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The Big Event: Labor and Delivery

And now for the moment, you’ve all been waiting for. . . .Like pregnancy itself, childbirth can go more smoothly if you know what’s going to happen. Despite the incredible advances that have been made in science and medicine, no one really knows what causes labor to begin. Labor may be triggered by a combination of stimuli generated by the mother, the baby, and the placenta. Or labor may begin because of rising levels of steroid-like substances in the mother or other biochemical substances produced by the baby. Because we don’t know exactly how labor starts, we also can’t pinpoint exactly when it will occur.

In this article, we are going to help pregnant women to recognize the signs of labor. We also discuss the different stages of labor and what should expect in the three stages of labor.

Knowing When Labor is REAL and When it’s NOT

Being unsure whether you’re really in labor is actually fairly common. Even a woman expecting her third or fourth child doesn’t always know when she’s genuinely in labor. In this section of the article, we are going to discuss all the necessary information that every woman should know. You may experience some of the early symptoms of labor before labor actually begins. Rather than indicating that you’re in labor, the following symptoms suggest that labor may occur fairly soon. Some women experience these labor-like symptoms for days or weeks, and others experience them
only for several hours.

Changes Before Labor Begins

As you near the end of your pregnancy, you may recognize certain changes as your body prepares for the big event. You may notice all these symptoms, or you may not notice any of them. Sometimes the changes begin weeks before labor starts, and sometimes they begin only days before:

  • Bloody Show
  • Diarrhea
  • Dropping and Engagement
  • Increase in Braxton-Hicks contractions
  • Mucous discharge

Distinguish between True and False Labor

In general, you’re in false labor if your contractions:

  • Are irregular and don’t increase in frequency
  • Disappear for any reason, but especially when you change position, walk, or rest
  • Are not particularly uncomfortable
  • Occur only in your lower abdomen
  • Don’t become increasingly uncomfortable

You’re more likely to be in actual labor if your contractions:

  • Grow steadily more frequent, intense, and uncomfortable
  • Last approximately 40 to 60 seconds
  • Don’t go away when you change position, walk, or rest
  • Occur along with leakage of fluid (due to rupture of the membranes)
  • Make normal talking difficult or impossible
  • Stretch across your upper abdomen or are located in your back, radiating to your front

Induction of Labor

To induce labor means to cause it to begin before it starts on its own. Induction may be elective (performed for the convenience of the patient or her practitioner) or it may be a necessity (due to some obstetric, medical, or fetal complications).

Elective Induction

Although some women like the idea of a planned delivery, others prefer labor to occur spontaneously. Some practitioners gladly perform elective inductions, and others are opposed to the whole concept of it. A woman may choose to undergo an elective induction for several reasons, including the following:

  • To enable her to make arrangements for her other children, for her work or her partner’s work, or for the convenience of other family members by knowing exactly which day she’s going into labor.
  • To ensure that a particular physician in a group practice, with whom she has developed a special relationship, delivers her baby.
  • To reduce anxiety after a history of poor pregnancy outcomes (such as a previous full-term fetal death) by delivering earlier than she naturally would.
  • To make sure she’ll get to the hospital on time if she lives far away and has a history of rapid deliveries.

Medically indicated induction

An induction is indicated (is a medical necessity) when the risks of continuing the pregnancy are greater — for the mother or the baby — than the risks of early delivery.

Problems with the mother’s health that may warrant induction include:

  • Preeclampsia
  • The presence of certain diseases, such as diabetes or cholestasis
  • An infection in the amniotic fluid, such as chorioamnionitis

Potential risks to the baby’s health that may warrant induction include:

  • Pregnancy well past the due date. Because this can increase the risk of certain complications, most practitioners induce labor after the 41st or 42nd week.
  • Ruptured membranes before labor has started, a situation that may place the baby at risk for developing an infection.
  • Intrauterine growth restriction
  • Suspected macrosomia (fetus weighing more than 8 pounds, 13 ounces).
  • Rh incompatibility with complications.
  • Decreased amniotic fluid
  • Tests of fetal well-being indicating the fetus may not be thriving in the uterus.

Inducing labor

The way in which labor is induced depends upon the condition of the cervix. If your cervix isn’t favorable, or ripe (thinned out, soft, and dilated), your practitioner may use various medications and techniques to ripen it. Occasionally, ripening alone may put you right into labor.

A common misconception is that oxytocin makes labor more painful. It doesn’t. Oxytocin is similar to the hormone that your body naturally releases during labor, and it is administered in about the same doses that your body would produce to cause normal labor.

Augmenting labor

Doctors can also use oxytocin to augment labor that is already happening. If your contractions are inadequate or if labor is taking an unusually long time, your practitioner may use oxytocin to help move things along. Again, the contractions produced as a result of this augmentation are no stronger and no more painful than contractions occurring during a spontaneous labor.

Stages and Characteristics of Labor

Each woman’s labor is, in some ways, unique. An individual woman’s experience may even vary from pregnancy to pregnancy. Anyone who delivers babies knows all too well that labor can always surprise you. Your practitioner can track your progress through labor by performing internal exams every few hours. How easily you progress through labor is measured by how quickly your cervix dilates and how smoothly the fetus descends down through the pelvis and birth canal.

In the proceeding sections, we are going to explain the stages of labor.

First Stage of Labor

The first stage of labor occurs from the onset of true labor to full dilation of the cervix. This stage is by far the longest (taking an average of 11 hours for a first child and 7 hours for subsequent births). It is divided into three phases:

1. Early or Latent Phase

During the early phase of the first stage of labor, contractions occur every 5 to 20 minutes in the beginning, and they increase in frequency until they’re less than 5 minutes apart. During the early phase, your cervix gradually dilates to 3 to 4 centimeters and becomes 100 percent effaced. At the beginning of the early phase, your contractions may feel like menstrual cramps, with or without back pain. Your membranes may rupture, and you may have a bloody show.

Many women find walking around makes them more comfortable and distracts them from the pain during the early part of labor. Others prefer to rest in bed. Ask your practitioner whether your hospital has any restrictions on walking during labor.

2. Active Phase

The active phase of the first stage of labor is usually shorter and more predictable than the early phase. For a first child, it usually lasts 5 hours, on average. For subsequent babies, it lasts about 4 hours. Contractions occur every 3 to 5 minutes in this phase, and they last about 45 to 60 seconds. Your cervix dilates from 4 to 8 or 9 centimeters.

You may feel increasing discomfort or pain during this phase, and maybe a backache as well. Some women experience more pain in the back than in the front, a condition known as back labor. This may be a sign that the baby is facing toward your front rather than toward your spine. Your partner may help ease your pain by massaging your back, perhaps by using a tennis ball or rolling pin.

3. Transition Phase

Many practitioners consider the transition period to be part of the active phase, but we prefer to label it separately. During the transition phase, contractions occur every 2 to 3 minutes and last about 60 seconds. The contractions during this phase are very intense. Your cervix dilates from 8 or 9 to 10 centimeters. In addition to very intense contractions, you may notice an increase in bloody show and increased pressure, especially on your rectum, as the baby’s head descends. During this last phase of the first stage of labor, you may feel as if you have to have a bowel movement. Don’t worry; this sensation is a good sign and indicates that the fetus is heading in the right direction.

Potential problems during labor’s first stage

Most women experience labor’s first stage without any problems. But if a problem arises, the following information prepares you with the information you need to handle it with a clear, focused mind:

1. Prolonged latent phase:

The latent or early phase of labor is considered prolonged if it lasts more than 20 hours in a woman having her first child or more than 14 hours in someone who has delivered a previous child. Your practitioner may not be able to determine when labor actually starts, so knowing for sure when labor becomes prolonged isn’t always easy either. When a practitioner determines that labor is taking too long, he responds in one of two ways. One approach is to use medication, such as a sedative, to help you relax. Labor may then subside (which means that it was false labor all along), or active labor may begin. The other approach is to try to move labor along by performing an amniotomy (rupturing the membranes or breaking your water) or by administering oxytocin (Pitocin).

2. Protraction disorders:

Protraction disorders can occur if the cervix dilates too slowly or if the baby’s head doesn’t descend at a normal rate. If you’re having your first baby, the cervix should dilate at a minimum rate of 1.2 centimeters an hour, and your baby’s head should descend about 1 centimeter an hour. If you have delivered previously, the cervix should dilate at least 1.5 centimeters an hour, and your baby’s head should descend about 2 centimeters an hour. Protraction disorders may be caused by cephalopelvic disproportion, or CPD, which is the term for a poor fit between the baby’s head and the
mother’s birth canal. Protraction disorders may also occur because the baby’s head is in an unfavorable position or because the number or intensity of contractions is inadequate. In both cases, many practitioners try administering oxytocin to improve labor progress.

3. Arrest disorders:

Arrest disorders occur if the cervix stops dilating or if the baby’s head stops descending for more than two hours during active labor. Arrest disorders are often associated with CPD but an infusion of oxytocin may solve the problem. If oxytocin doesn’t alleviate the arrest disorder, you may need a cesarean section.

Second Stage of Labor

Labor’s second stage begins when you’re fully dilated (at 10 centimeters) and ends with your baby’s delivery. This part is the “pushing” stage and takes about one hour for a first child and 30 to 40 minutes for subsequent births. The second stage may be longer if you have an epidural. The second stage begins once the cervix is fully dilated, contractions are strong and regular, and the woman has the desire to push.

The baby rotates and the position of its head changes as it passes down the birth canal so that the widest part of its head is in line with the widest part of the mother’s pelvis.
Once the head has emerged, the baby turns again so that its shoulders can come out easily, one after the other.

As soon as the baby emerges, the umbilical cord is checked to make sure it is not around the baby’s neck, and mucus is cleared from the baby’s nose and mouth to aid the baby’s breathing. The birth typically lasts about one to two hours.

The second stage of labor is the birth, culminating in the emergence of a new human being. Great effort from the mother, together with strong, frequent contractions, are needed to push the baby down the birth canal.

Third Stage of Labor

The third stage occurs from the time of delivery of the baby to delivery of the placenta — usually less than 20 minutes for all deliveries. Within seconds of delivery, a series of events occurs, beginning with the baby taking its first breath. The umbilical cord is clamped and cut soon afterwards, and the baby can then begin to feed without being directly connected to the mother.

Vaginal birth after C-section (VBAC)

It was once thought that if you’ve had a C-section, you’ll always need to get one to deliver future babies. Today, repeat C-sections are not always necessary. Vaginal birth after C-section (VBAC) can be a safe option for many.

Women who have had a low-transverse uterine incision (horizontal) from a C-section will have a good chance at delivering a baby vaginally.

Women who have had a classic vertical incision should not be allowed to attempt a VBAC. A vertical incision increases the risk of a uterine rupture during a vaginal birth.

It’s important to discuss your previous pregnancies and medical history with your doctor, so they can assess whether VBAC is an option for you.

Assisted Birth

Situations in which help may be needed to deliver a baby include being overdue, slow progress during labor, fetal distress, or an abnormal lie. Assisted deliveries may be planned or are required urgently if problems arise before or during labor.

Inducing Labor

Induction of labor may be recommended if a pregnancy goes beyond 42 weeks, if labor fails to start after the waters have broken, and with certain medical conditions, such as pre-eclampsia.
A membrane sweep, in which the membranes are gently pulled away from the cervix, may be performed during a vaginal examination. Another method is to insert a pessary of prostaglandin into the vagina. If these methods fail, syntocinon (synthetic oxytocin) in a drip may help increase contractions.

Delivery by Forceps and Vacuum

Forceps or vacuum deliveries are used in about 5–15 per cent of births, for a number of reasons, but most commonly, fetal distress (usually indicated by the fetal heart rate) and maternal exhaustion after a labor of many hours. Either one of these methods may be used to help the delivery of a baby when it is low in the pelvis, but the cervix must be fully dilated so that the baby can pass through.

Forceps are similar to large salad servers, which come apart in two pieces but lock to avoid crushing the baby’s head during delivery. The ends are curved to cradle the baby’s head. The vacuum (also known as the ventouse) extractor has a suction cup, which is attached to the baby’s head. An episiotomy is necessary with a forceps delivery, but may not be needed for a vacuum extraction.

Caesarian Section

In a Caesarean section, the baby is removed from the uterus through an incision in the abdominal wall. There are a number of reasons why the vaginal route becomes impossible or undesirable. A
Caesarean may be planned, due to a non-urgent reason, for example if the mother is carrying twins, or it may be unplanned, due to an urgent reason, such as the development of fetal distress,
or a less urgent one, such as slow progress in labor. Before the operation, the abdomen is numbed, either by a regional anaesthetic (epidural or spinal), which leaves the mother aware, or by general anaesthesia, with the mother unconscious.

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