Babies Tale

During labor the cervix thins and softens and then dilates to allow the baby’s head to pass through the birth canal. When the cervix is fully open it is considered “10cm dilated.” This marks the transition from the first to the second stage.

But before we get to that what are the signs and symptons the expecting couple can appreciate as the first indications that the birth of your child is near. These may be:

* Note that all women do not experience all of these signs; the most important ones are the last two. The others are more like warning signs that labor is coming soon.

During the first stage of labor, the cervix thins and softens and then dilates to allow the baby’s head to pass through the birth canal. When the cervix is fully open it is considered “10cm dilated.” This marks the transition from the first to the second stage.

Once labor has begun, contractions tend to become stronger as labor progresses, though they tend not to get closer together than about every three minutes. This means you usually get a break in between to recover from each contraction before the next one begins. Progress is not always uniform; occasionally contractions seem to run into one another, and sometimes a very strong contraction will be followed by a weaker one.

Once the woman is fully dilated, she may experience some strange symptoms. Shivering, trembling, sweating or nausea is all common. Some mothers feel restless and want to change position, often into the position in which they want to deliver the baby. At the end of each contraction the mother may begin to feel that she wants to bear down and begin to push the baby out. When the healthcare professional sees these signals, she will probably want to do an internal exam and check that you are fully dilated. If so, you are ready to begin the second stage. If you are not quite fully dilated, the nurse or midwife may ask you to “pant” during the contractions to help you resist the urge to bear down.

The Second Stage of Labor

Most women having an active labor find that the pushing sensation is a reflex and they can’t stop themselves. Usually women know instinctively to take a deep breath, lowering the diaphragm and putting pressure on the uterus. A series of short pushes at this time can be more effective than one long push. An upright or semi upright position is helpful in promoting the process; if you are lying down you actually have to push the baby uphill because of the angle of the birth canal. Most women also instinctively push with each contraction and rest in between.

With each contraction the baby should descend lower into the birth canal. At some point the baby’s head will become visible from the outside (crowning); this is an exciting moment for a partner or birth companion who is present. The mother can be encouraged to know that the baby is really there and about to be born. Just before the birth, the perineum begins to stretch to its widest. This can cause a stretching and stinging sensation. If you seem likely to tear, an episiotomy may be made (see page 116); otherwise the tissues become numb when stretched further. Once the baby’s head has crowned, it will slip out; another contraction should deliver the shoulders and then the rest of the baby.

When the baby is born it may look strange; somewhat gray colored and slimy with vernix and some blood. (Vernix is a waxy substance that helps protect the baby’s skin from fluids in the amniotic sac.) When the baby draws breath-and usually cries loudly-the color will change to a healthier pink. If the baby is breathing normally you will be able to hold your baby, discover whether it’s a boy or girl, count the fingers and toes and begin to get to know one another. Some mothers will want to put the baby straight to the breast.

The Third Stage of Labor

This is the delivery of the afterbirth. This stage may take up to 30 minutes. The umbilical cord, its job done, may be pulled gently, and the doctor or midwife may press her hand on your abdomen to assist delivery of the placenta. The uterus continues to contract. Your abdomen may be massaged to help the process along. If bleeding is heavy, you may receive medications in an effort to reduce the risk of postpartum hemorrhage.

Soon after the birth is a good time to put the baby to the breast for the first time, because research has shown that the sooner after the birth a baby feeds, the more likely it is that breast-feeding will be successfully established. In nature, the baby’s sucking at the breast helps with delivery of the afterbirth. Not all mothers and babies are ready for a breast-feed, however, so don’t feel rushed; take the time you need to get to know one another.

This is an artificial way of starting labor. Labor may be induced if all indications are the baby is overdue or if there is some need to deliver the baby early. Normally you will not be allowed to go much more than two weeks past your due date if the dates are firm and have been confirmed by ultrasound. There is some risk that the placenta will not be functioning as well by then. This is a particular risk in older mothers. Induction doesn’t always work. Then the mother may be under pressure to have a Cesarean.

“They took me in when the baby was due and said they’d like to induce me. They said that the placenta fails quickly in older mothers and I was 47. They said there was no sign of placental failure, but that this was a fact. They tried to induce me and it failed. The next day they tried again, but the doctor said, ‘Let’s do a Cesarean, we want a healthy baby.’ So they did.”

Tests can be done to find out that the placenta is working normally. You may also be asked to keep a record of the fetus’ movements. If there is evidence the baby is not growing well, that fetal movements are becoming infrequent or the mother is suffering from high blood pressure, then induction will almost certainly be recommended. By this time, many women are quite willing for the birth to be induced:

“The last few months of pregnancy I was in and out of the clinic having tests. I had an agonizing pain under the ribs, which I knew was from the baby, but they wanted to be sure it wasn’t something else. I felt incredibly tired-I couldn’t cope with the pain and not sleeping-so they decided to induce the birth. I was happy about that. But when I went to the hospital they told me I was too tired to cope with labor-to go home, rest for a week, not do anything. ‘Then, if the baby doesn’t come, we’ll induce it next week.’”

Labor can be started artificially in several ways. The membranes containing the waters can be broken if the baby is overdue or near term. This usually starts labor. But if it doesn’t, other intervention will be needed. That’s because if the baby isn’t delivered within 24 hours after the waters have been broken, he or she is at risk of infection. An artificial rupture of the membranes (ARM) or amniotomy is performed with an instrument that looks like a long crochet hook. This procedure is normally painless. The technique is also used to speed up labor. Once the waters have broken, the baby’s head, unprotected by the bag of waters, presses harder against the cervix, encouraging the uterus to contract. The contractions will become much stronger and you will also feel some of the waters gushing out with each contraction.

Prostaglandin suppositories may be used to start labor. These are usually inserted into the vagina. The effect of the hormones close to the cervix is to trigger labor. A man’s sperm contains prostaglandin, which is why women at risk of a premature birth should avoid full sexual intercourse and why one of the best natural ways to induce labor is to make love. A prostaglandin induced labor works well because, once started, it can proceed without further intervention.

If labor does not start in any other way, an oxytocin drip is used. Oxytocin is the hormone that naturally causes the contractions of labor. Various artificial forms of oxytocin can be used. (The trade name is Pitocin’v.) A drip is inserted into your arm-you can ask to have it put into the arm you use least. You can also ask to have a long tube connecting you to the drip so you can move around and change position as much as possible. Contractions caused when you are on an oxytocin drip are usually stronger, longer and more painful. You may also find that you are plunged into the height of labor without having time to adjust to gradually increasing contractions. This can make the pain more difficult to cope with. In fact, pain relief is often necessary in these circumstances. This in itself can lead to further intervention.

Normally the baby is born with the head down, facing backwards, so the widest part of the baby’s head passes through the widest part of the pelvis. The baby’s head pressing down on the cervix helps it dilate, and the baby rotates as it is born, helping the body slip out behind the head.

Some babies, however, are born in a different position. This normally causes problems in labor. A posterior presentation means that the baby faces forward; its spine can press against the mother’s as it moves down, causing her pain and slowing labor. And because the widest part of the baby’s head is passing through the narrowest part of the pelvis, the baby can get stuck here more easily, again prolonging labor and sometimes requiring the use of forceps.

A breech birth occurs when the baby does not turn, so that the head is not born first; breech babies are normally born buttocks-first, occasionally feet-first. About four births in a hundred are breech. Most breech births are straightforward, though you are most likely to need intervention, especially in a first birth. Many women are advised to have an epidural; usually the baby’s head is delivered with forceps to protect it, and you are likely to have an episiotomy to help the baby’s head out. If you wind up needing an emergency Cesarean, the epidural will already be set up.

Medical Intervention

Over the past decade or two, hospitals have increasingly used a variety of techniques that have revolutionized the process of childbirth. Most of these are intended to save lives, and frequently they do. However, many interventions have become routine in some hospitals, thus interfering with the birth process for many mothers who are not at risk. Hospitals are now more likely to discuss any possible intervention with you. You should make your views clear, although obviously everyone involved should accept that intervention may be necessary in case of an emergency.

Episiotomy

An episiotomy is a small incision made in the perineum, the skin between the vagina and the anus, to enlarge the vaginal opening and help the delivery of the baby’s head. The cut is made with scissors under a local anesthetic when the baby’s head comes into view. Done properly, the perineum will have stretched very thin and the cut can be made with a minimum of damage and bleeding. An episiotomy should not be necessary in a normal delivery, and you can ask not to have one if you prefer.

However, there is some controversy over whether it is better to have a small episiotomy or risk tearing the perineum when the baby’s head is born. Some feel that a small tear is better and heals more rapidly, while others believe it is easier to sew up a clean cut. You should not be in great pain when the stitches are put in; if you are, ask to have more local anesthetic.

Once settled in at the hospital, you will find a routine for handling contractions, perhaps based on what you learned in childbirth classes. For example, the following is a routine that many women learn and use successfully with their contractions.

1. Greet the contraction with a long sigh. As you breathe out, release all bodily tension.
2. At the same time, focus your attention in some way [for example, focus on you partner’s face or a picture or object of your choice, close your eyes and “see” your cervix opening as your uterus contracts;” see” a peaceful, relaxing place and picture yourself there; focus on music of your choice, or the soothing voice of your partner; or focus on the feel of your partner holding or stroking you].
3. Breathe slowly and easily.
4. Maintain relaxation throughout the contraction. Stay limp. It may help if you focus on one part of your body with each breath out. Try to release tension in that part as you breathe out. Then focus on another part with the next breath.

You can follow this routine with every contraction and in any position-lying down, sitting, standing, on hands and knees. You can do it in the tub or shower, in bed, in the car, in a chair, in the hospital corridor, or in your room. You can lean on your partner, the wall, or your bed.

These techniques are often effective in keeping pain within manageable limits for part or all of your labor. Women who use them generally need less pain medication than others. Indeed, some women do not need to use any pain medication when using these techniques.

Some women learn several types, or levels, of breathing to use progressively during labor. Besides the slow pattern just described, they may learn a lighter, faster, but still relaxing pattern and other variations.

Besides using a routine for each contraction, you should try and change position every twenty or thirty minutes, go to the bathroom every hour or so, and sip liquids or suck on ice after every contraction. These measures may be comforting.

You may find that hot packs on the lower part of your abdomen, your groin, and your perineum [external genital-rectal area]; cold packs on the lower part of your back; and a cool, moist washcloth rubbed over your face and neck will all feel wonderful. Being rubbed and touched, especially in tense, sore areas, such as the shoulders and lower part of the back, helps a lot if you feel a bit out of control. It helps if your partner holds you lightly or gently but firmly holds your head in his hands.

During intense periods, like the “transition” phase [from about seven to ten centimeters of cervical dilation] you may feel almost out of control. You may feel that your body is running away with you, and you are being swept along in a tide of intense sensations. Fighting these sensations is pointless.

However, you may feel an urge to push but be told that you are not yet fully dilated. It is important that-for the time being-you resist the urge. Pushing too soon could injure the cervix and perineal tissues and lead to heavy bleeding. What helps the most is knowing that there is nothing wrong. Let it happen-accept that your body is in charge, and don’t try to stay “in control”. Let your loved ones help you, moan and complain if you want to, you know that it will not last long.

Labor is described as having three stages; the first stage, from the onset of progressing labor contractions until the cervix is completely dilated; the second stage, from complete dilation of the cervix until the baby is born; and the third stage, from the birth of the baby until the placenta is expelled.

A fourth stage, from after the delivery of the placenta until the mother’s medical condition is stable and safe, is also frequently mentioned.

The First Stage

The first stage is almost always the longest [two to twenty-four or more hours], usually starting slowly and then speeding up when the dilation of the cervix reaches four or five centimeters. Your contractions may not be clear and strong at first, but they will become longer, stronger, and closer together with time.

Much of your time in the first stage may be trying to figure out if you are in labor or not. It may be exiting and fun for you, or it may be a little scary. After all, this is the moment you’ve been waiting for, learning about, preparing for and dreaming of.

It is a mistake to become preoccupied with labor. If you can be distracted from your contractions, it is very unlikely that you are in very advanced labor [On rare occasions, women have been unaware of labor until the baby was about to be born! In these cases, there is no way to prevent a hectic scene unless a woman has had such a birth previously. Then she should watch carefully for any sign of labor-subtle, preliminary, or absolutely clear-and call the doctor immediately].

As labor progresses, there is no longer any question whether you are in labor. It quickens its pace and the contractions usually become painful. Once certain that you are in labor, go to the hospital or birthing center [or if the birth is to be at home, await your care-giver’s arrival]. Of course, if you have any concerns or medical problem, feel free to go to the hospital. Be sure to take your bag and needed items on hand.

You may become serious and quiet, focused on only one thing-your labor. Jokes are not funny, world events lose their importance. You need support, encouragement, help, and comforting gesture from your partner, doctor, and nurse.

You will probably have emotional ups and downs throughout labor. You may feel discouraged and may weep from time to time, but if you accept labor as it comes and understand what is happening and what to expect, you will be able to recover from these down periods and go on.

Arrival at the Hospital

On arrival, your first stop is usually the admitting office., where you are asked to read and sign forms and indicate how you will pay for your hospital stay. However, since hospital procedures vary considerably, prior to going into labor it is a good idea to check with your hospital regarding their admitting policies-especially for late night and weekend admissions.

From there you go to the maternity ward, where a doctor or nurse greets you, does a quick health check on you, assess your contractions and the baby’s condition, and does a vaginal exam to establish how far along you are in labor.

From then on, hospitals vary in their routine care for labor. The following chart describes common procedures. Feel free to discuss these procedures in advance with your doctor and express your preferences.

Besides the routines described in the chart, your nurse or doctor periodically takes your temperature and blood pressure and , if an electronic fetal monitor is not being used, listens to your baby’s heartbeat and feels your abdomen during contractions to determine how labor is progressing. He or she also stays close by, offering encouragement, comforting you and answering questions.

The changes taking place in your body, placenta, and baby during the last three months of pregnancy accelerate at the end, culminating in labor. As the placenta ages and gradually loses its ability to maintain the pregnancy, the baby becomes strong and capable enough to survive outside the mother’s body; the uterus begins to let go and expel the baby; and the mother becomes ready to give birth and to feed and nurture her baby. Labor consists of rhythmic uterine contractions, which open the cervix and press the baby down through the birth canal and out of your body. The uterus is a big, long hollow muscle; when it contracts, it tightens and hardens. This may happen anywhere from twenty-five to three hundred times during labor, which may take anywhere from a few hours to more than a day. The process not only involves your uterus, but your entire body and mind; all your energy is devoted toward the one goal of giving birth to your baby.

How will you know when you are in labor? As basic as this question is, it is one of the most difficult to answer. It usually takes hours or even days to figure out whether your sensations are labor or something else [pre-labor or false labor]. This is because labor does not begin suddenly. It evolves gradually. At some point, you or your doctor will recognize that these sensations are true labor, meaning that they are accompanied by increasing dilation of the cervix.

The signs of labor may be divided into subtle signs, preliminary signs, and absolutely clear signs.

If you are within a week or two of your due date, you generally may wait until you have an absolutely clear sign of labor before going to the hospital, although your doctor may ask to let him or her know if your bag of waters [amniotic sac surrounding the baby] seems to be leaking. If your pregnancy has been complicated by diabetes, high blood pressure, or other medical conditions, or if you have twins or a breach fetus, your doctor may advise you to go to the hospital with the onset of preliminary signs. If you are several weeks before your due date, you should notify your doctor if you have any preliminary signs, because they could indicate early or premature labor. Premature labor can be stopped if treatment has begun early enough.

To determine whether your contractions are progressing [that is, becoming longer, stronger, and closer together] , you need to time them. On a sheet of paper, list the time when the contractions begin, and how long they last. Time them in this way for an hour or two. If they are not progressing, stop for a while until they seem different, then try timing again.

You should call your doctor or your hospital’s labor and delivery ward to tell them you are in labor or to ask for advice. Be sure to report the status of your bag of waters; whether you have had a bloody discharge [called bloody show, which you will continue to pass while you are in labor]; how long and how many minutes apart your contractions are; and how strong and painful they feel to you.

The second stage ranges in length from fifteen minutes to three or more hours. The baby is born during the second stage.

When your cervix is fully dilated, the intense out-of-control feelings may subside. The contractions seem to space out somewhat, and you may even get a short break from contractions [this is more likely with first time mothers]. It is always wonderful news when you are told that your cervix is fully dilated and you can begin pushing whenever you feel like it.

During the second stage, you may behave differently than in the first stage. You may find yourself holding your breath or slowly letting it out, while bearing-down [something like, but much more than, what you do when having a bowel movement] and releasing your pelvic floor [relaxing the muscles in the area around your vagina]. This last is most important, because tensing the pelvic floor is actually fighting against the birth of your baby-and it hurts much more than letting go.

You will probably notice a real change in your contractions in the second stage. Most contractions will contain a reflex need to strain or grunt, called an “urge to push”, which comes and goes three to five times per contraction. With each urge to push, the combination of the uterine contraction and your bearing-down effort pushes the baby closer to the outside. It is hard work and it hurts, but it is also an exciting time with lots of cheering and praise for your efforts. Most women find they have the strength to keep pushing.

The best way to push is to push only when your body makes it happen-only when the urge to push comes. That way you won’t hold your breath so long that you or the baby gets too little oxygen. The following is a routine many women use during second stage contractions.

1. Get the contraction with a long breath, and curl your body forward whether you are reclining, lying on your side, squatting, or even sitting on a toilet or birthing chair.
2. Breathe as you did in second stage contractions.
3. When you feel the reflux urge to push [it is unmistakable], follow it by grunting or holding your breath and bearing down. You will need reminders to relax your pelvic floor. The urge to push will go away after a few seconds. Then breathe again until the urge returns. Repeat until the contraction ends.
4. Relax or change positions between contractions.

Positions for the Second Stage

Unless the baby is coming fast, you will have time to change positions. Many childbirth educators encourage women to learn to squat comfortably before labor because this is such a helpful position for the second stage. When you squat, you are giving the baby more room to come down through your pelvis than in other positions. Sitting on the toilet may help if you have trouble relaxing your pelvic floor.

Lying on your side is a good position if the baby is coming fast, if you have painful hemorrhoids, or if you must lie down for some reason. Resting on your hands and knees may help if the baby is large or is having a slowing of the heartbeat during contractions. Semi-sitting is a good position because you can see your doctor and the baby as he comes out. It is also a convenient position for your doctor.

Lying on the back with the legs up in stirrups [the lithotomy position] used to be the way all women gave birth. Most women disliked the position. Their objections to it, plus the fact that it sometimes caused slowing of the baby’s heartbeat and other problems for the mother, finally led to its being discontinued as a routine position by most midwives and many physicians. It is still used however, particularly in anesthetized births and deliveries assisted with forceps or vacuum extraction.

You may use several positions during the second stage, ending with semi-sitting or lying on your side for the actual birth. Discuss positions for the second stage with your doctor in advance.

If you know in advance you are going to have a Cesarean, you can plan for it. You can choose to have the operation done under an epidural anesthetic. That way, you can see and participate in the birth and see or hold your baby as soon as he or she is born. Your husband or partner is also likely to be present for the entire operation. You can make plans for the extra support you will need when you come out of the hospital. If the operation is done as an emergency, however, you are likely to be given a general anesthetic, because setting up an epidural takes time. Your partner may not be able to be with you. In addition, you are likely to suffer aftereffects of the anesthetic, making it more difficult to bond with your new baby right after birth.

A typical Cesarean section usually takes about 45 minutes from start to finish. The baby is delivered in the first 5 to 10 minutes, and the rest of the operation is concerned with stitching you up. The surgeon makes a cut about 12cm long, usually horizontally and just below the “bikini line.” He or she then cuts horizontally through the lower part of the uterus, where there are no main blood vessels. The bag of waters may break of its own accord or have to be broken, and the fluid is sucked away. The surgeon then puts his or her hands into the uterus and rotates the baby’s head so that it appears in the incision. The surgeon helps deliver the baby’s head using his or her hands, or sometimes forceps, and an assistant usually presses gently on the top part of the uterus. A drug to make the uterus contract and stop any bleeding is given, and the rest of the baby is brought out. Then the placenta is delivered. Next, the uterus is sewn up and then the abdominal wall.

Although the Cesarean section is a very safe operation, it is major surgery. The risk of complications, although small in this case, exists wherever surgery is concerned. Many women experience a lot of postoperative pain and may find they cannot get comfortable for breast-feeding. Mothers often find it takes them longer to bond with their baby because they feel so uncomfortable in the days following the delivery:

“Having a Cesarean leaves you so incapacitated that it takes much longer to do things for the baby. Everything the baby does makes you feel so uncomfortable-lifting, feeding-and you are tied down with drips and bottles draining the wound for two days. Your mind is geared to you and not to the baby-it is harder to bond. Because of this I really appreciated the time I had with her at the beginning. My Cesarean was planned, so it was done with an epidural and I was awake. She was born onto me, although I couldn’t feel it. I was able to hold her right away. I was able to think, ‘This is my baby, all right,’ and the three of us had about 1-1/2 hours together after the birth. Without that I think it would have been really hard.”