pitocin is discontinued at night to allow you to eat and sleep. The advantage of this option is that it may improve your chances of a vaginal birth. The disadvantage, however, is that it may take several days for labor to start, which can be emotionally and physically draining for you and your partner. Extra support and patience are essential.

Today, caregivers rely on serial induction less often than they did in the past, mainly because having one family occupy a birthing room for days is costly to both the family and the hospital.

Option Two: Artificial Ruptures of Membranes (AROM)

With this option, your membranes are ruptured and your dose of Pitocin may be increased quickly. This more aggressive approach may start labor, but it must do so within a certain time frame (twelve to twenty-four hours). If you don’t have steady dilation within this period, the induction is considered a failure and a cesarean section becomes necessary.

The Strange Story of Misoprostol (Cytotec)13

In the mid-1990s, misoprostol was introduced as a quick, inexpensive way to ripen the cervix and induce labor. The use of the drug for this purpose became controversial because the United States Food and Drug Administration (FDA) had approved it for the treatment of stomach ulcers. No careful research had established safe dosages for cervical ripening and labor induction. In fact, the drug company had no legal requirement to scientifically evaluate the safety of misoprostol for these purposes. Using the drug for any purpose other than the treatment of stomach ulcers was (and continues to be) considered “off-label.”

At first, the use of misoprostol seemed to be a success, because it helped induce labor quickly. But along with fast labors came severe contractions (uterine hyperstimulation) and distressed babies. Many mothers and babies suffered physical harm, and some died. Many women found labor induced by misoprostol to be traumatic.

Several years passed before sufficient research determined that dosage size and frequency caused the dangerous side effects of misoprostol. Today, it’s clear that misoprostol must be given in low doses (typically, 25 micrograms for vaginal use and 50 micrograms for oral use), and dispensed no more frequently than every four to six hours. Sometimes, these low doses are all that’s needed to ripen the cervix and start labor; however, misoprostol is usually used along with Pitocin and AROM to increase the likelihood of inducing labor. If labor hasn’t progressed with repeated doses of misoprostol or if the baby becomes distressed, the drug is discontinued.

Some researchers believe misoprostol is as safe as other synthetic prostaglandins, all of which have potential undesirable side effects.14 (Visit our web site,, for more information.) However, misoprostol has special safety considerations. In general, after a woman’s membranes have ruptured, giving misoprostol orally is safer than administering it vaginally (to minimize the risk of infection).15 In addition, the American College of Obstetricians and Gynecologists (ACOG) warns that women with a prior cesarean birth shouldn’t use misoprostol, because of the increased risk of uterine rupture.16

If you’re planning a hospital birth, find out whether its care practices approve the use of misoprostol to ripen the cervix and induce labor, and if so, under what circumstances. Do your own research on the drug and ask your caregiver the key questions on page 10 so you can make an informed decision about whether it’s right for you.


If you’ve consented to a medical method of induction, here’s what you can expect to do:

• Call the hospital before leaving home for your scheduled appointment. The hospital staff can’t predict the number of women who will be in labor at any one time. If the maternity unit is especially busy at the time of your appointment, you may be told to call back in a few hours to confirm that they have room for you. Be prepared for this possibility so you aren’t overly frustrated and disappointed if your appointment is postponed at the last minute.

• Be prepared to wait. An induction may start labor in as little as six to eight hours, or it may take up to three days or longer. Pitocin is the drug most commonly used to stimulate contractions, and it sometimes takes several hours to start labor. Make sure you bring magazines, books, puzzles, needlework, or other projects with you to pass the time.

An induction that begins with an unripe cervix often takes a very long time to work, or it may fail. If your cervix is unripe at the time of your appointment, induction is postponed so you can have prostaglandins or cervical dilators inserted to ripen your cervix. Cervical ripening may require several trips to the hospital.

• Once you’re admitted to the hospital for induction, expect to have continuous electronic fetal monitoring (EFM) to keep track of your contractions and record how well your baby tolerates them. Continuous EFM restricts your ability to use self-help comfort measures (see Chapter 11). If available, ask to use wireless (or telemetry) monitoring, which allows you to walk and use the shower or bath. If wireless EFM isn’t available, try to move around as best as you can.

• Expect to become hungry if hospital policy restricts eating while receiving Pitocin and if contractions take a long time to begin. Pitocin increases the risk of a cesarean section, and the surgery is safest if done on someone with an empty stomach (to prevent food particles from entering the airway). If your hospital restricts eating while receiving Pitocin, you can probably still drink clear liquids.

• Be prepared for contractions that are more intense than normal. Labor is often more painful when it’s induced than when it begins spontaneously. It’s possible to ease the intensity of contractions by reducing the dose of Pitocin, but this doesn’t always work. Furthermore, reducing the dose may make induction less effective.

Two Views on Medical Induction

The most frustrating thing for me after receiving Pitocin was how it affected my ability to move around. First I got an IV for the Pitocin and fluids. Then I got an epidural, which meant I was hooked up to monitors and stuck in bed. Next I had a blood pressure cuff put on, and then I got a bladder catheter. All those wires and tubes made it really hard to move.


During labor my contractions repeatedly slowed down whenever I rested, so I walked around to get them going again. Ultimately, my doctor convinced me to use a very low dose of Pitocin so my contractions would become regular. They did, and my baby was at last born after twenty-one hours of labor. Even with the bumps, the experience was remarkable.


Prolonged Active Labor

In the first stage of labor, the early phase is prolonged if it takes longer than usual for the cervix to dilate to 4 to 5 centimeters and enter the active phase. Prolonged early labor usually resolves with time, self-care, and changes to the environment that reduce stress and increase the body’s release of oxytocin, the hormone that causes contractions. (See page 245 for more information on prolonged early labor.)

Typically in active labor, cervical dilation speeds up, contractions become more painful, and labor progresses with each contraction. If labor slows or stops in this phase, it may indicate problems with the mother or baby. By taking the same measures that can resolve prolonged early labor or by using the self-help measures described in the next section, a woman may speed up prolonged active labor. However, if these measures don’t work, medical interventions may be required.


Prolonged active labor can result from a number of things affecting the mother, including the following:

• A full bladder

• Medications

• Immobility

• Ineffective contractions

• A baby in an unfavorable presentation or position

• Dehydration and lack of nourishment

• Exhaustion or stress caused by environment, discouragement, anxiety, or fear

The following sections describe these problems and discuss self-help measures and medical approaches for resolving them.


When active labor is prolonged, the way to speed it up depends on the cause of the delay. In many cases, you may be able to solve the problem on your own, depending on how rested you are, the amount of pain you have, your state of mind, and whether you have emotional support and encouragement. These factors influence whether you can use the following measures and for how long.

Full bladder

A full bladder can delay labor progress and increase pain, so empty your bladder every hour or so.


If you’ve received pain medications or other drugs that may have slowed your labor, allow time for them to wear off, if it’s safe to do so.


If you’ve been lying in one position for a long time, walk or stand to let gravity help your baby descend. Or shift from lying on one side to sitting or to the hands-and-knees position. Use these positions even if you’re attached to an IV line and an electronic fetal monitor.

Ineffective contractions

To enhance the effectiveness of contractions, try acupressure, nipple stimulation, walking, and standing. (See pages 278–279.)

Unfavorable presentation or position of baby

To improve the presentation or position of your baby within your pelvis, try the techniques described on page 286.

Dehydration and lack of nourishment

To keep hydrated and provide fuel for the hard work of labor, drink plenty of fluids and eat foods that give you energy (if allowed).

Exhaustion or stress

If you’re discouraged, anxious, fearful, or exhausted, you need reassurance, encouragement, a safe and nurturing environment, and help with comfort measures and relaxation techniques (see Chapter 11). A doula can relieve your emotional stress and uncertainty, and can reassure and guide both you and your partner. (See page 23 for more information about doulas.) You can also reduce stress and build confidence by referring to the information you’ve learned in this book and in other resources on pregnancy and birth, or in your childbirth preparation classes. Lastly, don’t forget your nurses and hospital staff—their help can sustain you.


When active labor slows down or stalls, your caregiver’s goal is to assess and maintain your baby’s well-being as well as your own. If you’re both tolerating the delay, there may be time to let the problem resolve itself or to determine the cause of the delay and intervene as necessary. Additional vaginal exams are likely, to check for progress in cervical dilation and in your baby’s descent or rotation. Your baby’s heart rate is monitored closely, possibly with continuous electronic fetal monitoring. You may receive IV fluids to prevent or treat dehydration, and you may begin to welcome medications for relaxation and pain relief if your labor is unduly long. To try to speed up labor, your caregiver may rupture your membranes (see page 280), or he or she may administer Pitocin to augment your labor by increasing the frequency and intensity of contractions.

In a planned home birth or birth at a birth center, a transfer to the hospital becomes necessary if you need Pitocin or if your baby isn’t tolerating labor well. Prolonged active labor is the most common reason for transfer to the hospital during labor in a planned out-of-hospital birth.

If the monitoring of your baby’s heart rate shows that he isn’t tolerating labor well, or if your labor continues to lag even after receiving Pitocin, you and your caregiver may decide a cesarean section is necessary.


One of the most common reasons for prolonged active labor is a baby who’s in an unfavorable position, or malposition, and doesn’t fit into the pelvis as well as a baby in a favorable position does. About 25 percent of women begin labor with a baby in the occiput posterior (OP) position, in which the back of the baby’s head is toward the mother’s back. This malposition can prolong labor because the baby’s head must rotate further than usual to face the mother’s front, or occiput anterior (OA), the favorable position for birth. In addition, when the baby is OP, cervical dilation and the baby’s descent might not progress efficiently.

By the transition stage of labor, most OP babies have turned to the OA position on their own, although some turn after transition. When low in the birth canal, some OP babies are turned by the caregiver, who reaches inside the vagina and rotates the baby’s head to the OA position. This procedure has a significant success rate.17 Other babies are born in the OP position (sometimes called “sunny side up”), or are born by cesarean section.

In Their Own Words

According to several ultrasound scans, my baby had turned a couple times during labor, from faceup to facedown and back again. At the time of the birth, she was faceup, which gave me a lot of back pain. Luckily, we had a friend present who was training to be a doula. She did a wonderful job massaging my back during contractions, which made the pain tolerable.


If your baby is OP or otherwise malpositioned (such as a brow or face presentation—see page 295), you may have considerable back pain during and sometimes between contractions, possibly because your baby’s head is pressing unevenly on your sacrum, straining your sacroiliac joints and causing pain in your lower back. Back pain also may occur when your baby is transverse (lying sideways) or even OA.

Back pain or prolonged active labor is sometimes caused by a subtle malposition called asynclitism, in which the baby’s head is tilted and the top of it isn’t centered on the cervix. With asynclitism, the head doesn’t press evenly against the cervix (which makes dilation less efficient) and it doesn’t fit through the pelvis as well as when it’s centered on the cervix. When the baby’s head is tilted, the part of the head that emerges first through the birth canal is larger than when the top of the head emerges first.

Asynclitism is difficult to diagnose during labor, partly because it’s not as clearly associated with back pain as the OP position is. Clues that suggest asynclitism include delayed dilation or uneven dilation, in which most of the cervix dilates completely while the remainder doesn’t, creating a “cervical lip”. Another clue is a swollen cervix that seems to have closed a few centimeters. After the birth of the head, its shape is also a clue to the baby’s position. If the head has some off-center elongation, it indicates that the baby’s position was asynclitic.

What You Can Do If Your Baby Is Malpositioned

It can be difficult to identify a baby’s position; even seasoned caregivers and nurses often misidentify it.18 For this reason, assume your baby is malpositioned if your labor progress has slowed, if you have back pain, or if you have irregular or coupling contractions (occur in pairs with a short break between the first and second contractions). At any point in labor, try the positions and comfort measures described on pages 228–232 to help optimize your baby’s position and manage back pain. With continued use, these positions should guide your baby into a favorable position. Once your baby’s head fits into your pelvis, back pain often subsides and labor progress improves.


If you continue to have intense back pain even while using the positions and comfort measures described on pages 228–232, here are a few medical approaches that may help relieve the pain.

Sterile Water Block

If you have severe back pain but want to minimize use of pain medications, the sterile water block is a promising option. To administer a sterile water block, your caregiver or nurse injects tiny amounts of sterile water into four places on your lower back. The procedure provides almost immediate pain relief by rapidly increasing endorphin production in the area around the injection sites. The effects last for an hour or two, and the procedure can be repeated. The first injections may feel like bee stings for up to thirty seconds, but additional injections may be less noticeable. While the sterile water block can relieve back pain, it doesn’t relieve abdominal pain.19

If you’re interested in the sterile water block, discuss it with your caregiver.


Medications for Pain Relief

If you have severe back pain during a prolonged active labor and want medications for relief, you can ask your caregiver or nurse for an epidural or spinal narcotics. (See Chapter 10.)

Concerns about the Baby’s Well-being

Most healthy full-term babies get a better start in life if they undergo labor. Contractions jump-start many processes that improve a baby’s transition to life outside the womb, such as breathing, temperature regulation, alertness, and suckling.

During a contraction, the amount of oxygen that’s available to the baby varies. Although most babies compensate for this variation well, a few can’t and instead show signs of distress. For these babies, electronic fetal monitoring (EFM) of their heart rate patterns indicates they’re not getting the optimal amount of oxygen during contractions. Babies in this situation are described as having nonreassuring fetal heart rate, also called fetal intolerance of labor or simply “fetal distress.” See page 252 for more information.

The presence of meconium (a baby’s first waste) in the amniotic fluid may also indicate that a baby isn’t compensating well for the varying amount of available oxygen during contractions. When a baby’s oxygen supply is low, her intestines cramp to send oxygen-rich blood to other areas that need oxygen the most (such as her brain). This cramping causes meconium to pass from the intestines into the amniotic fluid, giving the fluid’s normal clear color a brownish or greenish tint. (If there’s a lot of meconium, the fluid becomes dark brown or black.) When a woman’s bag of waters breaks, the caregiver notes the presence of meconium and assesses the baby’s health. See page 253 for more information about this condition.

Although EFM and the presence of meconium don’t always identify oxygen-deprived babies (see page 313), caregivers won’t hesitate to take measures to improve the baby’s well-being if either assessment indicates distress.


If your baby has a nonreassuring heart rate pattern, you’ll need professional help to resolve the problem. Follow your caregiver’s or nurse’s requests to change positions, and breathe deeply; these measures are often enough to restore your baby’s heart rate to normal.


When a baby shows signs of distress, sometimes the problem resolves itself without intervention. For example, if your baby is pressing on the umbilical cord and constricting the flow of oxygen-rich blood, he may shift his position so he moves off the cord, thereby restoring normal blood flow.

If intervention is necessary, there are several options to restore a baby’s heart rate to normal. For example, you may breathe oxygen by mask and change your position to increase your baby’s heart rate. If Pitocin is causing contractions that are too intense, your dose can be reduced to slow or stop contractions, increasing the amount of available oxygen to your baby. If you’re not receiving Pitocin, you can receive a tocolytic (anti-contraction) medication to slow or stop contractions and allow oxygen levels (and thus your baby’s heart rate) to improve.

If the volume of amniotic fluid is too low to cushion the umbilical cord, your caregiver may use amnioinfusion, a procedure that replaces enough water in your uterus to remove the pressure on the cord caused by your baby’s head or trunk. If these interventions don’t resolve the problem and your baby’s condition worsens, a cesarean section may be necessary. See page 313 for more information.

Prolonged Second Stage of Labor

The second stage of labor begins when your cervix is fully dilated and ends with the birth of your baby. In this stage, labor progress may slow or stop for reasons that can cause a prolonged active phase (such as exhaustion or a malpositioned baby). In those cases, the same measures that can resolve a prolonged active labor can be tried to resolve a prolonged second stage. (See page 283 for more information.) Sometimes, receiving an epidural prolongs the second stage. (See page 259 for information on delayed pushing with an epidural.)


One problem that’s unique to the second stage is a baby that doesn’t descend through the birth canal, despite hours of pushing by her mother. In this situation, following the measures described on page 289often can help with the baby’s descent.

In rare circumstances, a prolonged second stage is more difficult to resolve than usual. For example, the baby can fit through the upper part of the pelvis (pelvic inlet), but she can’t rotate and descend through the lower part (pelvic outlet).

A second rare problem is a short umbilical cord, which can cause the baby’s heart rate to slow during contractions or limit her descent because the cord can’t stretch enough for her passage through the vaginal opening. Sometimes, a cord that’s of sufficient length can pose the same problem as a short cord, if it’s wrapped around the baby; however, in most cases the cord remains loose enough to prevent a problem.

In both of these examples, a cesarean section may be required if time and the measures taken to resolve the problem aren’t successful.

Shoulder dystocia is a rare but potentially serious complication that occurs when the baby’s head has been born, but the birth of her shoulders is delayed because they’re too broad to fit through the pelvis. It becomes critical for the baby to finish being born quickly, because her oxygen supply from the cord may be reduced. The caregiver may ask the mother to change position, as this may resolve the issue. The caregiver may also use skilled maneuvers to rotate the baby and deliver the shoulders. Often an episiotomy is necessary (see page 289), and sometimes the baby’s collarbone breaks in the effort to get her out quickly. A newborn’s collarbone is flexible and usually heals quickly.


If your baby isn’t descending during the second stage, a change in position can help resolve the problem with time, as long as your baby is handling labor well. Try squatting, lap squatting, the supported squat, or the dangle (see pages 221–223). These positions may be the best aids to help your baby descend and rotate because they use gravity and allow for maximum enlargement of the pelvic outlet.20 You may also try the standing, semi-sitting, and hands-and-knees positions. If you don’t have apparent progress after twenty to thirty minutes in one position, change to another one.

If you’re unable to use these positions because of your caregiver’s preference or because an epidural limits your movements, or if you try them but they don’t work, your caregiver may ask you to try the exaggerated lithotomy position, in which you’re flat on your back with your knees drawn up toward your shoulders. This position may help your baby move beneath your pubic bone.21

If tension in your perineum seems to interfere with your ability to effectively bear down—even after receiving warm compresses and reminders to relax—try sitting on the toilet to encourage the muscles of your perineum to release.

If trying various positions doesn’t enhance your labor progress, your caregiver may suggest that you use prolonged pushing (see page 259). In this situation, the advantages of prolonged pushing may outweigh the drawbacks.


With a prolonged second stage, the caregiver carefully monitors the baby’s heart rate. If your baby seems to be tolerating labor, expect your caregiver to encourage you to continue your efforts to speed up labor, such as using various positions.

If your attempts are unsuccessful, your caregiver may recommend using a medical procedure to facilitate the birth, such as vacuum extraction, forceps delivery, episiotomy, or cesarean section. Your caregiver also may recommend these interventions if you’re exhausted and unable to push effectively, if you’ve received medications that inhibit your efforts and slow your labor, if Pitocin augmentation isn’t helping (see page 281), or if your baby is no longer tolerating labor. The following sections briefly describe episiotomy, vacuum extraction, and forceps delivery; visit our web site,, to learn more information about them.


An episiotomy is a surgical incision of the perineum that enlarges the vaginal outlet. The procedure is performed just before the baby’s head is born, as the perineum is stretching. An episiotomy has been found to shorten the time to birth by five to fifteen minutes, which may be necessary for the baby’s well-being if he’s in distress. A caregiver also may recommend an episiotomy if forceps are used to deliver the baby, or if shoulder dystocia is suspected (see page 288).


After the birth, an episiotomy is repaired with sutures, and the mother may experience moderate to severe pain during the first few days. See page 336 for more on information on healing and comfort after an episiotomy or a spontaneous tear.

Routine Episiotomy

The use of episiotomy was once standard practice in maternity care, but well-designed studies performed in the 1990s found no benefit and some risks to routine episiotomy.22 As a result, the practice has declined in recent years.

Caregivers who continue to perform routine episiotomies (some of whom have rates as high as 80 percent) tend to hold on to two outdated beliefs, despite the studies that have disproved them: One, a spontaneous tear is always worse than an episiotomy; two, an intact perineum has been overstretched and is therefore more damaged than one that has had an episiotomy.

Other caregivers reserve episiotomies for situations in which there are problems with the birth. These caregivers usually have episiotomy rates between 5 and 20 percent. (Many mid-wives’ rates are less than 10 percent.) They point out that most spontaneous tears (which occur in half of all vaginal births) are smaller than the average episiotomy; furthermore, serious large tears are more likely to occur with an episiotomy than without one.

If avoiding an episiotomy is important to you, discuss it with your caregiver at a prenatal visit. Rather than asking if your caregiver does routine episiotomies, ask for his or her opinion on the practice and when he or she thinks it’s necessary. If you’re uncomfortable with the answers, you may want to consider changing caregivers. (See page 20 for more information.) In addition to choosing the right caregiver, follow the measures on page 264 to help safely avoid a tear or an episiotomy.

Note: Be aware that if your baby is in distress in the late second stage, your caregiver may decide that an episiotomy is necessary for your baby’s well-being.

Vacuum Extraction and Forceps Delivery

vacuum extractor is a silicone suction cup, and forceps are long steel tongs. Either instrument can be applied to the baby’s head to help make a vaginal birth possible, although the vacuum extractor is used more often than the forceps. Both instruments, however, are used much more frequently on women who have received epidural pain medication than on women who haven’t.

To use either instrument, the caregiver pulls on it as the woman pushes during contractions. When used according to established safety protocols, both instruments are generally safe for babies, although bruising, swelling, and scraping of the baby’s head often occur. To protect the baby, the caregiver discontinues use of the instruments if it’s obvious the baby isn’t descending. At that point, a cesarean section becomes necessary.


Preterm Labor and Premature Birth

A labor is preterm if it begins before the thirty-seventh week of pregnancy. If a preterm labor isn’t stopped, a premature birth occurs. The younger a premature baby’s gestational age is, the more problems she’s likely to have.


Certain indicators can identify women at high-risk for preterm labor, if caught early in pregnancy. Risk factors include a previous miscarriage, a prior premature birth, and a cervix that’s short, ripe, or dilating early in pregnancy. For women with these risk factors, caregivers may recommend options such as bed rest, medications, and cervical cerclage, to stop preterm labor and prevent a premature birth. See page 136 for more information about the risk factors for preterm labor as well as its prevention and treatment.

Some women have no risk factors for preterm labor and are caught by surprise when they begin showing signs of the complication (see page 137). If you experience any signs of preterm labor, call your caregiver immediately!The methods used to prevent a premature birth are more likely to succeed if preterm labor is detected before your cervix has dilated to 2 centimeters. After evaluating your cervix’s condition and your baby’s well-being as well as your own, your caregiver will decide whether it’s in your and your baby’s best interest to try to stop labor.

Because the management of preterm labor is a high-risk situation, it usually involves the specialized skills of an obstetrician. If your caregiver isn’t an obstetrician and you develop preterm labor, he or she may work closely with one to manage the problem. If a premature birth is unavoidable, a pediatrician or neonatologist (a pediatrician specialized in the medical care of newborns) is typically present at the birth for immediate evaluation and treatment of the baby.

The following sections describe the steps that are commonly taken if preterm labor is suspected or confirmed, as well as the care given to a newborn if a premature birth is unavoidable.


If your baby is born prematurely, expect your caregiver and the hospital staff to take the following measures:

• If your baby is born before the corticosteroids have had enough time to mature her lungs, treatment for RDS becomes necessary, which includes administering oxygen and mechanical assistance with breathing. In addition, your baby may need to have surfactant instilled into her lungs. This substance allows the lungs to expand during an inhalation and remain partially inflated during an exhalation.28

• If your baby is very premature, you may need to transfer to a hospital with an intensive care nursery and highly trained nurses and neonatologists. Because your baby is at high-risk, her heart rate may require continuous monitoring.

• Depending on your baby’s condition, you might not be allowed to hold her right after the birth. Most premature infants are taken to either a special care nursery or a neonatal intensive care unit (NICU), where they stay until they can breathe on their own, stay warm at room temperature, and breastfeed or take a bottle.

• Your premature baby may require prolonged hospitalization. Most hospitals recognize that having parents participate in their baby’s care benefits both the child and the adults. (See page 394.) Expect the hospital staff to encourage you to spend as much time with your baby as you can. They may even provide you with sleeping arrangements.

Kangaroo Care

Kangaroo care is a method of treatment in which newborns are kept in skin-to-skin contact with one of their parents as much as possible. Proponents of Kangaroo care believe it’s the most effective way to promote a baby’s well-being, especially for a premature or sick baby. It also helps parents show love for their baby by allowing them to participate in his care.29

With Kangaroo care, as soon as the newborn’s condition is stable after the birth he’s placed nude on his mother’s bare chest or abdomen (or that of the other parent or loved one, if the mother is unavailable). A blanket covers both of them. The caregiver and staff encourage the parents to give Kangaroo care for extended periods several times a day.

Studies show that a baby’s growth and development improve with Kangaroo care.30 He spends more time in deep sleep, more time in the quiet-alert state (see page 382), and less time crying. He has fewer episodes of apnea (suspension of breathing) and fewer episodes of bradycardia (slow heart rate). His temperature stabilizes, and he gains weight more rapidly, which can lead to a shorter hospital stay if he’s ill or was born prematurely. Although all babies benefit from Kangaroo care, a premature baby’s health particularly improves when allowed to smell his parents’ familiar scent, hear their heartbeats,31 and absorb their body heat. The skin-to-skin contact often helps ease any anxiety he may have from being connected to the various monitors, IV lines, and tubes for oxygen and food.

If you’re at risk for preterm labor and premature birth, contact the newborn nursery to learn about their policies on Kangaroo care and how to arrange for it.


If you begin showing signs of preterm labor, expect the following:

• When you call your caregiver or birthplace to report preterm contractions, you may be asked to drink one or two large glasses of water and lie down for an hour, then call again if the contractions continue. The rationale for this advice is that mild dehydration sometimes causes contractions.

• If you go to the hospital or clinic for advice, your contractions are then evaluated with an electronic fetal monitor, and you may receive a vaginal exam or ultrasound scan to discover whether your cervix is changing. If it isn’t changing, you aren’t in preterm labor. Instead, you may have an active or irritable uterus, and may be told to rest more to calm your contractions.

• If your cervix is changing, your caregiver then checks whether your baby’s lungs are mature enough so he can breathe on his own after the birth. To make this determination, your caregiver withdraws a small amount of amniotic fluid from your uterus (amniocentesis) and analyzes the surfactant levels to determine whether the lungs are mature.

• If your baby is immature and birth seems unavoidable, the focus of care shifts to prevention of respiratory distress syndrome (RDS)—the most common complication of premature birth. In this situation, your caregiver may try to delay the birth for a day or two in order to allow time for corticosteroids to speed up the maturing of your baby’s lungs.23 The administration of these medications has reduced the incidence of RDS by 40 to 60 percent. Corticosteroids also help decrease intracranial bleeding (brain hemorrhage) in a newborn.

• The drugs used to stop or slow preterm labor are powerful and have strong side effects. Although the highest doses are usually used only for a day or two, lower doses of some of these drugs, combined with bed rest, may be used for a longer period to keep preterm contractions from increasing in frequency and intensity. The following are the classes and examples of drugs used to prevent preterm labor:

* Beta-mimetic agents (terbutaline and ritodrine)24

* Calcium channel blockers (nifedipine)25

* Prostaglandin inhibitors (naproxen and indomethacin)

* Oxytocin receptor antagonists (atosiban)26

Magnesium sulfate, a drug frequently used to treat gestational hypertension, also has been used to stop preterm labor; however, this use has proved unsuccessful. Instead, this drug produces extremely uncomfortable side effects for the mother and is dangerous to the baby.27

• During preterm labor, giving the mother systemic pain medications (such as narcotics or narcoticlike drugs) usually isn’t recommended because these drugs can affect the baby’s heart rate and sometimes his breathing after the birth. Therefore, in early labor, plan to use relaxation and breathing patterns for pain relief. In active labor or during the birth, you can continue these techniques or you can request regional anesthesia (epidural), which has less effect on newborns than systemic pain medications have.

Gestational Hypertension and Preeclampsia

If you have gestational hypertension, expect your caregiver to monitor your blood pressure and your baby’s well-being closely throughout your pregnancy. If the condition is mild and stable—and remains that way—your pregnancy is typically allowed to continue to term. (To learn more information about hypertension and preeclampsia in pregnancy, see page 140.) However, be aware that preeclampsia rarely improves and often worsens as pregnancy continues. In severe cases, or when blood tests indicate HELLP syndrome (see page 142), most caregivers recommend managing a woman’s labor in order to keep her blood pressure down and prevent seizures from eclampsia.

Caregivers commonly recommend inducing labor in women with preeclampsia, because ending the pregnancy is often the first step to resolving the problem. Some caregivers also recommend an epidural because of its suspected side effect of lowering blood pressure; however, studies haven’t shown this practice to be effective.

Multiples (Twins, Triplets, or More)

When compared to a pregnancy with only one baby, a pregnancy with multiples is at higher risk of complications, such as preterm rupture of the membranes, preterm labor, preeclampsia, prolonged labor, prolapsed cord, and babies who are malpositioned or who are premature or small in size for their gestational age. In addition, although labor with multiples often progresses normally, the birth is usually more complicated than the birth of a single baby. For example, a woman’s overstretched uterus sometimes can’t contract efficiently, which slows labor progress and increases the risk of postpartum hemorrhage (see page 299).

The risk of all these difficulties increases as the number of babies increases. If you’re pregnant with multiples, expect more medical supervision and more interventions than are usual with a single baby at term.

Timing the birth of multiples is a controversial topic. Some caregivers believe that waiting for labor to begin on its own can affect the babies’ well-being; they argue that multiples are born healthier if labor is induced or a cesarean section is scheduled between the thirty-seventh and thirty-ninth weeks of pregnancy. Studies of these claims, however, have found inconsistent results. Other caregivers believe that the physiological process of labor and birth best benefits mother and babies; they wait for labor to begin spontaneously while monitoring the pregnancy and the babies’ well-being closely.32


With vaginal births of multiples, caregivers may recommend epidural anesthesia, in case an intervention that may be painful for the mother is needed to deliver one or more of the babies (such as forceps delivery). Although twins are often born vaginally at term (see below for more information), the rate of cesarean birth for twins is higher than for single babies, and the rate increases with the number of babies. In fact, it’s rare for triplets or more to be born vaginally at term. See Chapter 14 for more information on cesarean birth.


If you’re pregnant with twins, expect to receive an ultrasound scan during labor to help identify your babies’ presentations (that is, the parts of their bodies that will emerge first from the birth canal). The results help your caregiver determine whether a vaginal birth or cesarean birth is best for your babies’ well-being and your own. If a vaginal birth is attempted, it likely occurs in an operating room in case a cesarean section becomes necessary.

For the vaginal birth of twins, the most favorable presentation is vertex (head down), and in most cases both babies are vertex at the time of the birth. However, if both babies are breech (buttocks, legs, or feet over the cervix), a cesarean is usually performed. If the first baby is vertex and the second baby is breech, your caregiver may attempt to turn the second baby after the vaginal birth of the first, or the second baby may be born in the breech presentation. The birth of the second baby usually occurs within five to thirty minutes after the first, and the delivery of the placenta (or placentas) occurs after both babies are born.

Breech and Other Difficult Presentations

Typically at birth, the baby positions herself so her head is over the cervix; this vertex presentation is the most favorable for a vaginal birth. In about 5 percent of births, however, the baby is in a less favorable presentation.

Face and brow presentations occur in less than half of 1 percent of births, and they usually prolong labor. The very rare shoulder presentation (transverse lie) occurs in about 1 in 500 births. Because a baby in this position turns to a vertex presentation only occasionally, a cesarean birth is usually necessary.

The breech presentation (buttocks, legs, or feet over the cervix) occurs in 3 to 4 percent of births, although the incidence rises with multiples or premature births. The three types of breech presentation are:

• Frank: the baby’s buttocks are over the cervix and her legs are straight up toward her face (the most common breech presentation)

• Complete: the baby appears to be sitting cross-legged over the cervix

• Footling: one or both of the baby’s feet are over the cervix


In the United States, breech babies are typically born by cesarean section. To help avoid a cesarean, many women try to turn their breech babies before the birth by using different self-help techniques or complementary medicine methods. Some women consent to a medical method to try to turn their babies. The following sections describe these techniques and methods.


By the thirty-fourth to thirty-sixth week of pregnancy, your baby should assume his birth position and presentation. Your caregiver learns this information during your prenatal visits at that time. If your baby is breech, you may wish to try self-help techniques or complementary medicine methods (see page 297) to encourage him to turn to a vertex presentation.

The effectiveness of some of these self-help techniques to turn babies hasn’t been formally studied; however, others have been studied and found to be mostly ineffective.33 Nonetheless, these techniques help some babies turn and they pose few (if any) risks. Even if their chances of success are low, trying them may decrease your risk of cesarean birth.

Note: Although these techniques pose minimal risks, check with your caregiver before attempting any of them.

Breech Tilt Position


In the breech tilt position, your hips are higher than your head. Before trying it, check with your caregiver to make sure there aren’t any medical reasons for avoiding it. (If you’re in good health and your baby is thriving, your caregiver probably won’t object.) Have your partner nearby to help you.

One way to do the breech tilt position is to lie on your back with knees bent and feet flat on the floor. Raise your pelvis and place enough firm cushions beneath your buttocks so your hips are 10 to 15 inches higher than your head. (Ask your partner to help place the cushions.) Or instead of using pillows to tilt your body, lie head down on a wide flat board (such as an ironing board) that’s tilted so one end is on a chair and the other is on the floor. If the board is wobbly, have your partner hold it steady and help you get on and off the board.

Another way to do the breech tilt position is by getting into an exaggerated open knee-chest position. From the hands-and-knees position (see page 222), place a firm cushion or two beneath your knees. Then with your partner’s help, carefully lower your chest to the floor or bed so your buttocks are high in the air.

Do the breech tilt position for about ten minutes three times a day, when your baby is active. To ease discomfort, make sure your stomach and bladder are empty. Try to relax your abdominal muscles and visualize your baby somersaulting so her head is in position over your cervix. You may feel your baby squirm as her head presses into the top of your uterus (fundus).

Use of Sound

During active phases, babies can hear well and often respond to sounds. By playing pleasing or familiar sounds so they seem to come from low in your uterus, your baby may move his head down to hear them better.

You can play music through headphones placed on your belly just above your pubic bone. Or your partner can lay his or her head in your lap and talk to your baby. The sound should be at a comfortable volume. Use this harmless technique for as long as you like.

Use of Cold on Your Fundus

If your baby’s head is near your fundus (the top of your uterus), she may move her head down if the area becomes uncomfortably cold. To do this technique, place an ice pack on your fundus, making sure to have a layer of cloth between the ice pack and your skin. The typical advice is use the ice pack for no longer than twenty minutes at a time, but you may choose to use it for longer periods, if it’s comfortable for you. You can also decide how often to use the technique during the day.


The following methods are used to try to turn a breech baby without the use of medical equipment or intervention.


Acupuncture is used for numerous health-related purposes, including turning breech babies (see page 279 for a description of the technique). The acupuncture point associated with this purpose is Urinary Bladder 67, which is located on the outside tip of each little toe. To try to make the baby move out of the breech position, a trained acupuncturist places needles in both locations of this point.

Your acupuncturist may also use moxibustion (see page 279), and you may be taught the technique so you can do it yourself several times each day. Some scientific trials of moxibustion report that its success rate for turning breech babies by the onset of labor is 50 percent.34

Two Views on a Breech Birth

At the thirty-fifth week of pregnancy, when we learned our baby was breech, we went to a chiropractor and an acupuncturist. Fortunately for us, our baby turned head down two weeks later, and we were able to have the birth we’d planned.

—Megan and Peter

We’d planned a natural birth, but found out at thirty-five weeks that our baby was breech. We tried acupuncture, moxibustion, lights, talking, and pelvic tilts; nothing worked. We then tried an external version, which also didn’t work. So we scheduled a cesarean section for a day after the due date, to allow for our baby’s full development. Our caregiver helped us make a cesarean birth plan that would let us have the best possible birth experience.

—Jamie and Jonathan

Webster Technique

This technique for turning breech babies is based in chiropractics. It involves the analysis of the mother’s pelvis, an adjustment of her sacrum, and relief of abdominal muscle tension. The goal is to relieve any uterine constraint that may be preventing the baby from moving into a favorable birth position.35

Although this technique hasn’t been formally studied, its popularity is growing. To find a chiropractor trained in the Webster Technique, visit the web site for the International Chiropractic Pediatric Association at


If self-help techniques or complementary medicine methods don’t cause your breech baby to turn, your caregiver may try a medical procedure called external version and begin discussing your options for birth. External version is usually done around the thirty-seventh to thirty-eighth week of pregnancy, but some women consent to the procedure earlier in pregnancy on an experimental basis to evaluate success and safety.36

Studies of external version indicate that it’s a safe procedure with a roughly 65 percent success rate.37 For unsuccessful external versions, the baby either didn’t turn or had turned but resumed a breech presentation. In these cases, the babies usually were born by cesarean section.

Here’s what to expect if you consent to an external version:

1. Your baby receives a non-stress test before and after the version, to determine his well-being. (See page 144.)

2. Using ultrasound scans, your caregiver confirms that your baby is breech; estimates the volume of amniotic fluid; visualizes the uterus, cord, and the site of the placenta; and plans the direction in which to move your baby. External version isn’t done if the volume of amniotic fluid is low or if you have uterine abnormalities. The procedure may be avoided if the placenta is implanted in the front wall of your uterus.

3. You receive an injection of a tocolytic drug (such as terbutaline), which relaxes your uterus. The drug may make you feel nervous and a little shaky, but try to remember that a relaxed uterus makes the procedure easier to do.

4. Using ultrasound scans for guidance and to monitor your baby’s heart rate, your caregiver presses and pushes on your baby through your abdominal wall, encouraging him to turn to a vertex presentation.


External version takes five to ten minutes. If your baby’s heart rate shows that he’s in distress, the procedure is stopped. If the placenta begins to separate from your uterine wall during the procedure (a rare event) or if your baby remains in distress after it’s stopped, a cesarean section may be necessary.

It may take only a nudge or two to get your baby to turn. Or it may take constant, intensifying pressure on your abdomen to encourage movement. Try to relax your abdominal muscles and use light breathing (see page 225) to help you tolerate the procedure and give your caregiver the time needed to turn your baby. Your partner or doula can help you by maintaining eye contact and encouraging you to maintain rhythmic breathing. If you need a break, say so. Your caregiver can hold your baby in place until you’ve caught your breath and are ready for the procedure to be resumed.

Your caregiver may offer you an epidural or spinal block to reduce discomfort. Although anesthesia may make external version more comfortable for you and it may increase the procedure’s chances of success (because you can better tolerate the pressure for as long as is necessary to turn your baby), it’s unclear whether using anesthesia presents more risks than not using it. Anesthesia prolongs both the procedure and its recovery time; furthermore, it’s expensive. With support from your partner or doula, it’s likely that you can handle the discomfort of external version without medication.

Note to partners or doulas: Your help can make the difference in whether an external version succeeds in turning the baby. To encourage relaxation and help maintain rhythmic breathing, use the Take Charge Routine (see page 256).


Although vaginal breech births usually result in healthy babies, they carry potential risks that don’t exist for vaginal births with vertex presentations. For example, a breech birth increases the risk of prolapsed cord (see page 302) or even spinal cord injury, a rare problem that can occur if the baby’s head is tilted back (hyperextended) when it passes through the birth canal.

Another potential risk is a compressed cord. During a vaginal breech birth, the baby’s feet and body are born before her head. As the baby’s head comes through the cervix and birth canal, it can compress the cord and reduce the amount of oxygen in the blood coming from the placenta.

Also, because the baby’s feet and buttocks are smaller than her head, they may be born before the cervix dilates enough for her head to pass through. In this event, the birth of her head may be delayed, which may cause the baby distress.

Because of the potential complications of vaginal breech births, cesarean sections have become routine for delivering breech babies in the United States. The trend toward cesarean surgery for breech babies began in the 1970s, as safety improvements led to its increased use. As the number of vaginal breech births declined, fewer caregivers learned the skills to conduct them, which led to a further decline. Then in 2000, a large influential study found that breech babies born by cesarean had better outcomes than those born vaginally.38 Consequently, vaginal births of breech babies in the United States plummeted. (Recent criticisms of this study, however, have charged that it has many faults that affect the reliability of its conclusions.)

In other parts of the world, vaginal breech births are common. For many major hospitals in Europe and Australia, for example, they’re routine. The Society of Obstetricians and Gynaecologists, which is based in Canada, recently published a practice guideline that supports vaginal breech births in selected cases.39 It advocates screening for breech babies with high chances of having a safe vaginal birth, then planning vaginal births for those babies. The association also uses protocols that allow for an immediate cesarean, if necessary. When caregivers follow this practice guideline, about half of breech babies are born vaginally, the number of complications associated with vaginal breech birth decrease markedly, and both mother and baby fare well.

One day, maternity care in the United States may support vaginal births for breech babies. In the meantime, if your attempts to turn your breech baby are unsuccessful by the thirty-seventh to thirty-eighth week of pregnancy, it’s time to consider a planned cesarean birth. See page 327 to learn how to prepare for the best possible cesarean birth.

Complications in the Third Stage of Labor

The third stage of labor begins with the birth of your baby and ends with the delivery of the placenta. The following sections describe complications that may arise during this stage.


Postpartum hemorrhage is the excessive loss of blood (more than 500 milliliters or 2 cups) during the first twenty-four hours after the birth. It occurs in 20 percent of women, making it the most common problem during the third stage.

The treatment of postpartum hemorrhage depends on its cause. The three main causes of post-partum hemorrhage are uterine atony; vaginal, cervical, or perineal lacerations; and retained placenta or placental fragments. The following sections describe these conditions and their treatments.

Note: For any of the causes of postpartum hemorrhage, treatment may require IV fluids or a blood transfusion if the bleeding is severe. Also, the excessive loss of blood may lead to symptoms of shock, such as rapid pulse, pale skin, trembling, faintness, feeling cold, and sweating.

Uterine Atony

Uterine atony is poor uterine muscle tone, and it’s the most frequent cause of postpartum hemorrhage. If your uterus doesn’t contract after the birth, your caregiver will massage it to encourage contractions. Nursing your baby or lightly stroking your nipples also helps contract your uterus by stimulating the release of oxytocin. If these measures don’t control bleeding, your caregiver may give you medications, such as Pitocin, to promote contractions. Visit our web site,, to learn more information about these medications.


Lacerations (or tears) of the cervix, vagina, or perineum may occur, regardless of whether you have an episiotomy. If you have lacerations, they’ll be sutured to control bleeding. Your vagina also may be packed with sterile gauze to further stop blood flow. (See page 336 for comfort measures that you can take to ease the pain of a laceration.)

Retained Placenta or Placental Fragments

If the placenta or fragments of it aren’t expelled from your uterus, they interfere with postpartum contractions and allow blood to flow freely through vessels at the site where the placenta attached to your uterine wall. When this happens, the placenta or fragments are removed, you receive Pitocin or another medication to contract your uterus, and your uterus is massaged to promote further contractions. You can continue treatment by massaging your uterus yourself and by breastfeeding your baby (which stimulates the release of oxytocin, a hormone that causes contractions).

In rare cases, the placenta can’t be separated from the uterine wall (placenta accreta). The only safe treatment for this serious complication may be a hysterectomy (removal of the uterus).

Rapid Unattended Birth

Some women’s labors are much faster than usual. They begin with intense contractions that are less than four minutes apart and progress rapidly. If your labor is this fast, head for the birthplace immediately, or if planning a home birth, call your midwife. To travel to the birthplace, do not drive yourself. Instead, have your partner or someone else drive you there.

If your labor progresses so quickly that you push and strain involuntarily and can see your baby’s head at your vaginal opening or feel him coming down the birth canal, stay at home—don’t travel. It’s better to have shelter and essential supplies to help with an unattended birth than it is to rush to the birthplace and risk having an unattended birth along the way. If, however, you decide to travel to the birthplace and you begin to give birth en route, have the driver pull over to the side of the road, help you deliver your baby (see page 301), and then drive you both to the hospital.


Usually after a rapid unattended birth, both the mother and baby are fine; however, complications may develop, which is why medical professionals should assess both the mother and baby as soon as possible after the birth. If you have a rapid birth, medical help is most likely only minutes away. In the meantime, you may be able to help resolve the following potential problems or prevent them from worsening:

Quick Checklist for a Rapid Unattended Birth

Do as many of the following tasks as possible if you expect a rapid birth without the attendance of your caregiver or a medical professional. A rapid birth can be hectic, but try to remember to use what you’ve learned about the birth process, as well as relaxation and breathing techniques.

1. Get help, if possible. Call your partner, your caregiver, the hospital, or 911. If your partner can’t physically be with you, try to enlist the help of another person—even a child—to assist you.

2. Gather clean sheets, towels or paper towels, tissues, and extra clothing to be used during the birth and for your baby.

3. Wash your hands.

4. Remove all clothing from your bottom and vaginal area.

5. Lie on your side or sit leaning back. Make sure you’re in a clean place with enough room for your baby to rest as she slips out of your body.

6. Put a sheet, towel, or some clothing under your bottom.

7. Try not to hold your breath if your body is pushing. Keep panting through each contraction until your baby is born.

8. After your baby is born:

• Wipe away any mucus from her nose and mouth. Remove any membranes covering her face.

• Wipe her head and body to dry her.

• Place her on your bare abdomen or chest to keep her warm.

• Cover your baby and yourself using cloths, towels, or clothing.

9. Don’t cut the cord.

10. Put your baby to your breast, and let her breastfeed, if possible.

11. If you’re at home, await the birth of the placenta. (If the placenta isn’t expelled in fifteen to twenty minutes, try kneeling to see if gravity can help it come out. If unsuccessful, then go to the hospital.) If you’re in a car, have your partner or another person drive you and your baby to the hospital.

12. Place the placenta nearby in a bowl, newspaper, or cloth. (It’ll still be attached to the cord and your baby.)

13. Place towels or a pad between your legs to absorb the blood flow.

14. Go to the hospital or get medical help as soon as possible to check both you and your baby. A medical professional will also cut the umbilical cord and check your placenta. Note: The medical emergency team may arrive in time to help you with some of the these tasks.

If your baby doesn’t breathe spontaneously

Have someone call 911, if possible. Place your baby on his stomach with his head lower than his trunk, then rub his back briskly but gently. If he doesn’t respond within thirty seconds, hold his ankles together and smack the soles of his feet sharply. If your baby still doesn’t breathe, check for mucus in his mouth with your finger. If you know how to give infant CPR, do so. If you don’t, call 911 for help.

If you have excessive bleeding from your vagina

Some bleeding normally occurs after labor and birth, both before and after the placenta is expelled. However, excessive bleeding (more than 500 milliliters or 2 cups) may indicate a postpartum hemorrhage, especially if you begin to have symptoms of shock such as rapid pulse, pale skin, trembling, faintness, feeling cold, and sweating. If you or your partner suspect that you have a postpartum hemorrhage, call 911. Firmly massage your fundus (the top of your uterus) in a circle until the uterus contracts, and encourage your baby to nurse (or you or your partner can stroke your nipples) to stimulate the release of oxytocin, a hormone that causes contractions. To avoid shock, lie down and elevate your hips so they’re higher than your head. Get to the hospital or call for an ambulance if you haven’t already done so.

In Their Own Words

I went into labor with my second child two weeks early. My husband and I headed to the hospital, but I was ready to push before we arrived. We’d called 911, then called my doula, who told my husband what to do and coached me to breathe and tell my two-year-old that I was okay. The ambulance arrived just as the baby was born. We were all fine, but continued on to the hospital for observation and rest. Labor and birth took just an hour from beginning to end. What an adventure!


Prolapsed Cord

During a normal vaginal birth, the umbilical cord stays high in the uterus as the baby descends through the birth canal and out the vaginal opening. With a prolapsed cord, however, the cord slips below the baby so it’s either in the vagina or lying between the baby and the cervix. Although a prolapsed cord is rare (about 1 in 400 pregnancies), it’s a potentially serious complication because the baby’s body can compress the cord, especially during contractions, and reduce the amount of oxygen available to her.

A prolapsed cord can occur when your membranes rupture with a gush of amniotic fluid and the cord is allowed to slip toward the vaginal opening because your baby’s body doesn’t block its passage. This can happen if your baby is premature or in a breech or transverse (lying sideways) presentation, or if her head isn’t yet engaged in your pelvis and is still “floating high.” If you’re pregnant with multiples, the risks of prematurity and malposition increase, which further raise the risk of prolapsed cord.

At your prenatal visits in late pregnancy, ask your caregiver to check your baby’s position by using ultrasound scans or feeling your abdomen by hand. If your membranes rupture with a gush and you know that your baby is in a breech or transverse position, take the following steps to help ensure her well-being:

1. Get into an open knee-chest position (see page 229) so gravity can help move your baby away from your cervix and possibly off the cord. You might or might not be able to feel the cord in your vagina.

2. Arrange for immediate transportation to the hospital.

3. Remain in the knee-chest position in the vehicle or ambulance.

4. When you arrive at the hospital, tell the staff that you may have a prolapsed cord. If a prolapsed cord is confirmed, a nurse will insert a hand into your vagina keep your baby off the cord. Expect to have a cesarean section as soon as possible. If the cord isn’t prolapsed, you can resume your plans for coping with a normal labor.

If your baby’s head is still unengaged but low in your pelvis, you probably can follow your caregiver’s advice for managing ruptured membranes (see page 174).

If you don’t know whether your baby’s head is low or high in your pelvis, the risk of a prolapsed cord is less if the position of the head is unknown than if the head is known to be high. Regardless, you may wish to take the above steps as a precaution.

Seriously Ill Newborn or Infant Death

Although most babies are born healthy and normal, others regrettably aren’t. Some babies are born with health problems (congenital problems) or birth defects. Other babies are born dead (stillbirth) or die around the time of birth from genetic abnormalities, birth trauma, or infection. These tragic events are uncommon, but they do occasionally occur.

If your baby dies or has a serious health problem, you’ll experience deep, long-lasting grief, sadness, anxiety, and despair. To help you cope should either of these possibilities happen, during pregnancy decide your preferences for care. The following sections describe what to expect if your baby dies or has a health problem, as well as care options you may want to think about. By making these decisions in advance, you can have peace of mind that you won’t have to make them when grief or worry is affecting your ability to think clearly.


If your baby has a serious health problem, you can help by contributing to his care whenever possible. It’s likely that you or your partner can spend time with your baby, even if he’s in a special care nursery. If your baby is transferred to a hospital that specializes in the care of seriously ill babies, you may be able to arrange for an early discharge from your hospital so you can visit your baby. (If an early discharge isn’t possible, your partner may need to divide his or her time between visiting you and being with your baby.) Because of the special nutritive qualities of colostrum and breast milk (see Chapterr 18), you may want to nourish your baby by breastfeeding him or by bottle-feeding him your expressed milk.

The number of people and machines involved in your baby’s care may worry and exhaust you. You may become impatient with staff if you feel that they’re not fully answering your questions about your baby’s condition, treatment, and prognosis. To help you feel more in control of the situation, consider keeping a notebook with you so you can jot down your questions as they arise and record the answers as you receive them. You can also keep track of your baby’s treatment and progress.


If you have a stillbirth or your baby dies soon after birth, you’ll have to make several tough decisions. The emotional grief and sadness that follows an infant death will consume you, making it difficult to think clearly. To ensure that everyone knows your preferences for care in the event of stillbirth or infant death, it’s helpful to think about them in advance and note them in a special birth plan (see page 155).

To help you begin thinking about your options, ask your caregiver or childbirth educator how families are typically cared for after a stillbirth or infant death. Then begin thinking about your specific preferences. For example, if your baby dies before labor begins, do you want your labor induced? If so, when? Do you want to be awake and participate in the birth? Do you want the support of a doula or someone other than your partner (who will also need support during this difficult time)?

After the birth, do you want to recover in an area that’s separate from other mothers and babies on the postpartum floor, or somewhere else in the hospital? Do you want to have an early discharge from the hospital? Do you want to have an autopsy done to help find the cause of death?

What may make your memories of your baby more meaningful? You may want to hold your baby so you can physically acknowledge her existence. You may want to name your baby or have a religious ceremony for her, such as a baptism. You may want to photograph her, have her footprints taken, or obtain a lock of her hair. You may want to have a funeral or memorial service to provide an opportunity for family and friends to grieve together, say good-bye to your baby, and express their love and concern for you.


If your baby has a health problem, you and your partner will need to support each other and rely on supportive family, friends, and community resources to help you with the care of other children, transportation, food preparation, housecleaning, and notification of events to extended family, coworkers, and others. You may want to join a support group for parents in a similar situation.

If your baby is stillborn or dies after the birth, you and your partner will need the opportunity to grieve. The grieving process is necessary for coming to terms with your loss, but it’s a painful and exhausting experience, as you feel often overwhelming numbness, sadness, shock, disbelief, fear, anger, blame, and guilt. Make sure you and your partner frequently discuss what each of you is feeling; your reactions during the grieving process may differ at times. Rely on any emotional and practical help that family, friends, and community resources can provide. Also consider joining a group for parents who have experienced an infant death. While nothing can take away the pain of losing a baby, this group can offer support at an extremely difficult time. (See Appendix C for a list of resources.)

To help you accept the death of your baby, at some point in the grieving process you’ll need to review the birth experience and reflect on it. Recall the events with your partner, caregiver, doula, attending nurse, or childbirth educator. Use their recollections to help you write a record of your birth experience. Because remembering these events can be overwhelming, consider asking a counselor, therapist, hospital chaplain, or spiritual leader to help you work through your emotions.

Take plenty of time (months to years) to heal emotionally and physically. Eventually, you and your partner will reach a level of acceptance, although the sorrow may always remain. Allow yourselves to acknowledge your baby’s life and savor the good memories from pregnancy, the birth, and the special time you had with him.

Key Points to Remember

• Although most labors are normal, complications sometimes arise. Many problems are anticipated due to conditions such as a pregnancy with multiples, a preexisting illness in the mother, malposition, or developmental problems in the baby. Other problems are unexpected, such as a premature birth, post-date pregnancy, prolonged labor, distress in the baby, or postpartum hemorrhage.

• When a complication in childbirth arises, numerous medical and non-medical interventions are available to increase the chances of resolving the problem and improving the well-being of both you and your baby. By becoming fully informed about these interventions, you can decide whether they’re right for you and can participate meaningfully in your care.

• Although rare and often unexpected, tragedies in childbirth—such as injury to the mother, serious health problems for the baby, or even death of the baby—can occur. To help you cope should such a misfortune happen to you, it’s wise to think about your care preferences and make any practical decisions during pregnancy, when you can think about them clearly.