Breech Babies

Approximately 4% of babies will enter the last month of pregnancy in the breech presentation. When the baby is in the breech position, the obstetrician may attempt to turn it to the head down position. This turning is known as version.

The idea behind version is quite simple. The obstetrician attempts to manipulate the baby to shift into a more favorable position. Usually that means encouraging the baby to perform a forward somersault, changing direction 180 degrees. If the version succeeds, the head will become the presenting part, and vaginal delivery will be much more likely and safer.

Unfortunately, version is not appropriate in all situations and is not without risks. It is appropriate only in a single pregnancy where the position of the baby can be accurately diagnosed (usually by ultrasound). It is not appropriate for multiple pregnancies. The baby should not be unusually large and the presenting part should not be deep in the pelvis. Also, there must be a normal amount of amniotic fluid. All these conditions ensure that the baby has room to turn and will not be injured by the manipulations of the obstetrician's hands. In addition, a non-stress test must be reactive (indicating fetal well-being), and there should be no signs of placental problems (for example, low fluid, growth retardation, or vaginal bleeding). Version may represent a stress to the baby, and if there is evidence that the baby is not receiving adequate oxygen and nutrients at rest, it should not be attempted.

Version must be performed at the hospital because of the small but significant chance of causing fetal distress by turning the baby. If the baby experiences slowing of the heart rate after turning (bradycardia), perhaps because of the umbilical cord tangling, emergency C-section delivery will be required.

The actual procedure is quite simple. The mother reclines on a firm table. An ultrasound, to confirm fetal position, and a non-stress test, to demonstrate fetal well-being, are done. Some obstetricians will administer a dose of terbutaline by injection before the procedure to prevent uterine contractions. The mother's abdomen is dusted with powder to allow the obstetrician's hands to slide across it easily. The obstetrician uses one hand to pull the presenting part up out of the pelvis. With the first hand cupping the presenting part, the obstetrician's other hand is placed at the back of the baby's head. Both hands are used to induce the baby to do a forward somersault. If the attempt succeeds, gentle pressure is exerted to push the head into the pelvis. The fetal heart rate should be monitored again to make sure that the new position does not cause fetal distress.

Version is successful approximately half the time. Not every baby will turn, and some babies who turn easily will turn back to their original position shortly after the procedure is completed. Nonetheless, if your obstetrician is comfortable and experienced with the procedure and there are no problems indicated, version is often worth trying. If successful, version reduces the risk to the baby from breech vaginal delivery, and the risk to the mother from C-section delivery.

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How a Baby Is Delivered by Caesarian Section

Amid all the negative publicity about the rising rate of Caesarean sections, it is easy to lose sight of the fact that it is often a life-saving operation. Literally tens of thousands, and perhaps hundreds of thousands, of babies and mothers are saved each year. The Caesarean section is probably the single most important factor responsible for the dramatically lower rates of maternal and neonatal deaths since the beginning of this century (and medical advances have made it safer now than ever before).

Nonetheless, it is possible to have too much of a good thing. The odds are as high as 1 in 5 that Caesarean section will be recommended to you. How will you know if it is the right procedure for your situation? How can you avoid having an unnecessary Caesarean section? The first step toward answering both questions is to understand exactly what a Caesarean section is-and when it is recommended.

Caesarean section is the operation in which a baby is delivered through an incision in the abdomen, rather than through the vagina. It is named after Julius Caesar; as legend has it, he was born this way. It is often referred to as C-section.

The most common reason for a C-section is cephalopelvic disproportion (CPD), which is just a complicated way of saying that the baby's head does not fit through the mother's pelvis. This can happen for a variety of reasons, including an unusually large baby, an unusually small pelvis, or an unusual position of the baby, such as occiput posterior presentation. CPD is a diagnosis that can be made only during labor. If the labor fails to progress beyond a certain point, despite good contractions for at least two hours (often strengthened by Pitocin), it is unlikely that the baby is going to fit.

You might imagine that every labor would automatically progress to 10 cm. dilation and that the difficulty would arise during the attempt to push the baby out. However, in some way that we do not yet understand, the uterus senses that the baby cannot fit properly. Cervical dilation may stop several centimeters before full dilation, and no further progress will be made despite many additional hours of labor. Whether progress stops in the active phase or during pushing, it is a sign that C-section may be necessary. Without full dilation of the cervix, C-section is the only option; if progress stops during pushing, forceps or vacuum extraction may be considered if the baby's head is low enough.

There are undoubtedly some unnecessary C-sections that are done presumably because of CPD. It is important for the practitioner to wait until the active phase before making the decision that the baby cannot fit. In the latent, or first, phase of labor, progress may be extremely slow and may take many hours; this is a sign that labor hasn't really started efficiently, not a sign that the baby doesn't fit. As a general rule, the diagnosis of CPD should not be made before approximately 5 cm. dilation.

Another contributing factor to unnecessary C-sections for CPD is pain relief that is given too early. Short-acting narcotics and epidural anesthesia sometimes interfere with the progress of labor before the active phase begins. If you are anxious to avoid a C-section, it is best to wait until 4-5 cm. dilation before asking for pain relief.

Additionally, a large number of C-sections are done for breech presentation. As discussed in detail in Chapters 12, 26, and 27, vaginal delivery from the breech presentation involves much greater risk than vaginal delivery head first. If attempts to turn the baby have been unsuccessful, C-section is often recommended. In this situation, most women, wishing to minimize any risk to the baby, select C-section as the preferred delivery option. However, most C-sections done for breech presentation could be considered unnecessary in the sense that vaginal delivery of most breech babies turns out fine. Unfortunately, at present we have no way of determining with any certainty which breech babies will be permanently injured by vaginal delivery.

Another common reason for C-section deliveries, and probably the most controversial, is fetal distress. These C-sections are performed because the practitioner suspects that the baby is being deprived of oxygen. The diagnosis is usually made by analyzing the fetal heart rate tracing, although other factors such as moderate to thick meconium in the amniotic fluid can raise suspicions or lend support to the diagnosis. More sophisticated tests, such as fetal scalp sampling (in which a tiny sample of the baby's blood is taken from its scalp and tested for oxygen content) may be used to confirm the diagnosis of fetal distress, especially if there is an element of doubt about the meaning of the heart rate tracing.

A lot of C-sections done for fetal distress are probably unnecessary. Many babies who experience even prolonged oxygen deprivation during labor probably will sustain no permanent brain damage. Unfortunately, it is very difficult to determine which babies are in danger of suffering irreparable damage. Obviously, no obstetrician wants to wait until the damage is done; at that point, the diagnosis is easy-but by then it's too late. Caesarean section should be performed while the baby is still healthy if fetal distress is strongly suspected. Yet when that healthy baby is delivered, it is often impossible to determine if the obstetrician acted too quickly, or acted prudently to avoid permanent injury.

In most situations, it is no longer considered necessary to have a repeat C-section if you had one in a previous delivery, provided that the incision made in the uterus was transverse-that is, made horizontally across the uterus. Vaginal birth after a previous C-section is commonly referred to by the acronym VBAC. Women have the option of requesting a repeat C-section, and many do, especially if they had a particularly difficult first labor. However, if you had a vertical incision on your uterus the first time, C-section will be recommended. Vertical incisions are considered less likely to withstand the stress and strain of contractions.

There are also some uncommon situations in which C-section is always necessary and appropriate. These include placenta previa (when the placenta blocks the cervix), heavy bleeding and cord prolapse (when the umbilical cord falls out before the baby is delivered). In these cases, C-section is undoubtedly a life-saving procedure.

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Pain relief in Labour

There is probably no area of obstetrics that generates more anxiety and more controversy than the subject of pain relief. That's not surprising when you consider the reputation childbirth has for being so painful. The truth of the matter is that the reputation is well deserved. The good news is that there are many ways available to cope with or ease the pain. These methods can be divided into three basic types: psychological, narcotic, and conduction anesthesia (epidural and spinal anesthesia).

You should learn all you can about each of these types and determine your preferences. But do not make any firm decisions before labor begins. It is impossible to know beforehand what your labor will be like. Committing yourself to one particular type of pain relief, and no other, is a setup for disappointment. You may find that you need something quite different than your original preference, and you should never feel disappointed, or reproach yourself, if you change your mind in the face of actual experience.

Psychological methods of pain relief have come to be known as "natural childbirth." They were formulated in the 1950s as part of a larger effort to wrest control of childbirth from the medical establishment and give it back to women. Natural childbirth depends, in large part, on becoming knowledgeable about the entire process of giving birth. If you know what to expect, you are less likely to be frightened by this incredible process. Assuming that increased fear leads to increased pain, knowledge and preparation become your first line of defense.

Psychological methods of pain control involve focusing and relaxation exercises specifically tailored to each stage of labor. Most of these exercises involve specific types and patterns of breathing that are designed to focus your concentration on mastering the pain. Many women find that what they learn during natural childbirth preparation is all that they need to negotiate the long hours of labor. The advantages of natural childbirth include absence of side effects from pain relieving medications and no slowing down of the labor process.

Unfortunately, to promote natural childbirth, some of its supporters have claimed that using the breathing techniques makes childbirth, at best, painless or, at worst, only slightly uncomfortable. Neither scenario is true. For the vast majority of women, childbirth is extremely painful. Although the breathing exercises will help you to maintain control in the face of the pain, they will not relieve pain; after all, they are just prescribed breathing patterns.

Many women who are determined to use natural childbirth techniques often become frightened as labor progresses. The pain is so much greater than they have been led to expect and they fear that something is wrong, either with the labor or with themselves. Nothing could be further from the truth. Part of being knowledgeable about the process of childbirth is understanding how painful it is likely to be.

At a minimum, you should be sure to take a childbirth preparation course (offered by most hospitals and birthing centers) in order to prepare for labor and to familiarize yourself with the techniques of natural childbirth. However, if you decide that you need a bit more than natural childbirth breathing exercises to manage the pain, short-acting narcotics are often the first choice. These medications, such as Nubain and Numorphan, are related to stronger narcotics, such as morphine or codeine, which you might be given after surgery or a dental procedure. They differ in that they are much shorter-acting; they will be out of your bloodstream within an hour or two. That way, they are unlikely to be present in the baby's bloodstream at the time of birth.

Short-acting narcotics are given by injection, either into a muscle (like the buttock) or through an intravenous line. They do not take away the pain; they just "take the edge off." Some women find that this is the boost that they need to help them continue with the breathing exercises.

Because of some disadvantages that are associated with short-acting narcotics, it is preferable to avoid narcotics if the delivery is anticipated to occur within the next hour. Given too early in labor (that is, before 4 cm. dilation has been reached), they may slow down the progress of the labor. Narcotics cross the placenta and enter the baby's bloodstream, which has minimal effects before the baby is born. However, if the baby is born shortly after their administration, it could result is a sedated baby that is reluctant to breathe on its own. The effects of the short-acting narcotics on the baby can be reversed by administering an injection of naloxone.

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How and Why a Baby Is Delivered by Forceps

In the mid-1500s William Chamberlen invented the obstetrics forceps, an instrument that changed the practice of obstetrics, or midwifery. Forceps were considered so amazing and so valuable that the Chamberlens guarded the design as a family secret for more than 100 years. During that time, the family became socially prominent and financially successful. In fact, when a descendent of the Chamberlen family was finally persuaded to sell the forceps for a tidy profit, he sold only half of the instrument, thus rendering it useless. Ultimately, however, the secret of the design was revealed and the lives of many women and babies were saved.

Obstetrical forceps were designed to solve the problem of the baby getting stuck in the birth canal, due to its size or position, during pushing. Using forceps enables the physician to pull the baby out. Until this century, when Caesarean sections, or C-sections, became possible, the use of forceps was the only technique available for treating this condition.

Forceps can be used only after the cervix is fully dilated and the head has begun to descend through the pelvis. If the fetal head stops descending despite good maternal pushing efforts, the use of forceps may be indicated. They are also helpful in situations in which the head has been descending slowly, but an immediate delivery is indicated because of fetal distress, or when the mother has become too exhausted to push anymore.

Modern forceps come in many types and are used in several circumstances. They look like large tongs. The two individual pieces (known as blades) are inserted separately into the vagina and guided into the appropriate position around the baby's head. Then the handles are locked together. When the next contraction comes, the obstetrician pulls on the forceps. These pulling forces, added to the pushing forces of the uterus, will cause the head to descend further. Often, several contractions are required before the head begins to crown. A generous episiotomy must be made to accommodate the baby's head with the forceps around it. The rest of the delivery is accomplished in the usual way.

The use of forceps is not without risk. Forceps can cause temporary or permanent injury to the baby or the mother, especially if they are used to turn the baby from an unfavorable position to a favorable one. As Caesarean sections have become safer, they are often recommended instead of forceps delivery because the risk of injuring the baby during a C-section is very small. This is one reason the rate of Caesarean deliveries has risen over the last few decades.

How would you know if a forceps delivery would be right for you? As stated above, forceps can be used only when the cervix is fully dilated and the baby's head has begun to descend through the pelvis. Perhaps you have been pushing well, but delivery is still an hour off and the fetal monitor shows signs of fetal distress. Perhaps you have pushed the baby's head down to +3 station, but it will go no further despite additional pushing. These are typical situations in which forceps may be recommended.

Unless the baby's head is very low (+4), there may be some discussion of a C-section versus a forceps delivery. That's because forceps cannot deliver a baby that is too big to fit. This is a common reason for the head to stop descending despite the fact that you may be doing a good job of pushing. If the baby is too big to fit, attempts to pull it through can cause serious injury. That's why the decision whether to use forceps must be made only by an obstetrician highly trained in their use.

If, after discussion, forceps seem to be your best choice, you will be given a spinal or an epidural anesthetic, if you have not already received one. (Forceps are large metal instruments, and placing them in the vagina would cause too much pain if anesthesia were not used.) Then, your bladder will be emptied with a catheter, both to provide additional room and to avoid injury to the bladder. If your bladder is full, it may be injured by pressure from the forceps.

It is possible that the delivery may not be accomplished even with the use of the forceps. If the baby is too large, or the position too unfavorable, the head might not descend even after forceps are applied. In that case, Caesarean section is the treatment of choice.

Babies born by forceps delivery often have temporary marks on their faces and heads from the instrument. These marks heal quickly and are no cause for concern.

It is important to remember that a forceps delivery is a medical procedure, with the possible risks that that implies. Forceps should be used only for a medical reason and not because you don't want to push. It is far better to push the baby out on your own than to have it pulled out.

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How and Why an Episiotomy Is Performed

Episiotomy used to be one of the most common procedures performed in obstetrics, but that has changed dramatically over the last decade. Research showed that the benefits of episiotomy were vastly overrated and it is well on its way out of obstetrical practice.

Episiotomy was though to prevent uncontrolled, jagged tears during delivery by artificially enlarging the external vaginal opening. The area under the vaginal opening was anesthetized with a local anesthesia (unless the mother has already had an epidural), and a scissors was used to cut into the space. The cut could be either straight up and down (median episiotomy), or, if the baby was very large or the space very short, the cut was made off to one side (mediolateral episiotomy), to avoid damaging the anal sphincter, which is the muscle that controls bowel continence. After delivery, the episiotomy is closed in layers with absorbable sutures. There is no need to remove stitches later on because they dissolve and are absorbed.

Doctors thought that episiotomy represented the solution to an engineering problem: The baby's head is often too large to fit through the external opening of the vagina without causing significant tearing of the vagina and the surrounding tissues (these tissues are called the perineum). In some women, the external opening of the vagina will stretch to accommodate the baby's head. However, in many women having their first baby, it will not stretch enough to prevent tearing. The rationale behind episiotomy was that fewer stitches would be needed to close an episiotomy than multiple jagged tears. Scientific research showed that this was not the case, and, in fact, an episiotomy might lead to additional tearing.

There are now only a few situations in which an episiotomy appears to be helpful. The first is when forceps are used to aid delivery in the second stage. Forceps are relatively large, and in order to apply them to the baby's head safely and properly, an episiiotomy is needed.

The second situation is when the baby is quite large and a shoulder dystocia could occur. Shoulder dystocia happens when the baby's head is born, but the shoulders become wedged behind the mother's pelvic bone. This is an emergency because the baby can't get oxygen through the umbilical cord, which is compressed between the baby and the walls of the vagina. It also cannot get oxygen by breathing because its chest is compressed by the walls of the vagina and it can't take in a breath. It is important to deliver the baby as quickly as possible and that often requires maneuvers to twist the baby so the shoulder will pass. An episiotomy makes more room for a practitioner to reach around the baby and release the shoulder.

The other major reason why episiotomy was thought to be beneficial was to prevent urinary incontinence in women after their childbearing years. As women age, the tissues in the pelvis relax and women may find that they have difficulty holding in urine. It is well known that previous vaginal deliveries make this problem more likely. Doctors thought that preventing the vagina from being stretched could prevent urinary incontinence. Unfortunately, that is not the case because it is the stretching of the ligaments inside the pelvis that probaly lead to weakening and subsequent problems with holding in urine.

Because of the lack of benefit, and, indeed, an increased risk of tearing, episiotomy should now be used only in specific situations and not for uncomplicated vaginal deliveries.

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How and Why the Fetal Membranes Are Ruptured Artificially

The fetal membranes protect the baby by forming a barrier to infection within the underwater world of the amniotic sac. The amniotic fluid cushions the baby from the bumps and bruises of the outside world. When the membranes rupture, announcing the imminent arrival of the baby, the delivery will take place within hours or days. Rupturing of the membranes is commonly called "breaking the water."

We do not have a very good understanding yet of exactly how or why the membranes rupture. Although natural rupture of the membranes is more likely as labor progresses and the cervix dilates, in some instances the membranes may rupture shortly before labor begins-even if the cervix has not dilated at all. In fact, in some women, the rupture of the membranes seems to trigger the onset of labor.

In almost every pregnancy, the membranes will rupture naturally at some point before the baby is born. In the rare cases that this does not happen, the membranes should be ruptured artificially. This will prevent the baby from being born in caul, which means the head would be covered by the membranes. If this were to happen, the baby would be unable to draw its first breath because it is still within the sac.

There are other, more common reasons why membranes may be ruptured artificially. The most common is to speed up labor. It is well known that when the membranes rupture during the active phase of labor (either naturally or artificially induced), the contractions often become stronger and more frequent. Sometimes, this is all that is needed to speed up a labor that has been making minimal progress over many hours.

Another common reason to rupture the membranes artificially is if fetal distress is suspected. Rupturing the membranes serves two purposes: First, it allows the practitioner to place an internal electrode on the baby's head to record the fetal heart rate more accurately (see Chapter 18). It also allows the practitioner to determine whether there is any meconium in the amniotic fluid. Meconium is a sticky, green substance that is produced by the fetal intestine; it is the equivalent of a bowel movement. There will be meconium in a newborn's diapers for the first few days of his or her life.

The baby will pass meconium into the amniotic fluid in response to stress (such as oxygen deprivation). A small amount is not harmful, but a moderate to large amount is cause for concern. First, it suggests that the baby may be subject to stress by labor. Second, meconium can get into the baby's lungs, where it could cause breathing problems and even pneumonia after birth. If there is a significant amount of meconium in the amniotic fluid, a pediatrician or anesthesiologist may be asked to attend the birth and examine the newborn immediately, to suction out the meconium before it can be breathed farther into the baby's lungs.

Rupturing the membranes artificially is a very simple procedure. It is done during an ordinary vaginal exam; an amnio-hook, which looks like a large crochet hook, is used to scratch the surface of the membranes. It is painless for both mother and baby.

In many cases, your practitioner will offer you the option of artificial rupture of the membranes. In those instances, it is just a matter of personal preference as to whether you would like it done to speed up your labor. However, this procedure is advisable if the fetal heart rate tracing suggests the possibility of fetal distress. Rupturing the membranes artificially can provide valuable information for taking proper care of your baby.

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How and Why a Baby Is Delivered by Vacuum Extraction

Forceps have been around for hundreds of years, and although they have saved the lives of thousands of babies and mothers, they also can cause injury. The obstetric vacuum was invented specifically to address this problem. It is an alternative to using forceps to pull the baby through the birth canal. However, unlike forceps, the obstetric vacuum does not compress the fetal skull, and therefore reduces the possibility of injury.

Obstetricians and midwives often joke that it is a shame that babies do not have handles on their heads to allow them to be pulled out when they get stuck. The vacuum extractor, which has a handle attached to a plastic suction cup, comes close to fulfilling this wish. In a vacuum extraction delivery, as with forceps, the cervix must be fully dilated, and the fetal head must have begun its descent through the pelvis. In a vacuum extraction delivery, however, the mother must be able to participate actively. When the vacuum is turned on, the cup sticks to the top of the baby's head, so the obstetrician can pull on the handle during contractions, adding pulling force to the pushing forces of the uterus and the mother. Unlike using forceps, it is almost impossible to pull too hard; the suction cup will just pop off.

There are advantages and disadvantages to the vacuum extractor when it is compared to forceps. In difficult situations, such as a higher station or sub optimal position of the fetal head, the use of the vacuum extractor has a lower success rate as compared to forceps. However, the vacuum extractor requires less maternal anesthesia, makes the mother an active participant in the delivery process by enlisting her pushing efforts, and is less likely to cause injury to the mother or the baby. Although there are some situations in which one method is preferable to the other, for the most part, the decision should rest with the obstetrician. The best method is usually the one that he or she is best trained in and has the most experience with.

In which situations might vacuum-assisted delivery be offered to you? The situations are similar to those in which forceps might be recommended: a period of pushing with progress to a low station, such as +3, followed by minimal further progress; fetal distress during the second stage (pushing); or maternal exhaustion. The vacuum extractor cannot pull the baby out without the help of maternal pushing. The same important warning that applies to the use of forceps also applies to the use of the vacuum extractor: If there is evidence that the baby is too large to fit, a C-section is the appropriate treatment.

What procedures can you expect if a decision is made to use the vacuum extractor to assist the delivery of your baby? The obstetrician will attach the cup to the device that creates the suction (usually a hand pump) and test it against his or her hand. Then the obstetrician will apply the cup to the baby's head and examine it carefully to be sure that it is properly positioned. At the next contraction, the nurse will pump up the vacuum and the obstetrician will begin pulling while you are pushing. Between contractions, the vacuum is released. The process is repeated until the baby's head is delivered. When the vacuum extractor is used, an episiotomy is not always necessary, because the cup is small and flexible; it does not add to the diameter of the fetal head. You can see that there is much less preparation involved than for the use of forceps. There are no special anesthesia requirements, because the suction cup is soft and causes no additional discomfort. There is no need for bladder catheterization, either.

After your baby is delivered, you may be surprised and a little worried to find that the baby has a big bump on its head where the cup was attached. This bump (known as a chignon) is not harmful and will disappear in 24 to 48 hours.

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How Labor Is Induced

Your due date came and went a week and a half ago. Your telephone rings constantly and every time you answer it, a friend or relative exclaims, "You're still home!" These last few days seem longer than the previous nine months. Your practitioner told you at this week's appointment that if you haven't gone into labor by next week, you will need to be admitted to the hospital so labor can be induced. Emotionally, you're relieved to have an end to the waiting in sight, but you wonder whether inducing labor is necessary and if it is safe.

Because no one really understands how normal labor starts, we are at a loss to explain why some labors don't start until weeks after the due date. This would not be of concern, except that after nine months of pregnancy have passed, the placenta often fails to keep up with the growing oxygen and nutritional needs of the overdue baby. In fact, the mortality rate of babies born after 43 weeks is double that of those born on time. After 44 weeks, the mortality rate is triple the normal rate. That is why most practitioners are extremely reluctant to allow pregnancies to continue much past 42 weeks.

Antepartum testing determines which babies are at highest risk for difficulties before and during labor. Most practitioners routinely recommend such testing after 41 weeks. It includes a non-stress test (see Chapter 18) and a biophysical profile (see Chapter 4) performed during an ultrasound exam. If this testing reveals abnormalities, induction of labor is recommended. Even if the test results are normal, induction is recommended at 42 weeks.

How is labor induced? There are a variety of methods, used alone or in combination, which can induce labor. If the cervix is more than slightly dilated, the simplest way is to rupture the membranes artificially (see Chapter 20). Most women will go into labor within 24 hours after the membranes rupture.

There are a number of disadvantages to using this method alone, however. First, not all women will go into labor. Second, as soon as the membranes are ruptured, the potential exists for chorioamnionitis, infection of the membranes and amniotic fluid. This type of infection affects the mother as well as the baby. The risk of infection increases over time. There is not much chance for infection to occur if the labor is well along and the delivery will happen within the next few hours. However, if labor has not even started, the delivery may not take place for 24 hours or more, which significantly raises the possibility of infection. Chorioamnionitis can be treated with antibiotics, but it is far preferable to avoid infection all together, if possible.

The second method of inducing labor is the use of prostaglandin gel. This technique became available only a few years ago, but it has become popular very quickly. Prostaglandin gel contains one type of the hormone prostaglandin, which naturally causes the cervix to soften and thin out in preparation for labor. Prostaglandin gel may even stimulate mild contractions and, for some women, this is enough to start labor.

Prostaglandin gel is applied directly to the cervix during a cervical exam. Because of its potential to cause contractions, it is usually applied in the hospital setting and the baby is monitored for several hours thereafter. If no significant change occurs after four hours, a second dose of gel may be applied.

Prostaglandin gel may stimulate labor alone, but more commonly it is used in conjunction with Pitocin. Pitocin is the synthetic version of the naturally occurring hormone oxytocin, which causes uterine contractions. The advantage of giving prostaglandin gel first is that the cervix tends to become thinner and even slightly dilated after the gel is applied, making the Pitocin more likely to be effective at smaller doses. Pitocin is administered initially in minute quantities, and the amount is gradually increased over 20-minute intervals until contractions begin. The fetus is monitored during administration of Pitocin to make sure that the amount given does not cause the baby stress or contractions that are too frequent. If labor has not started within 12 to 24 hours after application of prostaglandin gel, the mother is readmitted to hospital to receive Pitocin through an intravenous line.

Are there disadvantages to Pitocin? Some practitioners believe that Pitocin causes stronger contractions than those that occur naturally. Most research suggests, however, that Pitocin-induced contractions are very similar to those of normal active labor. The potential does exist to cause contractions that are more frequent than naturally occurring contractions and, therefore, these contractions may be more stressful for the baby. That's why careful monitoring is essential during administration of Pitocin. It is easy to decrease the frequency of contractions just by lowering the dose of Pitocin if there is any indication that the contractions are occurring too close together.

The disadvantages must be weighed against the risks, of course. It would be inappropriate to induce labor just to have the delivery occur on a convenient date. The use of Pitocin for induction is justified only if the baby is at significant risk for serious problems, either because an abnormality has been found on antepartum testing, or because the baby is two weeks overdue or more.

There are other, less common reasons for inducing labor. These include preeclampsia, gestational diabetes (but not before 38 weeks), and intrauterine growth retardation (IUGR) if the fetus is in less than the 10th percentile for gestational age. In the case of pre-eclampsia, induction is performed to treat the mother. In the case of gestational diabetes or IUGR, the fetus is at risk.

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Part 3-Common Obstetrical Practices

Obstetricians and midwives have become so successful at routinely delivering healthy babies to healthy mothers, that most people don't realize that this is a development of the twentieth century. In 1900, the death of women in childbirth was common, and virtually every woman expected to lose at least one child during labor and delivery. The practices and equipment of modern obstetrics have made all the difference in dramatically increasing the chances of a safe delivery.

There are proponents of natural childbirth without medical intervention of any sort. They contend that pregnancy and childbirth are and should be entirely natural processes. However, there is no reason to believe that just because something is a natural process, it is inherently safe. Think about it this way. While it is very likely that your baby will have a safe and healthy childhood, you are probably not planning to leave that to chance. You will take your baby to the pediatrician for routine checkups and immunize him or her to prevent dangerous childhood diseases. If your baby gets sick, you will not hesitate to use antibiotics, or whatever else is necessary to restore good health. The entire process of pregnancy through labor merits the same degree of close supervision and treatment, if it is indicated.

Modern obstetrics is based on the principle that most women will have uneventful labors and deliver healthy babies easily. Nonetheless, careful monitoring is done to detect those few babies that show subtle signs of difficulty and to treat them before a problem develops. Moreover, obstetricians are regularly called upon to rescue those babies that find it difficult or impossible to negotiate the birth canal.

Do obstetricians and midwives sometimes overtreat? Undoubtedly! That's because their standards are so high. To be sure that not even one baby will be harmed during delivery, it is almost impossible not to treat some babies that probably would withstand the stress of birth without help. To do otherwise is high stakes gambling. Most babies, even those showing signs of significant distress, would probably be okay without intervention. Some definitely will not. The average obstetrician or midwife is not a betting person; most won't take chances with your baby's health, even if the chances of a bad outcome are relatively small.

The chapters in this section are devoted to describing and explaining the most common practices and procedures of modern obstetrics. Each practice will be considered in detail, including possible reasons for its use, as well as how it works, and how it feels. Many of these procedures are optional in a lot of circumstances. That's why it's important to know as much as possible about them beforehand, because your practitioner will likely want to know your preferences.

In order to make a reasonable decision about what methods are best for you, it is important to be realistic about just how much pain is involved. The good news is that there are lots of options available for pain control-psychological options as well as medical ones.

Here, some particular comments are in order about childbirth and pain relief. Contractions are not called "labor pains" for nothing. They are not "sensations" and I've certainly never heard a patient characterize them as "orgasmic," though some books describe them as such. Although the pain of childbirth has been recognized in ancient writings dating back thousands of years, the following new myth about childbirth has become popular in recent years: Childbirth is not inherently painful, so "real women" don't need pain medication because they are actually "empowered" by experiencing the pain. But when you stop and think about it, this doesn't make much sense. A seven-pound baby is about to be pushed out of your body through a narrow (although elastic) tube. How could this be pain-free? There are a few lucky souls who may experience painless childbirth, but the vast majority of women describe it as the most physically painful experience of their lives. Whatever you do, do not plan too far ahead. You do not know how much pain you will have and you do not know how you will respond to it. Keep your options open.

In our relentlessly competitive society, it is often difficult not to set goals for ourselves, even in the most intimate of circumstances. It is important to remember that childbirth is not an athletic event. No team of judges will award the perfect score to the woman who refused an episiotomy, or deduct points from the woman who requested an epidural. Childbirth is a deeply personal experience. You should feel comfortable making the choices that are right for you; do not judge yourself by someone else's standards.

Giving Birth 2

When your baby is almost here, the practitioner will don gown and gloves in preparation for catching your new arrival. There's tremendous excitement in the room. Everyone shouts encouragement with each contraction. "Push, push, a little bit harder, a little harder!" Everyone is anticipating the birth, anxiously waiting. What exactly is the baby doing at this point?

The baby has just one more obstacle to negotiate. The top of his or her head must slip under your pubic bone before delivery can take place. With every push, the head comes down a little farther, but between contractions, it also seems to slide back a little each time. You feel the next contraction starting and summon all the strength that you have left. You push and push and push. There is a wild cheering. The baby's head has slipped past your pubic bone and is crowning!

Most practitioners do not decide whether an episiotomy is needed until this point. (See Chapter 21.) That's because it's difficult to anticipate how large the baby's head is and how much the mother's tissues can stretch. As the head is crowning, if the tissues of the vagina and perineum stretch to maximum capacity, and begin to tear and bleed, it may become clear that an episiotomy is warranted.

You feel tremendous pressure and burning, and the mixture of sensations is almost overwhelming. Your practitioner tells you, "With the next contraction, the baby's head will be born. As the head is being delivered, I'll ask you to stop pushing so the baby can have a gentle birth. Then I'll suction the nose and mouth so the baby's first breath will be easier." Once again you feel a contraction beginning and start to push. "Stop pushing," the practitioner calls. Your eyes are probably closed, but everyone present watches as the baby's head is born. The top of the head comes first, then the eyes, the nose and the mouth; finally the whole head is out.

The baby's mouth and nose are gently suctioned for mucus and amniotic fluid. The head, which has been facing the floor, naturally turns to one side. That's because the shoulders are entering the pelvis; they fit best if the baby is facing your side. Your practitioner then says, "With the next contraction, you'll push again for the baby's shoulders." Sure enough, the next contraction begins, as if on cue. The practitioner tilts the baby's head toward the floor and the top shoulder slips underneath the pubic bone. As the baby's head is tilted toward the ceiling, its bottom shoulder is born. "Open your eyes!" someone shouts. You look down in time to see the rest of the baby slip out.

Your practitioner tells you either, "It's a boy!" or "It's a girl!" and then hands you the wet and wriggling baby. The umbilical cord is still pulsating. Your newborn draws his or her first breath and cries out. You're laughing and crying at the same time. Your baby is here!

Giving Birth 1

Hooray! Your cervix has finally dilated to 10 cm. after 14 hours of labor. You may have thought that you were exhausted, but hearing this good news gives you a second wind. This is very important because the real work of labor is about to begin. It's time to push the baby out. Your practitioner may tell you that the baby's head is at +3 station. That means there are only 2 cm. between the baby and the outside world. Station refers to the actual location of the diameter of the baby's skull in relation to the midpoint of the mother's pelvis. The baby's head can be anywhere from -3 station to +5 station. The head achieves +5 station at delivery.

During the first stage of labor, as your cervix dilated from 0 to 10 cm., you were a spectator to the powerful forces that are unleashed in labor. The second stage of labor, in which the baby is pushed out, depends on your pushing efforts. Although the uterus is still contracting approximately every 2 minutes, and pushing the baby further down, the most important force in the second stage is maternal pushing. This means that the harder you push during each contraction, the faster and more efficiently your baby will descend.

For some women, particularly those who have not had epidural anesthesia, pushing provides real relief. They may have struggled through transition against the almost unbearable urge to push. Now they do not have to resist the urge any longer and they can give in completely, following the natural cues of their bodies. However, other women do not find that pushing brings any relief. For them, the intense pressure caused by the baby's head as it descends just continues to increase the pain. Nevertheless, the thought that labor is almost over motivates them to push through the added pain and hastens the moment of their baby's birth.

A woman who has chosen epidural anesthesia does not feel these sensations. She may encounter a different problem, however. Because she does not feel the urge to push, she may not know when to push. She must rely on an assistant, such as the labor nurse or her coach, to let her know when each contraction starts, so she can coordinate her efforts. The assistant can tell when contractions are starting by feeling the mother's abdomen. In addition, some women experience a motor block as well as a sensory block when they receive epidural anesthesia. In other words, the epidural diminishes their muscle power even as it controls the sensation of pain. Although they may push with all their might, their pushing efforts are not nearly as strong as they might be without receiving an epidural. The fetal monitor can be especially helpful if you have an epidural, because you may not feel your contractions. Watching the monitor lets you know when they are starting, so you can coordinate your pushing efforts with the contractions. Pushing is effective only during the contractions.

This may pose a problem if there is a relatively tight fit between the fetal head and the mother's pelvis. The mother cannot push hard enough to push the baby out. That's why many practitioners recommend decreasing the amount of medication in the epidural, or even turning it off, in the second stage. Although there is increased pain along with the increased muscle power, it is often all that is needed to avoid a Caesarean section or a forceps delivery.

As the baby's head descends, the excitement in the room increases. This process usually takes from 1 to 2 hours in first-time labors, though it may be as brief as a few minutes if you have given birth before. Everyone can tell when the time for delivery draws near. First, the baby's head appears at the opening of the vagina during contractions. Then, as the head descends even lower, it remains visible even between contractions. You may experience intense sensations of burning and stretching as the baby's head fills the lower vagina.It's important to push past the pain. Sometimes it's hard to know exactly where to direct the pushing, and you can waste your efforts by pushing into your legs or against the bed. This position minimizes wasted effort. Also, opening your legs wide makes more room for the baby as its head descends.

In the second stage, the fetal monitor is used more frequently and for longer periods of time-sometimes continuously. That's because this stage is often the most stressful for the baby as well as the most demanding for the mother. Some babies may demonstrate signs of mild distress during pushing. Usually, supplemental oxygen given to the mother is enough to correct this problem.

There's no such thing as too much encouragement when you're pushing. It's hard work, and progress is often made slowly. Lots of love and support can make all the difference when your spirits are flagging.

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The Active Phase of Labor

Your practitioner has just rechecked your cervix. He or she tells you, "Seven centimeters dilated, and your baby's head is at +1 station. You're well into active phase labor." You don't really need anyone to tell you that you're in the active phase, though, because you can sense the difference. The contractions are now longer, stronger, and closer together. When did that start? You can't remember exactly, but it must have been shortly after you noticed that your membranes had ruptured. So now, in addition to enduring the contractions, you feel fluid leaking a bit at a time. During the active phase, most women also experience uncontrollable shaking in addition to the pain. No one knows why this happens, although hormonal changes are undoubtedly involved. Amazingly, women who have no labor and undergo Caesarean section deliveries (perhaps because the baby was breech) also experience shaking when the baby is delivered. There is no way to stop the shaking; it's just a normal part of the active phase. Overall, things feel out of control, and you may be worrying. Is everything okay?

The active phase of labor is the second part of the first stage, during which the cervix dilates from 0 to 10 cm. As the name implies, this phase tends to be faster and more efficient than the latent phase. The contractions are longer, lasting from 60 to 90 seconds, and they are often more frequent, coming regularly every 2 minutes. Many women report that the contractions are stronger and felt more intensely as well.

In active labor, your body is working at maximum capacity, and it's easy to become overwhelmed by all the different things that are happening to you that are completely beyond your control. If you know what to expect, though, you need not worry that these very powerful sensations indicate something is wrong. Generally, they are a sign that everything is all right, that your body is performing this most miraculous of tasks with all the strength and ability that nature intended.

What might you feel? Well, first and foremost is the pain. There are a few lucky women who have painless labor, but the vast majority do not. Strong, painful contractions regularly occurring every 2 minutes and lasting 60 to 90 seconds characterize active labor. And they are enough to test anyone's endurance, especially if the active phase lasts several hours, which it usually does in first labors. During the active phase, many women rely most heavily on the breathing exercises that they learned in childbirth classes.

Some women find that the breathing exercises are not enough. This should not be surprising when you consider that breathing exercises do not relieve the pain, they just help you to cope with it. At this point, a lot of women opt for some form of pain relief, either a short-acting medication such as Numorphan, which dulls the pain but wears off quickly, or epidural anesthesia, which stops the pain altogether by anesthetizing the lower spinal nerves. Both methods will be considered in detail in Chapter 24.

As the cervix dilates to 8-9 cm., the active phase becomes known as transition. This refers to the transition between the first stage, when the cervix dilates to 10 cm., and the second stage, when the baby is pushed out. Many women experience nausea and vomiting during transition, whether or not they have received anesthesia. No one understands why this happens, but it is a normal, if unpleasant, part of labor.

New sensations often develop during transition. As the baby’s head descends, you may experience an almost uncontrollable urge to bear down or push. That sensation is going to be very important and helpful when it's actually time to push the baby out. Unfortunately, the sensation often begins before 10 cm. dilation is reached. Pushing before the cervix is fully dilated may cause the cervix to swell or to tear and bleed, so it's very important to avoid pushing until your practitioner tells you when you're ready.

The breathing exercises specifically designed for transition can be very helpful. You can't push when you are blowing! If you have opted for epidural anesthesia, you will not feel the urge to push. This can be a big advantage during transition, but it can also make pushing less effective in the second stage.

The active phase of labor is a very intense experience. As you feel engulfed and overwhelmed by many strong sensations, it helps to remember that these are the signs that your labor is progressing normally. Most importantly, they are bringing you ever closer to seeing your baby.

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How Your Practitioner Checks Your Cervix

You’ve been in labor for several hours and you are anxious to find out about your progress. You might get very excited when your practitioner agrees that it's time to check your cervix. You watch him or her don the sterile glove, you feel fingers being inserted into your vagina, and you hear the approving announcement that you have dilated to 4 cm. But what on earth did the practitioner just do? What does the number mean?

When doctors or midwives do vaginal exams, they are able to feel three different things with their fingers. They measure cervical dilation, which is the amount that the cervix has opened, and fetal station, which is the relationship between the largest part of the fetal head and the midpoint of the maternal pelvis. If the cervix is dilated far enough, they can even feel the position of the baby’s head. (See Chapter 12 for details on fetal positions.)

Cervical dilation is easy to measure. After identifying the cervical opening overlaying the baby’s head, the practitioner slips one or two fingers into the opening cervix. If only one finger can be admitted, the cervix is approximately 1 cm. dilated. If two fingers can be placed in the opening, the cervical dilatation is 2 cm. or greater, depending on how wide the fingers can spread. As the cervix approaches full dilatation, an ever-smaller rim of the cervix can be felt at the outer edge of the fetal head. At 10 cm., no cervix can be felt at all.

As the cervix dilates, it is not only opening wider; it is also thinning out, or effacing. Before labor begins, the cervix is 2 to 3 cm. long. As labor progresses, it becomes shorter. This effacement is described in relation to the original length of the cervix. When it is half as long as the original measurement, the cervix is 50 percent effaced. When it is paper thin, it is 100 percent effaced.
Fetal station is measured by determining the location of the largest part of the fetal head in relation to the midpoint of the mother's pelvis. If the largest part is at the midpoint of the maternal pelvis, the station is 0. If the biparietal diameter of the fetal head is 1 cm. above the midpoint, the station is -1. As labor progresses, the baby’s head descends into the pelvis, ultimately culminating at +5; at that point, the fetal head is at the vaginal opening. When your practitioner explains your progress, he or she will refer to both these numbers. For example, if you are examined after several hours of latent phase labor, your exam may show 4 cm., 0 station. Several hours later you may have progressed to 7 cm., +1 station. This means that in the intervening time, the cervix has dilated an additional 3 cm. and the baby’s head has descended 1 cm.

If the cervix is sufficiently dilated, your practitioner may be able to determine the position of the baby’s head. This is done by feeling for landmarks on the head. The bones that make up the baby’s skull are separate and not fused together, as they are in the adult skull. The space between each bone is called a suture, which can be clearly felt between the bones. At the places where several bones adjoin, there are even larger spaces called fontanelles. The fetal head has two fontanelles, anterior and posterior, commonly referred to as "soft spots." By feeling the location of the fontanelles and the sutures, your practitioner may be able to determine which direction your baby is facing (occiput anterior or posterior, for example) and whether its chin is tucked on its chest.

In most cases, it is not possible to feel the landmarks on the baby’s head clearly and accurately until the membranes of the amniotic sac rupture. When the sac is intact, the membranes overlaying the baby’s head feel like a balloon, and the details of the head cannot be discerned.
In early labor, especially if the baby’s head is high, the cervical exam may be a bit uncomfortable. As labor progresses, the cervix dilates more and the head descends closer to the vagina. Consequently, each additional exam is usually easier for the mother than the last.

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How the Uterus Contracts

You recognize contractions when you feel them because the pain and pressure are unmistakable. But what are contractions? How do they cause the cervix to dilate? What happens to the baby during a contraction?

In order to understand contractions, it is important to consider how the uterus acts on the baby. Think of the uterus as a muscular bag that is made up of involuntary muscle. You cannot flex or release this type of muscle as you can the muscles that control the movements of your limbs. Therefore, you can't strengthen these involuntary muscles by exercising before labor. If the hormone oxytocin is present in sufficient quantities, it will cause the involuntary muscle of the uterus to contract in a regular pattern.

The involuntary muscle of the uterus is divided into two parts. The upper part is the active segment; it contracts and pushes against the baby. The lower part of this muscular bag is known as the passive segment. This part actually remains relaxed during the contraction. The net effect is to push the fetal head against the cervix. Repeated pressure of the fetal head on the cervix causes the cervix to thin out (efface) and then retract around the fetal head. The baby is not so much forced out of the bag, as the bag pulls up around its head.

The average diameter of a fetal head is 10 cm. That's why the cervix is not considered to be fully dilated until 10 cm. is reached. At that point, the cervix has thinned out so much that there is no cervix left to hold back the fetal head, and the baby can be pushed out. If you start pushing before 10 cm. dilation is reached, you may damage the cervix.

When the involuntary muscle of the active segment contracts, it also compresses the blood vessels that travel through the uterine wall and carry oxygen to the placenta. This means that during the contraction, no oxygen can be transferred to the baby. It's as if the baby holds its breath for the length of the contraction. However, the placenta is designed to compensate for this under normal circumstances. Enough oxygen is transported to the baby between contractions to allow the baby to tolerate each contraction without any difficulty.

If there is a problem with the placenta-perhaps the baby is overdue and the placenta is a bit "worn out"-the baby may not tolerate the contractions nearly so well. In such a case, the baby may receive the minimally acceptable amount of oxygen between contractions, but may have no reserves with which to "hold its breath" during contractions. In this case, the baby's heart rate may drop immediately after each contraction. Continuous fetal heart rate monitoring can alert your practitioner to this potentially dangerous situation. Often, administering supplemental oxygen to the mother will correct the problem.

If this problem persists despite additional oxygen, the doctor or midwife must consider the possibility that the baby will remain oxygen-deprived for the rest of labor. This condition is known as fetal distress. If there are many hours of labor remaining (perhaps the mother's cervix is dilated to only 5 cm.), a C-section would most likely be indicated to prevent the possibility of brain damage caused by chronic oxygen deprivation.

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What Happens in Early Labor

Starting labor is a little like starting your car on a cold January morning; sometimes it takes a few tries before it "turns over." A few women start true labor abruptly, but many experience one or two episodes of false labor before the real thing begins. Since that's the case, you might worry about whether you are really in labor. There is no reason to worry, though, because nobody ever missed her own labor. If you are not sure you're in labor, you probably aren't. And even if you are, you'll most likely have plenty of time to get to the hospital.

How can you tell the difference between false labor and true labor? In true labor, you will feel regular uterine contractions, every 5 minutes or even more frequently. Each contraction will last at least 45 seconds. These regular contractions must continue for at least an hour before you should consider it to be labor; even then, you may be wrong. In true labor, the contractions become increasingly longer, stronger, and more frequent. In response to these contractions, the cervix thins out and begins to dilate (open).

Many women who have already delivered one baby find that their next labor is considerably shorter; it's like getting extra credit for having been through it once before. These women are advised to call their doctor when they have had regular contractions for an hour-even if the contractions are further apart than every five minutes.

The average first labor lasts for 12-18 hours before the cervix dilates to 10 cm., and it usually takes an additional 1-2 hours to push the baby out. Therefore, not much is likely to happen in the first hour. In false labor, the contractions weaken or occur less frequently. In this case, the contractions will eventually stop, only to start again hours (or even days) later.

Progress is usually very slow during the early phase of labor, which is also called the latent phase. Many contractions and a lot of time are required to make the cervix dilate the first few centimeters. However, each subsequent centimeter of dilatation takes less time to occur than the previous dilations. Stronger contractions facilitate increased dilation as they intensify during the course of labor.

You probably will be relatively comfortable during the early part of the latent phase of labor. Walking around is strongly encouraged, because it naturally stimulates labor. As the hours pass, though, you may become frustrated by the slow progress and the increasing discomfort. You may become so tired and fed up to the point where that pain medication seems very appealing.

Unfortunately, pain medication or an epidural given in the latent phase is likely to slow down your labor, possibly so much so that medical intervention (such as administering Pitocin to induce labor) may be required to get it back on track again. (For more on epidural anesthesia, see Chapter 24.) This is why it's important to try to hang on until the active phase of labor begins. At that point, pain medication or an epidural cannot slow down or stop your labor.

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Before Labour begins

Has the baby dropped yet? Friends and complete strangers are asking the same question. What are they talking about? How will you know the answer to this question? As the end of pregnancy draws near, the fetus is likely to take a position that will be favorable for the coming journey. Over 95 percent of all fetuses will be facing head down, with their chins tucked on their chests. Some babies, particularly those of first-time mothers, will literally drop into the pelvic opening. The cervix may not have dilated, and the fetus is still totally within the uterus, but the fetal head is now nestled within the pelvic opening instead of above it. Doctors and midwives refer to this process as engagement.

Engagement is also known as lightening, probably because it provides relief from some common pregnancy symptoms. When your baby drops, pressure on your stomach and diaphragm drops, too. You will probably have less heartburn and shortness of breath. Of course, these symptoms may merely be exchanged for new ones. You may feel increased pelvic pressure, and some women complain that it's hard to walk because it feels like the baby's head is between their legs. However, it's important to remember that many women have no change in their symptoms and never even notice when the fetal head engages. In any event, it is quite possible that the baby will not drop until labor begins.

There are other signs that the time for labor may be drawing near. For example, the mucous plug, which has kept the inside of the uterus sealed off from the vagina, falls out as the cervix begins to soften and thin in preparation for labor. The mucous plug may fall out hours or even days before labor begins. Sometimes the membranes of the amniotic sac rupture (this is called "breaking your water") minutes or hours before labor begins. If your membranes rupture, you should call your practitioner. Some doctors and midwives prefer that you come in for examination right away. Others will advise you to wait at home to see if labor begins spontaneously.

Some women exhibit other physical symptoms that signal labor is approaching, including diarrhea, low-back ache, or abdominal cramping. There are many who believe that impending labor causes psychological changes as well. Some women are seized with the nesting instinct in the hours and days before labor begins: They are suddenly consumed with the urge to clean and arrange things, when just a few days before they were too exhausted to move.

Can you do anything deliberately to start your own labor? Well, there are a lot of old (and new) wives' tales that you can consider. Some women insist that spicy food started their labors, and others claim it was because they dosed themselves with castor oil. Then there are those who swear by sex, reasoning that even if it doesn't work, at least they'll have a good time. Unfortunately, it's not likely that any of these home remedies are effective. Labor starts when the baby is ready-and not one second before.

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Part 2-Labor and Delivery

The weeks and months have passed, and your due date is rapidly approaching. The event that you have waited, planned, and hoped for is almost here. It seems that everywhere you go people have stories to share about their own birth experiences. Some sound sublime and others sound, well, just awful. Why do some women have such great labors and others such miserable ones? What can you do to ensure the best possible labor and delivery?

Someone once described labor as dependent on the three Ps-pelvis, passenger, and power-and that's not far from the truth. These three factors, individually and in combination, determine the length of your labor and whether you ultimately might need a Caesarean section.

The first P stands for the pelvis. What is meant here is the bony pelvis, the bone structure that supports the lower body and through which the baby's head must pass during labor. The mother's soft tissues will stretch during labor and delivery, but the pelvic opening, being bone, will not. Not surprisingly, women with a small pelvic opening will find it difficult, if not impossible, to deliver a large baby.

Of course, most women have a pelvic opening that is more than adequate to deliver an average baby. Your doctor or midwife will most likely do an internal exam a few weeks before your delivery date to assess your pelvis. The important thing is not the absolute size of the pelvic opening, but rather its relative size compared to the size of the baby's head.

The second P refers to the passenger (your baby). While it will be more difficult to deliver a larger baby than a smaller one, it's not the baby's weight that counts; it's the size and the position of the fetal head that are most important. Obviously, a bigger fetus will have a bigger head, but there are ways for the fetus to position his or her head that will make it easier to pass through the pelvis.

During the course of labor, while the cervix is dilating, the pressure of the uterine contractions encourages the fetus to assume the position in which the smallest possible diameter of the head is "presenting," or coming first. Not all babies cooperate, however, and if yours decides to go through the pelvis facing up or turned sideways rather than down toward your back, your labor will be longer and more difficult. It is much easier to deliver a baby whose head is tucked down on his or her chest rather than one attempting to come out face first (fortunately, this is a very uncommon position).

Even if the fetal head is large (compared to the mother's pelvis), or is in a less than ideal position, all is not lost. That's because the fetal head is capable of changing shape during labor. The bones of the fetal skull are not fastened to each other the way they are in the adult skull. The bones are free to move in relation to each other, allowing the fetal head to conform to the size and shape of the pelvic opening. This process is known as molding. Molding takes time, which is why a baby born after a long labor has a "cone head." The head actually gets longer and thinner to fit through the pelvic opening! It will return to normal shape in 24-48 hours, without any harm to the baby.

The final P stands for power-that is, the power of the uterine contractions. Not all contractions are alike; some are stronger than others. Usually, as labor progresses, the contractions become longer and stronger. However, some women never have strong enough contractions to get the job done, that is, to cause the cervix to dilate the necessary 10 cm. and to push the baby out. If your practitioner suspects that your contractions are not strong enough, she or he can strengthen them by giving you Pitocin, a synthetic version of the hormone oxytocin, which causes contractions.

If you need Pitocin, you will probably realize it at the same time that your practitioner does. Perhaps you've been in labor for many hours without dilation of your cervix, or maybe you made great progress until a certain point but then, despite additional hours of labor, nothing changes. Pitocin may then get you back on track by causing the contractions to become stronger and more effective.

However, there's no guarantee that Pitocin will cause continued progress. The uterus is an amazing organ, and it appears to be able to sense if the fetus is too large to deliver. In such cases, the cervix will not dilate any further, even with Pitocin. Then, it is clear that a C-section needs to be done.

What can you do to improve the course of your labor? Well, not much. The size of your pelvis was determined long ago, and you don't have any control over the size of the baby or the position it decides to assume. There are, however, a number of things you can do to ensure that your contractions are as strong and effective as they can be. The following seven chapters discuss the process of labor and delivery in detail, from the first contraction to delivery of the placenta, placing special emphasis on the things that you can do to encourage a smooth and efficient labor.

Next Chapter: Before Labor Begins

How the Fetal Monitor Works

Using an electronic fetal monitor is the best method of monitoring your baby during labor. It is the one piece of equipment that is routinely used in all labors, both normal and abnormal.

The fetal monitor looks quite impressive, but it's just a more sophisticated version of the monitor that your practitioner used to check the baby's heart rate at each prenatal visit. It operates on the same principle, using ultrasound waves to detect the movement of the fetal heart, and translating the changes in the waves to sound. In addition, the monitor can create a visual record of the heart rate because it contains a computer that instantaneously calculates the heart rate and displays the number. A pen continuously records the changing heart rate, producing a permanent graphic record. A second pen records the contraction pattern below the heart rate on the monitor paper. Monitoring contractions is very important because the heart rate pattern is almost impossible to interpret, unless you know when the contractions are occurring.

What do we learn from fetal monitoring? Monitoring the fetal heart rate can give valuable information about the baby's well-being, or health, in the last trimester of pregnancy. Also, fetal heart rate monitoring can be used to assess how well the fetus is tolerating the stresses of labor.

The non-stress test is an important method used to assess the condition of the fetus before labor begins. The name refers to the fact that when the test is administered, the fetus is not being subjected to the stress of contractions. A healthy baby, receiving an adequate supply of oxygen, will demonstrate a heart rate in the normal range (120-160 beats per minute). Also, a healthy baby is expected to move intermittently. This will be reflected by a rising heart rate that gradually returns to normal when the baby stops moving. Most babies who are receiving an adequate supply of oxygen will experience at least two accelerations (increases in heart rate) of at least 15 beats per minute above the baseline heart rate during a 20-minute period. These accelerations are usually associated with fetal movement. A healthy baby who is receiving adequate oxygen will move frequently. An oxygen-deprived fetus will move sluggishly or not at all.

There should not be any decelerations (dips in the heart rate) on a normal non-stress test. A non-stress test is called reactive if the results are normal, an excellent prognostic sign. If the heart rate is not reactive, the fetus may be okay, but further testing is clearly indicated.

The process of monitoring the fetal heart rate in the presence of contractions is called a contraction stress test, although the test is done exactly the same way as the non-stress test. When interpreting a contraction stress test, two questions must be asked. Is the fetal heart rate reactive? And, how does the heart rate respond to the contractions? A fetus that was fine before labor started may have trouble once contractions begin to occur regularly.

The baby who is receiving adequate oxygen across the placenta should not show any change in heart rate in response to the contractions. However, sometimes the fetal heart rate will decelerate. Not all decelerations are ominous. The significance of decelerations is determined by their relationship to the contractions-late decelerations cause the greatest concern. Late decelerations occur as each contraction is ending and persist after the contraction has stopped. Repetitive late decelerations are a sign of utero-placental insufficiency. This means the placenta is unable to supply enough oxygen between contractions to allow the fetus to "hold its breath" during contractions. Late decelerations warrant further testing if delivery is not imminent, and indicate a need for supplemental oxygen and other maneuvers that may increase the amount of oxygen available to the fetus. If late decelerations persist despite all efforts at treatment, emergency delivery may be needed.

Bradycardia, or slow heart rate, is another sign of significant fetal compromise.
If the fetal heart rate drops below 100 for more than one minute, the dip is no longer called a deceleration; it has now become a bradycardia. A drop in heart rate lasting several minutes or more is, of course, cause for serious concern. If the usual treatment measures fail to correct the problem, emergency delivery is required. Sometimes a lack of oxygen causes bradycardia. Other less common causes of bradycardia include compression of the umbilical cord, or even a true knot in the cord.

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Pre-eclamsia

Every visit to your doctor or midwife starts with the same routine, a blood pressure check, weight check, and the testing of a urine sample. These simple tests are designed to detect pre-eclampsia.

Pre-eclampsia (also known as toxemia or pregnancy-induced hypertension) is a disease that affects only pregnant women. This disease is much more common in first pregnancies, and is more likely to affect women at either end of their reproductive years-that is, both very young and older first-time mothers. Pre-eclampsia was originally characterized by elevated blood pressure, edema (swelling), and protein in the urine. As our understanding of this condition has grown, additional signs and symptoms have been identified. The most important of these is extreme sensitivity of the nervous system, which may cause seizures. Pre-eclampsia can also cause abnormalities in blood clotting and liver function.

Blood pressure measurement is expressed with two values, one value "over" another value. The upper number is the systolic pressure, and the lower number is the diastolic pressure. A typical blood pressure for a pregnant woman might be 110/70, or 110 "over" 70. If the diastolic pressure (bottom number) rises into the 90s and is sustained at that level, the possibility of pre-eclampsia must be considered. A sustained diastolic pressure above 100 is usually indicative of a severe case of pre-eclampsia.

It is important to remember, however, that a diagnosis of pre-eclampsia can only be made by comparing changes in a pregnant woman's blood pressure with her own blood pressure earlier in the pregnancy (preferably the first trimester). What is normal for one woman may be abnormal for another.

In the days before pre-eclampsia could be treated, serious complications often developed. These included seizures, strokes, and kidney damage. Today, these complications are almost never seen. Pre-eclampsia is usually diagnosed early and treated effectively. For example, women who have moderate to severe symptoms may be treated with magnesium sulfate administered through an intravenous line; this treatment will usually prevent seizures.

If your doctor or midwife has any reason to believe that you might be developing pre-eclampsia, you will get a thorough physical exam and a variety of blood tests that can give you more information about the course of the disease. You will also be advised about certain symptoms to watch for, including headache, blurry vision, and upper abdominal pain. These symptoms may indicate that your blood pressure is too high. If necessary, your practitioner may prescribe drugs, such as hydralazine, to lower your blood pressure.

Your practitioner will also recommend bed rest on your left side. In mild cases of pre-eclampsia, bed rest may be all that is needed to lower your blood pressure until delivery. The reason the left side is preferred is that this position takes the weight of the uterus off the major blood vessels that lie behind it, allowing maximum blood flow to the uterus and placenta.

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