Labor and Delivery Overview

Preparing for Labor

The things you do for yourself and your baby during your pregnancy are very important. Preparing for labor is one of the most essential. Below is a list of some of the many things you may want to consider as you plan for your labor and delivery.

• Choose a healthcare provider who has the same goals and philosophy that you do. You may be able to choose a physician or certified nurse midwife.
• Enroll in childbirth classes through a private institution or with your healthcare provider. These classes will give you the opportunity to meet with other expectant parents, learn breathing and relaxation techniques, and learn what you may expect during labor, delivery and the immediate post partum period.
• A doula is someone you can hire to help you during labor and delivery. He or she provides emotional and physical support and coaching.
• Choose a birthing facility. Your choices may be limited by where your healthcare provider practices. However, you may have an option between a traditional hospital, or a birthing center.
• Discuss with your healthcare provider when you should notify them if labor begins and when you should go to the hospital. Be prepared to time your contractions.
• Determine the quickest route to the hospital. Anticipate potential delays, such as road construction, traffic, and the weather conditions.
• If necessary, make arrangements for someone to take care of your other children and pets.
• If the hospital/birthing facility allows it, prepare any photo/video equipment you may want to take with you.
• Prepare a suitcase of necessities to take with you. You will need a robe, toiletries, and clothes for leaving the hospital. You will also need clothes, blankets, a hat, and a car seat for the baby.

The Stages of Labor

Stage 1 - Effacement & Dilation of the Cervix

The first stage of labor is divided into three phases: latent, active, and transition. Many physical and emotional changes occur during this stage.

The latent phase is usually the longest. It may last for many hours and usually begins with irregular contractions. During this phase, contractions gradually become more frequent, and more intense. The cervix begins to dilate to 3 centimeters and effacement, or thinning, occurs. Other symptoms you may experience include bloody show (an indication that the cervix is dilating), menstrual-like cramping, backache, diarrhea, or rupture of the amniotic membrane ("bag of water").

Although you will be very excited, try to relax and stay calm. You may not need to hurry to the hospital. However, you probably will want to call and let your healthcare provider know what is happening and how you are feeling. He or she can help you decide when it is time to go to the hospital. Try to stay as comfortable as possible.

The active phase is characterized by dilation of the cervix from 4 cm - 7 cm. Contractions are usually more intense, 3 to 5 minutes apart, and lasting for 40 - 60 seconds. You may find that you become more fatigued and restless, as it becomes more difficult to relax. If you haven't already, you will probably want to go to your birthing facility. Follow the advice of your healthcare practitioner.

During the active phase, many women find that they need to use the breathing and relaxation techniques learned during childbirth classes. If you find that those techniques are not working for you, look for other ways to help you relax and become more comfortable. The birthing staff at your facility can assist you.

During the transition phase, the cervix dilates from 8cm to 10cm. Contractions usually occur every 2 - 3 minutes and last 60 - 90 seconds. You may begin to feel strong pressure in your lower back, rectum and/or the perineum. You may experience nausea, cramping in the legs, exhaustion, and an urge to push. Let your healthcare provider know if you have any of these complaints. They will let you know when it is OK to begin pushing.

You may feel overwhelmed and discouraged, and easily irritated. It may be difficult to concentrate on the task at hand. This is a good time to remind yourself of how far you have come and how soon your baby will be born. Continue to use your breathing/ relaxation techniques and remain calm.

Stage 2 - Pushing

When your cervix is completely dilated (approximately 10 cm), your healthcare provider and the birthing staff will assist you with pushing. Your contractions may become slightly further apart, to allow you time to rest between. The urge to push may become stronger as the baby begins to move down the birth canal. As the head crowns out of the vaginal opening, you may feel a burning or stinging sensation.

Emotionally, you may finally feel relieved, and a new sense of energy at the prospect of seeing your baby soon. If your labor is long, you may be preoccupied with getting through the delivery process. This is a normal, temporary reaction.

Listen to instructions from your healthcare provider and birthing staff regarding pushing. Rest between contractions and gather your strength for the next pushes. Before you know it, your baby will be born.

Stage 3 - Delivery of the Placenta

After the baby is delivered, and the umbilical cord is cut, you will feel a few more mild contractions. These contractions are necessary for the placenta to separate and be delivered. Any episiotomy or tears that occurred during the delivery will be repaired. While still in the delivery room, mother and baby will receive matching identification wristbands.

After Delivery

Following delivery, the newborn will receive a thorough physical examination. This may occur in your room or in the nursery, depending on where your deliver, and your wishes. Eye drops or ointment may be applied to your baby's eyes to help prevent infection.

You will have a vaginal discharge, called lochia, which is similar to your menstrual flow. It usually lasts 2-4 weeks and changes in color and amount. Most women continue to experience mild uterine contractions for several days after birth, as the uterus begins to shrink down to its pre-pregnant size.

Monitoring of Mother and Baby During Labor

Electronic Fetal Heart Rate Monitoring

Continuous electronic fetal heart rate

monitoring (EFM) is common during labor and delivery in the U.S. It is estimated that 3.3 million babies (of 4.0 million annual births) were monitored with this technique in 1998. Fetal heart rate monitoring gives important information to the obstetric care providers about the baby's heart rate and the mother's uterine contractions.

There are two types of continuous electronic monitoring, external and internal. In the external mode, small sensors called transducers are placed on the abdomen. One is an ultrasound transducer, which detects the baby's heart rate. The other transducer is pressure-sensitive and records how often the contractions occur and how long they last. Both of these external transducers are held in place by cloth or elastic belts, which go around the abdomen. These belts are only used to hold the transducers in place and do not limit movement. The other type of electronic monitoring is called internal monitoring. The internal mode uses two small devices. The first is called a spiral electrode, which is attached to the baby and tracks the baby's heart rate. Internal monitoring of uterine contractions is done by using a soft, thin plastic tube, which is placed through the vagina into the uterus. This internal catheter, known as an intrauterine pressure catheter, measures the actual strength of the contractions in addition to recording how often the contractions occur and how long they last. Readings from either external or internal sensors are processed by the fetal monitor and continuously recorded on a paper strip, which may be reviewed by the obstetric healthcare team.

In many situations, it may be possible to monitor the baby's heart rate intermittently, either with an electronic fetal monitor or a machine called a Doppler. Occasionally, an instrument that looks like a stethoscope called a fetoscope may be used to listen to the fetal heart rate.

Fetal Oxygen Saturation Monitor System

Although electronic fetal heart rate monitoring is safe and has been used routinely for over 20 years, it does not always provide a clear picture of a baby's condition when certain heart rate patterns are present. Sometimes, non-reassuring patterns are a sign of stress in the baby. However, in other situations, the baby is doing fine and has an adequate supply of oxygen even though there may be a non-reassuring heart rate pattern on the monitor strip. The only way to directly measure the baby's oxygen level during labor is to use a fetal oxygen saturation monitor such as the OxiFirst ™ system. When used along with electronic fetal heart rate monitoring, fetal oxygen monitoring provides additional information about the baby's condition. Fetal oxygen monitoring is a relatively new technology which has been proven to permit the safe continuation of labor during periods of non-reassuring fetal status.

The technology used in fetal oxygen monitoring is similar to conventional pulse oximetry, which has been in used routinely in infants, children, and adults for almost 20 years. If additional information about a baby's oxygen status is needed during labor, a flexible oxygen sensor may be inserted through the birth canal to rest on the baby's cheek or temple. The sensor is noninvasive to the baby, meaning that it does not go through the baby's skin. The sensor is connected to a monitor, which displays the baby's oxygen saturation level. If the baby's oxygen saturation levels are in the normal range, the physician or midwife can use this information to manage your labor. The readings are a line on the uterine activity area of the fetal heart rate strip.

In order to place the fetal oxygen sensor, the cervix must be dilated to at least 2 cm. In addition, the fetal oxygen sensor should only be used after maternal membranes (bag of water) have ruptured and on a singleton fetus in vertex (head down) presentation with a gestational age greater than or equal to 36 weeks. Occasionally, a small red mark may be noted on the baby at the place where the oxygen sensor was resting during labor. This mark is similar to the impression that may be left by a watch, and will usually go away within a few hours if it is present.

Fetal Scalp Blood Sampling

If a non-reassuring fetal heart rate pattern is present, and if the physician or midwife is concerned about the baby's oxygen status, a fetal scalp blood sample may be obtained. To obtain a scalp blood sample, a speculum is placed into the birth canal so that the baby's head is visible. A small incision is then made in the baby's scalp. A tiny sample of blood is then taken and the blood sample is sent to the laboratory for evaluation of the pH status. Based on the results of this test, a physician may determine that prompt delivery of the baby is necessary. If the test is reassuring, the labor may continue. However, the test must often be repeated if certain non-reassuring fetal heart rate patterns continue.

Fetal scalp blood sampling is not a common procedure in the United States. However, it is still practiced in certain regions of the country and in some hospitals overseas.

Assisted Vaginal Delivery

Forceps Assisted Vaginal Delivery

If the mother is unable to push effectively due to exhaustion or other reasons, a forceps assisted delivery may help deliver the baby. However, forceps may also be used in certain situations that would not be appropriate for a vacuum-assisted delivery (see below). Obstetric forceps are tong-shaped metal instruments which resemble large salad spoons. In 1998, it was estimated that forceps were used to assist with 2.6% of all live births in the U.S. There are two pieces to each pair of forceps, applied to the baby's head one side at a time. Once the forceps are in the proper position (usually around the baby's cheeks and temples), the physician applies gentle traction (usually while the mother pushes during a contraction) to help guide the baby down the birth canal.

Vacuum Assisted Vaginal Delivery

A vacuum assisted delivery is generally used for the same reasons that a forceps delivery may be chosen. In 1998, it was estimated that 6% of U.S. births were assisted with the use of a vacuum device.

The vacuum system is composed of a cup, a traction system, and a vacuum pump. The vacuum cup is placed gently on the baby's head. After making sure that the cup is placed in the proper position, it is then attached to either a handheld device or a suction system that creates a vacuum suction. The vacuum suction, along with gentle traction by the physician or midwife, helps to assist the baby's descent down the birth canal. In order to properly use a vacuum device, the mother's cervix must be completely dilated, and the baby's head must already be near the entrance to the birth canal.

Cesarean Births

Overview

A cesarean birth is an operative procedure by which the baby is delivered through an incision in the mother's abdomen. About 22% of babies are born via cesarean in the U.S., which makes this procedure the most common type of surgery in America. A cesarean delivery may be performed for an elective reason (a mother or physician's preference), a previous cesarean birth or a twin pregnancy. The procedure may also be indicated if complications arise during labor such as a non-reassuring fetal heart rate pattern, or if the cervix does not dilate completely. While cesarean delivery is a routine operation, there are risks (as with all surgeries). However, these risks may be outweighed by the potential benefit to the mother or baby. The decision to perform a cesarean delivery should be discussed and made by you and your physician.

Types of cesarean incisions

There are two common types of incisions in the uterus used for cesarean delivery. The lower uterine segment transverse incision, or "bikini cut", is characterized by a sideways incision in the lower part of the womb. It is the most common type of cesarean incision. However, in certain situations, other types of incisions may be preferred. Women who have undergone a cesarean delivery with a bikini cut incision in the uterus may be offered the opportunity to try to deliver vaginally with subsequent pregnancies (VBAC - Vaginal Birth After Cesarean).

A classical cesarean delivery is characterized by a vertical (up and down) incision in the upper part of the uterus. Certain situations make the classical route the incision of choice, such as when the baby is premature and breech (buttocks or feet first) or when the mother has had a prior classical cesarean birth. Women who have had a classical cesarean delivery usually undergo a repeat cesarean delivery with all subsequent pregnancies.

Factors Influencing Cesarean Births

Non-reassuring Fetal Heart Rate Patterns

The baby's heart rate pattern provides important information on how the baby is tolerating labor. If certain signs are present on the fetal heart rate tracing, it is considered reassuring. In this case, your physician or midwife is generally reassured. However, in the case of certain non-reassuring (or abnormal) fetal heart rate patterns, the obstetrical team may look for ways to reassure themselves of the baby's status. The baby may be fine, or may be not getting enough oxygen. In addition to electronic fetal heart rate monitoring, a clinician may choose to use other techniques to determine if the baby is tolerating labor. For example, he/she may use a technique called scalp stimulation. This is a simple technique in which the clinician uses a gloved finger to gently rub or tickle the baby's head. Usually the baby responds to this stimulation. They may also use vibroacoustic stimulation. Other techniques of determining if the baby is getting enough oxygen include those mentioned above such as fetal scalp blood sampling or fetal oxygen saturation monitoring. If a non-reassuring fetal heart rate pattern continues, and without confirmation that the baby is adequately oxygenated, many physicians will encourage cesarean delivery. Of all cesarean deliveries performed in the United States, 11.8% are done for the indication of non-reassuring fetal status.

Breech Delivery

A baby is in a breech presentation if the buttocks or feet are coming out first. There are three different types of breech presentations: frank breech, complete breech, and footling or incomplete breech. A frank breech presentation is when the baby is curled up in half and the feet are up near the baby's head. In a complete breech presentation, the baby is in a "squatted" position. When one or both of the baby's feet are presented first as the baby descends through the birth canal, the baby is in the footling breech or incomplete breech presentation. Some healthcare providers will consider assisting with a vaginal breech delivery, depending on the size of the baby, the type of breech presentation, and the progress of labor. However, cesarean births are more common than vaginal deliveries in the U.S. when the baby is in the breech presentation. Of all cesarean deliveries performed in the United States, 18.2% are done for breech delivery.

Labor That Does Not Progress (Dystocia)

Continued dilation of the cervix and descent of the baby down the birth canal over time typify a labor that is progressing. Ineffective uterine contractions, small pelvic size, and a large baby are just some of the factors that can lead to an abnormal progression of labor. Dystocia or dysfunctional labor are the words often used to describe a labor that does not progress. If a labor is not progressing as expected and if the baby is tolerating labor well, a medication to stimulate stronger contractions may be administered. Sometimes when labor does not progress in spite of adequately strong contractions, the healthcare provider may suggest a cesarean delivery. Of all cesarean deliveries performed in the United States, 9.8% are done for the indication of dystocia.

Repeat Cesarean Delivery with Subsequent Pregnancies

For years, it was believed that once you had a cesarean, you would always have a cesarean for future pregnancies. However, due to the increase in "bikini cut" or low transverse incisions in the uterus over the past several years, many women with prior cesarean incisions are encouraged by their healthcare providers to undergo a trial of labor with subsequent pregnancies. If the trial of labor is successful, the woman may have a Vaginal Birth After Cesarean ("VBAC"). If a mother has had a previous cesarean delivery, she may wish to discuss VBAC with her healthcare provider to see if it is right for her.

Demographics

Women who are becoming pregnant at a later age tend to have a higher risk of complications than do younger women. As a result, cesarean birth rates are known to increase with maternal age. In 1998, pregnant women between the ages of 40 - 54 years were twice as likely than pregnant women between 15 - 19 years of age to have a cesarean birth.

Medical Conditions of the Mother and/or Baby

Certain medical conditions in the mother or baby mean that a cesarean delivery may be considered safer than a vaginal delivery. For example, if the mother has active genital herpes, a cesarean delivery may be better for the baby than a vaginal delivery. Another example would be if the baby has a condition known as hydrocephalus. In this situation, it may be safer for the baby to be delivered through an incision in the mother's abdomen rather than to pass through the birth canal.

References:

References:

1. Ventura SJ, Martin JA, Curtin SC, Mathews TJ, Park MM. Births: Final Data for 1998. National Vital Statistics Reports. 2000; v48, n3.

2. Eisenberg A, Murkoff HE, Hathaway SE. What to Expect When You're Expecting. 1996.

3. May KA, Mahlmeister LR. Maternal & Neonatal Nursing: Family-Centered Care. 1994.

A special thanks to Marti Letko Porter RNC MS MBA, Leslie Gardner MSN RNC PNNP and Nancy Townsend RN MSN for their significant contributions.