Thursday, February 5, 2015

Childbirth Choices Series Part VI: Labor and Delivery

This is the sixth and final article in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

Previous articles in this series:

Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!


Welcome to the sixth and final installment of the "Childbirth Choices Series"! You've made it! Your pregnancy is nearing the end; you're finally going to meet your baby after nine long months. But first there's that pesky labor and delivery thing to get through. While your care throughout your pregnancy can and will affect your health and your baby's health, it's the birth experience itself that is likely to leave the most lasting impression on your and your child, both physically and emotionally. The experience of birth is profound for most women, no matter how your baby is born, and being informed and educated about the process and your options in advance will help you achieve the healthiest possible outcome, whatever that looks like to you.

This article is admittedly quite long. There's a lot of important stuff to know about labor and birth. Feel free to scroll down to find sections of interest to you, or simply read straight through to get the whole story at once.

What is a Birth Plan? Do I Need One?

Your care provider may ask you if you have a birth plan, or you may come across the term in your own reading and research. A birth plan is simply a written record of the way you hope your birth will play out and your preferences when certain decisions have to be made. It can be as simple as, "Get the baby out" to as complicated as a several-page document outlining every possible scenario and what your choices are in any given situation. You don't have to write a birth plan at all. It is not a legal or binding document. But it can be helpful to write down your desires in advance, or at least think them through, so that you have an idea of what you want before you're in the immediate excitement of labor itself. It can also be helpful to clearly express your preferences to your care provider in advance to make sure he or she is going to be supportive of your desires. See my article on birth plans for more information and an idea of what you might want to include in yours. You can also search the internet for fill-in-the-blank birth plans that may help you consider options you may not have thought about. Be aware that sometimes crazy things happen or things go way askew and you may have to toss the birth plan for the health of mother and/or baby, but knowing your options and rights is still better than going in blind.

Find out Your Baby's Position

A subject that is not discussed enough in preparation for birth is your baby's position in the womb. Most people know that it's best if the baby is head down for delivery. If a baby is not head down, that is called "breech" presentation. There are several possible breech positions. In some of these positions, such as transverse breech, where the baby is horizontal across your body, it is not possible to safely deliver vaginally and your provider will schedule a c-section to deliver your baby. In others, most notably "frank breech," which is when the baby's bottom is pointed toward the cervix, with the legs folded up, it may be possible to deliver vaginally if your provider is trained in the process. If your baby is breech as your estimated due date approaches, discuss your delivery options with your CP!

While most people know that the baby should be head-down at delivery, there are other positioning issues that I want to bring up. The best scenario is if your baby is head down with his or her face toward your back, with the chin tucked down toward the chest. This is called "occiput anterior (OA)" (the back of the head toward the front of the mother). The occiput is the narrowest part of the head, and it is easiest to push a baby out if that part of the head comes first! This is not to say that it is impossible to deliver vaginally if your baby is "occiput posterior (OP)" (the back of the head toward the back of the mother), but it will be more difficult. If your baby is OP, labor may stall, last longer, or not progress at all, and even if you get all the way to the pushing stage, it may be more difficult for the baby to get through the birth canal and you may experience more tearing of the perineum or vaginal canal. You may also experience back labor, which is when contractions are felt in the lower back. This is typically more painful and difficult to manage than more standard contractions, which are felt in the lower part of the abdomen. Plenty of babies are born posterior with no major complications, but for the smoothest possible birth, occiput anterior is ideal. 

While your care provider will certainly discuss with you whether your baby is head-down, he or she may not mention or even know whether the baby is posterior or anterior. Some providers can tell by touch, while others can take a peek with an ultrasound machine. If you are concerned, you can try to figure it out for yourself! Check out the website for more information about positioning and exercises you can do before and during labor to help your baby settle into an optimal position for delivery.

Being mobile toward the end of your pregnancy and during labor is very beneficial for promoting healthy positioning and a smooth delivery.

How Do I Know if I'm in Labor?

This is the big question, of course! Most women do end up in spontaneous labor, meaning your body starts labor without help from medications or interventions. The experience of labor will vary from woman to woman and even pregnancy to pregnancy, but it does follow a basic pattern for most people.

In about 15% of pregnancies, the bag of waters will break before any labor contractions begin. Despite what you see in many sitcoms, however, most women do begin having contractions before their water breaks. If your water breaks and contractions do not start within 12 to 24 hours, call your care provider to find out what you should do. If your water has broken, do not put anything in your vagina or take a bath or do anything else that may introduce bacteria into the vaginal canal, as this puts you and your baby at risk of infection.

Some other signs that labor may begin soon:
  • The loss of your mucus plug: Over the course of the final weeks of your pregnancy, you may notice gobs of mucus when you use the toilet. The mucus plug has closed up the cervix during your pregnancy to prevent foreign substances and infectious agents from entering the uterus. This has to fall out before your baby can be born.
  • The "bloody show": You may see mucus streaked with blood in your underwear or in the toilet. This usually indicates that labor will begin within the next few hours or days.
  • Your baby "dropping": You may notice that your baby is sitting much lower in your abdomen than in the previous weeks. For some women, this happens several weeks before labor, but others may experience this in the hours leading up to labor. This also depends on whether it is your first pregnancy. Babies tend to drop earlier in a first pregnancy than in subsequent ones.
  • "Nesting": You may feel a burst of energy and the sudden desire to clean, bake, or organize. You may feel agitated and the need to take care of things, especially things related to the baby, such as washing all the baby's clothes or rearranging the nursery.
  • Loose bowels: Often your body starts getting ready for labor by emptying your bowels, and you may experience diarrhea-like symptoms or very loose bowels and intestinal cramping.
But labor hasn't really begun until you're having contractions! You have probably already been experiencing strong but typically not painful contractions called Braxton-Hicks contractions. Labor contractions are stronger and more painful than Braxton-Hicks contractions and are more regular. Early labor contractions may feel like very strong period cramps. Many women in the last stages of pregnancy report that they feel much like they do in the days leading up to their period starting. These contractions differ from Braxton-Hicks in that they will not stop with activity, rest, or fluids. Your provider will probably tell you to call when your contractions are lasting about one minute (timed from when it starts to when it is over) and occur about every five minutes (timed from the beginning of one to the beginning of the next). There are several apps you can download for your smartphone that can help you time and record your contractions, if you're nervous about keeping track of it yourself. If you begin to experience regular contractions, try drinking two full glasses of water and taking a 15 to 30-minute walk and then lying down on your left side for a little while to rest. If the contractions continue or become more intense, you are likely in labor, and the walking and hydration will be great for helping labor along. If they subside, you may be experiencing what is called "prodromal" or "false" labor. If the contractions do die down or become less intense and frequent, take the opportunity to get some rest. Labor will come soon enough, and it's hard work! 

In the early stages of labor, your contractions will be painful but probably manageable. That is, you will still be able to walk and talk through them. You may try taking a hot shower or a long walk to cope with the early contractions. Don't over-exert yourself, and stay hydrated. Eat if you're hungry. Many women lose their appetite or even feel nauseated as labor progresses. Move in ways that feel good, lie down or sit down in positions that feel more comfortable and relieve some of the pressure. If you have a yoga ball, bouncing on that can be soothing as well. Having someone massage your lower back can feel great. Try getting on your hands and knees or into the yoga position called Child's Pose. Squatting helps to open the pelvis and allows the baby to move downward toward the cervix.

What Does a Contraction Feel Like?

It's difficult to describe a contraction if you've never experienced one, but I'd hate to say, "You'll know it when you feel it" and leave it at that! Milder contractions may feel similar to period cramps or intestinal cramping. You may feel like you need to go to the bathroom urgently, but when you go to the toilet, nothing comes out. As contractions build in intensity, you will feel a tightening in your lower abdomen. Usually, the pain starts in the lower part of the abdomen, and then as the uterus tightens, radiates upward through your belly. It may feel like you are clenching your stomach muscles, but you can't make them unclench. If you place your hand on your abdomen, you should be able to feel your uterus contract and then release as the contraction passes.

At the height of a strong contraction, you may find it difficult to breathe, talk, or walk. It may help to moan or hum during the contraction to help keep yourself focused. Screaming or yelling is usually less effective, but if you feel the need to yell or scream, you have my permission to do so! You may also want to grip something - a popular choice is your partner's hand!

When Do I Call My Provider?

Your care provider will give you an information sheet with instructions on when and who to call if you think something is wrong or you suspect you are in labor. The typical recommendation is to call when your contractions are lasting for one minute and coming every five minutes for at least an hour. When your contractions are strong enough that you have to stop whatever you're doing and can't talk during one, it's probably time to call! However, some women's labors don't follow this exact pattern, so if you strongly feel you are in labor or have any questions, don't hesitate to call. Your CP will listen to your concerns and give you advice on what to do. If it's after hours, you may be instructed to call the hospital (if that's where you're delivering) labor and delivery unit directly to speak to the triage nurse there. She can also give you some tips on how to tell if you are in labor or whether you should come on in to the hospital. It's usually good to call ahead just in case, so they can prepare a room for you and assign you a nurse.

When Do I Go to the Hospital, and What Will Happen When I Get There?

This section assumes you are delivering at a hospital, which is true for about 99% of births in the United States. 

The earlier in your labor you are when you arrive at the hospital, the higher the likelihood of interventions. For most first-time mothers, labor lasts many hours, and you don't have to go to the hospital as soon as labor starts. Some women do experience very quick labors (defined as under three hours), but it is unusual. Staying at home, in a comfortable and familiar place, can help you relax, manage early labor on your own, and allow you the freedom to move around, rest, eat and drink, shower, take a bath (as long as your bag of waters is intact), go shopping, or whatever seems like a good idea! If you have hired a doula, she can come to your house to be with you while you labor and can help you decide when it's a good time to go to the hospital.

If you are at all high risk and have been told to be at the hospital at the earliest signs of labor, then please heed that advice!

Some women are more comfortable being at the hospital. If that is the case for you, be aware that many hospitals won't admit you to L&D until you're clearly in active labor, usually at 3 to 4cm dilation. 

When you arrive, they will have you undress and put on a hospital gown and will hook you up to two monitors - one that measures the baby's heartbeat and one that measures your uterine contractions. These are attached to elastic bands that are wrapped around your belly. With these, they can "watch" the baby to make sure he or she is tolerating labor and they can see how often and how strong your contractions are. A nurse will check your cervical dilation by inserting her gloved fingers into your vagina. If your labor is not far along, they may suggest that you go home and allow labor to progress for a while. If your contractions are strong and regular and your cervix is dilating, you will be admitted.

They will probably take one last urine specimen and do a blood test. They may ask to insert an IV, or at least a hep lock or saline lock, which would allow them to attach an IV bag at some point in the future without having to insert the tube during a crisis. If you are Group B Strep positive, they will use the IV to administer antibiotics. You can also receive fluids via IV to prevent dehydration. The IV can be used to give you Pitocin or narcotic medication. You are within your rights to refuse an IV if you feel it interferes with your birth plan, or you may find it reassuring to have an IV ready to go in case it is needed.

They'll also have you do some paperwork. You probably filled out some kind of preregistration for the hospital so they'll have some information about you on file already. You will probably have to fill out some more forms when you get there, including insurance information, emergency contacts, and admission notes such as your religious preferences, food service needs, and so on. They'll get your medical history and information about this and previous (if any) pregnancies. You will also be asked to sign certain consent forms for medical treatment, which may include consent to use medications in labor and consent to c-section if the provider deems it necessary. Read through what you're signing, or ask to have it explained to you. It is important that you understand what you are agreeing to!

The Stages of Labor

Labor is typically divided into three general stages.

Stage One is the process of your cervix dilating, which is what we generally call "labor." It begins with the first phase, which is the early hours of labor as your cervix begins to dilate, until you reach about 4cm. Next is active labor, where your cervical dilation will speed up, contractions will become more intense and possibly more frequent, and your cervix will dilate to about 8 or 9cm. This second phase can take many hours in a first-time labor. The third phase is when you reach full dilation and enter transition.

Transition is when you switch from laboring to open the cervix to laboring to actually get the baby out. Transition can involve symptoms such as shaking, nausea and vomiting, screaming and yelling and thrashing about, shouting obscenities or cursing at your partner or your birth team, sweating, and other somewhat disturbing reactions. These are all normal and will be familiar to a competent birth team, though they may be frightening to you! Transition usually happens quickly, and brings you to the second stage of labor.

Stage Two is actually pushing out the baby. You will feel a strong need to push, which may feel like having a large bowel movement. Your provider or nurse may want to do a cervical check to ensure that you are fully dilated before you begin to push so as to avoid the cervix swelling up and preventing the baby's exit. Some babies come down slowly as you push, while others slide right out. The length and difficulty of the pushing stage can be affected by your position as well. If you are mobile, pushing in a squatting position or on hands and knees may be more effective for you than lying reclined on the hospital bed with your legs up. Once the baby is out, you go into the final stage.

Stage Three is the process of shrinking the uterus down and expelling the placenta. This usually happens without too much additional effort on your part, although you may need to push slightly or allow some uterine massage. Once you have delivered the placenta, labor is over, and the postpartum period begins. 

Let's talk a little bit about some of the decisions you'll need to make during labor.

Fetal Monitoring

You will most likely be asked to wear fetal monitors for most or all of the time that you are laboring in the hospital. In a home birth, your midwife will listen to the baby's heartbeat regularly but not continuously. In a hospital, the monitors strapped to your abdomen will feed information about the baby's heartbeat and your contractions directly to the nurse's station so that your nurse can see what's happening at all times, even when she is out of the room. A sudden deceleration of the baby's heartbeat (if the baby's heart rate suddenly slows down or stops) can indicate fetal distress and may mean there is an emergency situation. Typically this is caused by the umbilical cord becoming compressed or twisted. These decelerations can often be managed by changing your position to untwist or free the cord and by taking in extra oxygen through a mask to ensure the baby is getting enough as well. 

"Continuous fetal monitoring" means that you wear the monitors the entire time you are in labor. Many hospitals and providers require this. If it is not required, you may want to request "intermittent monitoring", which means that you will wear the monitors for 20 minutes every hour to check on the baby but will otherwise be mobile. This will allow you to walk around, change positions, use the bathroom, or take a shower (if available). Continuous monitoring limits your movement. If you receive an epidural, you will be immobile anyway and will probably require continuous monitoring.

Sometimes your provider will ask to use internal fetal monitoring. This is uncommon and involves inserting a wire through the cervix and attaching a monitor directly to the baby's head. This is used when a reliable reading is not possible with an external monitor. Internal fetal monitoring carries many risks that rarely outweigh the benefits. Ask your provider why he or she is recommending this course of action and if it is necessary for your health or the safety of your baby.

Non-Medical Pain Relief

Learning some strategies for managing the pain of labor without medications is valuable. Even if you are certain that you will request medications at some point, delaying these medications is typically associated with healthier outcomes. I discussed some of these techniques above and will go into more detail here.

Breathing: It may sound silly, but controlled breathing during a contraction can help you tolerate the pain and then release the tension once the contraction is over. Blowing air out will force you to inhale deeply and ensure that you continue to breathe regularly, rather than holding your breath and increasing the stress you are putting on your body. Think about what you do when you stub your toe. You rub it and breathe rapidly and loudly to try to dispel some of the pain. In the same way, breathing - and concentrating on the breathing rather than the pain - can help you get through the contraction and prepare you for the next one. It's helpful to try to relax as much as possible between contractions.

Movement: Find a position or movement that makes the contraction as comfortable as possible. This may mean standing up and swaying, bouncing on a yoga ball, kneeling beside the bed, squatting, getting up on your hands and knees, getting into Child's Pose, lying on one side or the other, leaning against a wall, or some combination or variation. It's okay to sit up, lie down, stand up, kneel, dance, walk, squat, lean, hug your partner, or whatever feels good. You don't have to spend your entire labor lying flat on your back. Indeed, you shouldn't!

Warm Bath or Shower: Warm water can be soothing, and sitting in a warm bath or standing in a stream of warm water in the shower may help dull the sensation of pain and help you relax. You may use your bath or shower at home, and if you have the option to use one at the hospital or birthing center, you may be interested in taking advantage of it.

Massage and Counterpressure: Especially if you are experiencing back labor, having someone massage your back or even use tennis balls to provide counterpressure during a contraction can lessen the pain of the contraction. A massage between contractions can help you relax as well.

If you have a doula, she may have other tools at her disposal to assist you, such as essential oils, aromatherapy, massage techniques, and equipment that she specializes in using.

Medical Pain Relief

There are basically three types of medical pain relief you may be offered.

Gas: While common in other countries, few hospitals and care providers in the United States offer nitrous oxide (like what you might get at the dentist) to help you relax during labor. It is becoming slightly more common, however, and you may be interested to ask your provider if gas and air is available to you.

IV Narcotics: Your care provider may offer you narcotic pain relief via your IV. Ask which specific medications are in the narcotic mix they offer. There are pros and cons to using narcotic pain relief. It can be an effective short-term option to help manage contractions without getting an epidural. The effects of one dose last about 60 to 90 minutes, and the dose can then be repeated if desired. It may be a welcome break from the pain and you may feel dreamy, happy, high or sleepy while the medication is in effect. The risk of taking the narcotics is that the baby will receive some of the drug through the umbilical cord, and if you deliver the baby while the medications are still in your system, your baby may be sleepy or lethargic at birth, which is not desirable. If you would like to try the narcotic pain relief, it's best to get it early enough in labor that it will wear off before you deliver.

Epidural: The epidural is an extremely common method of eliminating the pain of labor. The majority of hospital births in the United States involve an epidural. It is very effective at blocking the pain while allowing the contractions to continue so that you can, in theory, painlessly (though not effortlessly) birth your baby. But the epidural is fraught with controversy, and rightfully so. I'm going to spend some time here discussing epidurals, because I believe it's important to make an informed choice, and many providers gloss over some of the risks.

First, what is an epidural? An epidural is an injection of medication into the space just inside the spinal column, outside the dura, which is a layer of tissue that surrounds the spinal fluid. An anesthesiologist will insert a needle between two of your vertebrae and into the epidural space. The needle will be attached to a tube which will be fed a short way into the epidural space, and then the needle will be pulled out. The tube will be supply anesthetic medication directly into the epidural space continuously for as long as you want pain relief (typically until labor is over). The medication works by blocking pain signals to the brain. You will probably still feel the pressure of the contractions, but they should not register as painful.

In order to administer the epidural, you will be asked to sit up on the edge of the bed and hunch your back in a C shape. This allows the anesthesiologist to feel for the space in which he or she needs to insert the needle. You will need to hold as still as possible during the procedure, which is difficult while having contractions, but an experienced anesthesiologist understands this and should be quick. Once the tube is in place, the anesthesiologist will tape it down so that you can lie back without worrying about dislodging the tubing. The medication will begin to flow and can take up to 15 minutes to take effect. You will need a urinary catheter because the epidural will make you unable to pee on your own. They will adjust the medication as necessary so that you feel no pain but can ideally still move your legs and feel the urge to push when the time comes.

There are documented direct risks of epidural, most of which are small or fairly easily managed. The most significant risk is that of a drop in maternal blood pressure. Your blood pressure will be monitored, and if it drops too low, you will be given fluids via IV to raise your blood pressure back to a safe level. If your blood pressure drops, blood flow to the placenta may be reduced, which would cause distress to the baby. It is important to monitor maternal blood pressure and fetal heartbeat to ensure that both mother and baby are safe. 

A second small risk is that of epidural headache, which is quite rare and occurs if the dura is accidentally punctured during insertion of the epidural needle. The headache will usually clear within a week or two.

Tenderness or bruising at the insertion site may occur and will heal on its own.

My concerns with epidurals have more to do with the indirect or secondary risks. While research shows very low risk to mother or baby with epidural and does not show a correlation between epidural and c-section, there are secondary effects or consequences of epidural that you should be aware of.

I have stressed above that being mobile in labor can be very important for your comfort and to assist the baby in his or her descent through the birth canal. Once you have an epidural, you will be confined to your hospital bed, lying reclined on your back. For some women, this can slow or even stall labor. Additionally, you will have to push in this position, with your legs up in stirrups or held up by your or birth attendants' hands. This position is not ideal for pushing out a baby, because you are working against gravity and your pelvis cannot open as wide as in other positions. Depending on the size of your baby's head and the position of your baby, it may be more difficult or take longer to push out the baby. Indeed, epidural is associated with a lengthened pushing stage. You may risk increased tearing or require an episiotomy or other intervention such as forceps or vacuum extraction when delivering in this position, which I will discuss in more detail below. If the epidural is particularly strong, or you react strongly to the medication, you may find it difficult to push effectively, which will also lengthen the pushing stage.

A lengthened labor and poor position may lead to a suggestion of augmenting your labor with Pitocin to speed things up, which carries its own set of risks. I will discuss Pitocin in more detail below.  

If the epidural causes your blood pressure to drop, which is fairly common, you will be given extra fluids via IV to bring your blood pressure back up. If your labor is long, you could receive upwards of 5000cc (that's five liters) of fluids. All this extra fluid has to go somewhere. Some of it will go to the baby, which may artificially inflate the birth weight. After birth, the baby will quickly shed this extra weight, leading to concerns about whether the baby is getting enough to eat. The rest of the fluids will go to your hands, feet, and breasts, which will cause swelling until you can pee out the excess fluids. This swelling of the breasts, especially, can make it difficult for your baby to latch and remove milk, delaying the increase in milk production that should occur by the third day postpartum and possibly having long-term effects on your milk supply. There are techniques to mitigate this problem, most notably "reverse pressure softening," which you should be aware of if you choose to have an epidural and require extra fluids.

Finally, while the epidural medication is not likely to affect the baby strongly, some babies born to mothers who chose an epidural do appear more lethargic, sleepy, or less responsive compared to babies born without medications. This sleepiness or lethargy may make it difficult to initiate breastfeeding and keep the baby awake to receive feedings during the first several hours or days of life. As the medications work their way out of the baby's system, your baby should perk up and be fine. I think it's important to be aware of the ways in which epidural can impact early breastfeeding, as many women do wish to breastfeed and are not informed of these potential difficulties or how to manage them.

While for some women, epidural does slow labor, possibly due to inactivity, immobility, or position, others find that they are unable to release the stress caused by the pain of the contractions, and once they receive an epidural and can relax, their labor progresses more steadily. If you feel exhausted, overwhelmed, or frightened, getting an epidural may be a good choice for you. Keep in mind the possible complications or risks, but you should feel comfortable choosing one if you feel it is the right decision for you.

Augmentation of Labor/Pitocin

If labor is slow to start, starts and stops, or is not progressing as quickly as your provider would like, it may be suggested that your labor be "augmented" with Pitocin. Pitocin is a synthetic form of the hormone oxytocin, which is naturally produced in the brain. Oxytocin is released during sex, prolonged physical touch, breastfeeding, and labor. During labor, it specifically stimulates uterine contractions. Giving synthetic oxytocin (Pitocin) through your IV can help to increase the frequency and strength of your contractions. Doing so may also help get labor started if an induction of labor is deemed necessary.

The effect of Pitocin is increased contractions. The contractions tend to be stronger, more painful, and more frequent than non-augmented labor. This can be effective for opening your cervix and moving labor along, but it can also be intense and difficult. Many women opt for an epidural after receiving Pitocin.

There are risks to Pitocin which your provider may or may not discuss with you. 

Pitocin use is associated with higher risk of uterine rupture. (For this reason, it is often not recommended for VBAC, although it may be administered in low doses in certain cases.) It is also associated with postpartum hemorrhage due to hyperstimulation of the uterus. For the baby, Pitocin increases the risk of jaundice, and may contribute to fetal distress in labor due to the strength and frequency of the contractions. Fetal distress may lead to emergency c-section. As mentioned previously, even if a laboring mother had intended to give birth without pain medication, she may opt for an epidural after being given Pitocin because of the increased intensity of the contractions. (This is not to say that it's impossible to give birth without pain relief if you're given Pitocin, only that some women find it more difficult to bear.) In this case, the additional risks of epidural would apply.

It can be difficult to know whether a Pitocin augmentation is truly necessary. You'll need to consider whether your labor is progressing at all (Are you having regular, strong contractions? Is your cervix dilating, even slowly?), whether you've tried other means to encourage labor to progress (Have you taken walks, tried nipple stimulation, changing positions?), and how long you've already been in labor (Have you been having regular contractions for three or four days now? Are you exhausted? Is your baby tolerating labor?). Many doctors will begin to pressure you to speed up your labor after you have been at the hospital for over 12 hours, either because they need the bed emptied or because they genuinely believe that labor shouldn't last that long. However, many women experience healthy labors and births that last considerably longer than 12 hours, so this is an artificial limit that you are not obligated to meet! This is why I and many other normal birth advocates strongly recommend that you stay at home during the early hours of labor and let your labor progress naturally for as long as possible so that you don't end up on the hospital time table.

There may be emergent reasons for needing to birth your baby quickly, such as the onset of fever or distress that require immediate delivery vaginally or an emergency c-section. Pitocin can be very helpful in such a situation so that you can avoid major surgery, if desired.

Being aware of the risks and benefits of the use of Pitocin before you go into labor can help you decide if you will consent to using it if the option is presented.

Breaking of Waters

Your care provider may offer to move your labor along by breaking your bag of waters manually if it has not broken on its own. There is no way to predict at what point the amniotic sack will rupture. Some women (about 15%, as stated above) experience a rupturing of membranes before labor begins. For others, the water breaks somewhere in the middle of the labor. For some, the water breaks just before or during transition. And in rare cases, the baby is actually born inside an intact amniotic sac - called being born in the caul, and the sac must be broken after the baby is birthed or as he crowns!

It is believed that rupturing the membranes can speed up labor and increase the frequency and strength of contractions without the use of medication. It is not clear if artificial rupturing of membranes in fact decreases the length of labor, however. It has become so routine to break the waters that many providers may suggest it simply as a matter of course, believing that there is no great risk to doing so.

Because it is so routine, you may decide to allow the procedure - a simple and painless one which involves the care provider inserting a hook into your vagina and through the cervix to tear a hole in the sac. You may also wish to consider some of the risks or consequences associated with your waters being broken before deciding whether to allow artificial rupturing of membranes.

Once the membranes are ruptured, the baby is no longer protected from infection. If your waters break and the baby is not born within about 48 hours, there is an increased risk of infection that may require a NICU stay and IV antibiotics for both mother and baby. If you are GBS+, the risk is greater, as there is a chance of bacteria entering the birth canal and endangering the baby. Once your waters are broken, you should avoid excessive vaginal exams (such as to check dilation).

Another risk of ruptured membranes is that contractions tend to become more painful without the cushion of the bag of waters. The baby may also be affected by the increased pressure of the contractions. The consequence of increased pain is, of course, that you may opt for epidural pain relief. If the baby is affected by the increased pressure of each contraction, he or she may experience distress, which could lead to an emergency c-section.

Of course, since many women do experience a natural rupturing of membranes, the risk is probably fairly low, and it is up to you whether to consent to the procedure if it is offered.

Pushing the Baby Out

Yes, at some point you will actually have to get the baby out. That is the goal of labor, of course! In a vaginal birth, you will reach a point at which you are told to "go ahead and push." This happens when you get through transition and your cervix is fully dilated, measured at 10cm by an internal vaginal exam. In a birth that doesn't require any intervention, the pushing stage can last as little as a few minutes to as long as three or more hours.

Unless you have a very strong epidural, you will likely feel your body telling you to push. With each contraction, you'll take a big breath, hold it, and concentrate on pushing down and out, almost like when you're trying to poop when you're constipated. You'll feel pressure in your perineum or rear that feels much like the need to go to the bathroom. You'll push for as long as you can, usually about 10 seconds or so, and then take another breath and push again, typically two or three pushes per contraction. Rest in between contractions and catch your breath for the next round!

If you are mobile, it may help to push in a position other than lying on your back. If you get up and squat, or turn around and kneel, or get on hands and knees, you may be able to open your pelvis more and give the baby more room to come down. Plus, if you're more upright, gravity will help the baby come down with less effort from you.

A good provider will massage your perineum and help to stretch it as you push. The more your perineum can stretch, the less damage will be done by the baby coming through.

Because the action of pushing is similar to the action of having a bowel movement, many women do poop on the table. I promise that you will very likely not even notice that you have done so, because you'll be concentrating so on the baby. But, there's no need to be embarrassed about it. It happens all the time, and providers and nurses are used to it and will simply clear it away, wipe you off, and continue to cheer you on as you push.

The pushing stage is hard, whether it's minutes short or hours long. This is when having a good cheering section around you is vital. Your partner (if applicable), your delivery nurse, your provider, and your doula (if you have one) will tell you how well you're doing, will encourage you to push a little harder, will offer whatever kind of support you need. Strong support can make a huge difference in your will to keep pushing. You may experience thoughts of wanting to quit and demand a c-section just to get it over with. You may feel resentful that no one is helping you with this part, that you have to do it all yourself. You may change your mind and decide you don't want to have a baby after all! It's amazing the tricks the mind can play when you're exhausted, amped up from adrenaline, and have crazy hormones coursing through your body.

Keep your goal in mind: That baby will come out. You can do it. You will do it. If you need to take a short rest break, as long as the baby's vitals are stable, you can opt to not push for one or two contractions. But it usually feels better to push than not once you're in the pushing stage! Plus, I promise, you'll feel almost immediately better once the baby is OUT.

Your provider will check for the baby's head as you push and may announce the baby's "station." The station just means where along the birth canal the baby's head is. Negative station numbers mean the baby is still inside the uterus and hasn't passed through the cervix. Station 0 means that the head is at the cervix. Positive station numbers mark the progress down the birth canal. As long as the baby is making progress, you will be encouraged to keep pushing. You may hear your provider or a nurse tell you to "bear down." This just means to push downward as hard as you can. Try to direct your pushing down and out and not up into your face. You can burst capillaries in your eyes and cheeks if you push your breath outward in your face, and it's a less effective push than if you can focus downward toward your abdomen and vagina.

Within minutes or within hours, your baby's head will finally emerge into the world. Your provider may ask you not to push for a moment if there is a need to suction fluids from the baby's nose and mouth or to uwrap the umbilical cord from around the baby if the baby has gotten tangled. Or, your provider may help the baby rotate his or her shoulders to better fit through. Then you will give another good push to get the rest of the body out. Hearing the baby's first cry is exhilarating!

What Happens Immediately after the Baby Comes Out?

There will still be a little more work to be done once the baby is out. You have to expel the placenta. You may request "delayed cord cutting," which means that you wish to wait until the umbilical cord stops pulsing, usually two to five minutes, before cutting the baby off from your blood supply. Research suggests that this extra burst of maternal blood boosts the baby's iron stores and can make for a healthier baby in the first several months of life. There is no risk to waiting to cut the cord unless there is an emergency situation that requires that your baby be taken from you for help from a NICU team.

Within a few minutes of the birth, you will feel the need to push once more, and the placenta will slide out. Your provider may assist in this step by gently tugging on the umbilical cord. The placenta will be checked to make sure it is intact. If any piece of the placenta is retained in your uterus, it can lead to postpartum hemorrhage, infection, delay in milk production, and other complications and may require surgery to remove. It is important to ensure that you have completely expelled the placenta!

If you have requested immediate skin-to-skin, you may want to wait until your baby is wiped off with a towel and diapered, or you may want to hold the baby as soon as he or she emerges. That's up to you! Put your baby on your chest between your breasts, and your nurse will put blankets over both of you to keep you both warm. Introduce the baby to the breast, which may require assistance from your doula, partner, and/or nurse (as applicable). Your baby should be fairly alert in the first hour or two after birth and actively seek out the breast. Help your baby find the nipple and latch on. The sucking will release additional oxytocin to help your uterus to shrink, stemming the flow of postpartum bleeding. That first dose of colostrum will help prime your baby's digestive system, help him or her start moving out the meconium that has coated the intestines in the womb, and give you something to focus on and help you start bonding with your baby.

The neonatal team (usually a nurse and occasionally a pediatrician as well) will want to weigh your baby, measure his or her length and the size of his or her head. They will also suggest putting antibiotic ointment on the baby's eyes and giving the baby a vitamin K shot. I won't go into all of these procedures here, but I do recommend you do some reading about the purpose of these medications. You may request to wait for weighing and measuring until the baby has taken a break from the initial breastfeeding, or you may wish to have it done right away and then take the baby back to breastfeed (if you're planning to breastfeed). They will also ask if you'd like your baby bathed. You may choose to delay the bath or you may like to have your baby bathed immediately. Research does suggest that holding off on the bath for 12 to 24 hours can help your baby maintain body temperature and has other benefits as well, such as protecting the baby's delicate skin.

If there was any damage to your perineum or vulva during the baby's exit - either tearing or an intentional cut, called an episiotomy (see below) - your provider will assess the need for stitches. If you have an epidural, they will keep the medication flowing while they stitch you up. If not, they will offer a local anesthetic. In my experience, you are often fairly numb from all the stretching anyway, but a local may still be welcome, depending on how much stitching you need.

Your provider, your labor nurse, and/or your doula will massage your uterus to encourage it to spring closed, near to its prepregnancy size and shape. It takes a few weeks to completely return to normal, but this initial shrinkage is very important to prevent hemorrhage. This will probably be painful. They may also show you how to massage it yourself and instruct you to do so periodically over the next several days. If there are any concerns about postpartum hemorrhage, they may also recommend a dose of Pitocin to help the uterus contract.


An episiotomy is a deliberate cut to the perineum made by your provider during delivery. The perineum is the area of skin and muscle between your vaginal opening and your anus, and it needs to stretch to allow the baby to come through the birth canal. Episiotomy was once a routine procedure. It was believed to cause less damage and heal faster and more cleanly than the natural tearing that might occur during a normal delivery. Evidence has shown this not to be the case, and episiotomy is considerably less common now than in decades past. Tearing of the tissues can be minimized by perineal massage and warm compresses, by being in a comfortable and optimal position while pushing, and by allowing the baby to descend slowly so that the tissues can stretch. There may still be tearing, especially if this is your first vaginal delivery, but these tears can be repaired with stitches after the delivery.

However, your provider may still suggest an episiotomy under certain circumstances. If your baby is malpositioned - that is, not in an optimal position for delivery - your tissues may need to stretch and tear more to allow your baby's exit, or you may simply not be able to push the baby out easily. An episiotomy in this case may help to widen the vaginal canal to allow the baby's exit. In other cases, the perineum is tough and will not stretch as much as needed, and your provider may feel that a tear would be more traumatic than a small cut. Finally, if your baby is in distress and needs to be delivered quickly, an episiotomy can help speed delivery by providing more space for the baby to emerge.

Risks of episiotomy include infection, more painful recovery, and difficulty sitting, defecating, and urinating for a few days or weeks after delivery. There is also a risk of cutting too deeply and causing severe damage to the perineum, or that the episiotomy will tear further as the baby emerges. Your provider should make the smallest possible cut to allow the baby to pass through.

Discuss the risks and benefits of episiotomy with your provider before your delivery, if possible, so that you can make an informed decision if one is suggested or offered.

If an episiotomy is warranted and you do not have an epidural, your provider will inject a local anesthetic so that you don't feel the actual cut. After your baby is born, your provider will then stitch up the episiotomy and/or other tearing.

You will be given instructions on caring for your episiotomy or tears to prevent infection, speed healing, and reduce pain.

Assisted Delivery

Sometimes, despite your best efforts and the support of your birth team, it becomes clear that the second stage (pushing stage) of your labor is not progressing well, or that the baby needs to be delivered quickly for his or her safety or for yours. In these cases, an assisted delivery may be deemed appropriate.

There are two instruments that may be used to assist you in delivering your baby vaginally. These are the vacuum extractor and forceps. Your provider may prefer one to the other, but they serve the same purpose: to allow your provider to help pull the baby out as you push.

Vacuum Extraction

One method to assist you in birthing your baby is the use of vacuum extraction. In this procedure, your care provider will attach a cup to the top of your baby's head using a vacuum pump. Then, as you push, the provider will tug on the cup to try to help pull the baby out.

Use of the vacuum has some risk, including injury to the baby's scalp or skull and injury to the mother's vagina or perineum. It may cause swelling of the baby's scalp where the cup attaches. The risks associated with vacuum assisted delivery are relatively minor, but if you are able to deliver your baby without assistance, it is safer for you to do so.


Forceps have been around to assist birthing women for hundreds of years. They look roughly like large salad tongs. The care provider inserts the forceps into the vagina and grasps the baby's head on either side, then gently pulls on the baby's head as the mother pushes. In this way, much like with vacuum assistance (above), the provider can help the mother deliver the baby.

Risks of forceps use include minor bruising or cuts to the baby's head (which will heal on their own), additional tearing of the mother's vagina or perineum, and, more rarely, nerve damage to the baby's face (which will heal). If forceps are used properly, the risks associated are relatively minor. However, as with vacuum-assisted delivery, if you are able to push the baby out on your own, it is safer for you to do so.

Emergency Situations

I am including this partial list of possible emergency situations so that if something does occur during your labor, you will have some understanding of what's going on. This is not meant to frighten you or dissuade you from giving birth in the location and manner you feel most comfortable. These situations are rare, and if attended to quickly, generally mother and baby come out healthy and safe.

While most women go in, give birth, and everything is fine, emergency situations do arise that will require quick responses from your care team. "Fetal distress" is a catch-all term for evidence that the baby is not tolerating labor for whatever reason. Typically, the baby's heart rate slows down or speeds up to dangerous levels, as noticed on the fetal heart monitor or during a routine listen with a stethoscope or Doppler machine. If the heart rate doesn't recover to the normal range within a few minutes, it may be declared an emergency.

Emergencies can happen for a variety of reasons. For example, the umbilical cord may be too short, or the baby may be tangled in the cord, or the position of the baby may mean he or she is putting pressure on the cord and blocking blood flow. In rare cases, the cord may actually be twisted or tied in a knot. In many of these cases, the baby may not be able to drop into the birth canal and emerge vaginally, and a c-section is necessary to safely deliver the baby. Sometimes, repositioning the mother can help take pressure off the cord and resolve the situation with no further intervention.

Another emergency situation is cord prolapse, which is when the umbilical cord emerges from the cervix before the baby crowns. This is a definite emergency, because it is impossible for the baby to be born vaginally without cutting off his or her own blood supply. This situation necessitates an emergency c-section.

Placental abruption is when the placenta detaches from the uterine wall before the baby is born. This is also an emergency situation because once the placenta detaches, the baby can no longer receive oxygen and nutrients from the mother. The baby must be delivered immediately.

Shoulder dystocia is a rare condition in which the baby's shoulders get stuck in the birth canal. If not resolved quickly, this can be very dangerous. However, a trained birth team will be able to jump to action to free the baby, which may require breaking the baby's collarbone and pulling him out.

Meconium in the amniotic fluid is a situation that may warrant attention from a NICU team. Meconium is a sticky substance that coats the intestinal tract of the baby while in the womb. If the baby has a bowel movement in utero, which can occur either because the baby was in distress or sometimes when you are well past your estimated due date, it is possible for the baby aspirate the meconium into his throat and lungs. Because it is sticky, it is difficult to expel, and this can cause respiratory distress once the umbilical cord is cut and the baby needs to start breathing on his own. If meconium is found in the amniotic fluid when the sac is ruptured, a NICU team will be on call for the delivery.

Uterine rupture is when the wall of the uterus partially or completely opens. This is an emergency situation requiring immediate surgery. Usually, mother and baby are perfectly fine once the crisis has passed, and often the mother's fertility can be saved as well if action is taken quickly. Sometimes uterine rupture can have more catastrophic results, unfortunately. The good news is that uterine rupture is very rare. It is slightly more common in women who have had one or more cesarean sections or more than five pregnancies, but the risk is small even in these cases.

Fever/Infection in the mother may warrant emergency action by the delivery team. If the mother develops a fever during labor, it may indicate that she has an infection that requires immediate attention. Infection in the mother during labor may put the baby at risk as well, and infection or fever can be very dangerous for a newborn, whose immune system is not developed yet.


Conspicuously absent from the discussion above is the other way to give birth, cesarean section, or surgical birth. You should know what a c-section is and what the risks are if you are thinking about choosing a cesarean birth. You should also know the circumstances under which a c-section may be suggested or required so that you can make informed decisions if the situation should arise.

A c-section may be planned, non-emergency but unscheduled, or emergency. A planned c-section is when it is known in advance that a surgical birth is necessary or desired. You and your doctor will choose a date no earlier than your 39th week of pregnancy (unless other circumstances require an early birth). A scheduled c-section is associated with the lowest risks for the mother, compared with unscheduled and emergency c-sections, but there are risks to both mother and baby with cesarean section, and unless otherwise indicated, typically a vaginal birth is safest.

A non-emergency but unscheduled c-section occurs when you had planned on a vaginal birth, but it becomes clear during labor that you will not be able to deliver vaginally, or you and your provider determine together that you do not wish to labor any longer. You and your provider may decide that the baby's position or your physiology simply will not allow the baby to completely emerge through the birth canal. There are other situations that may arise as well. For example, you may have tried an induction that did not result in sustained labor. Or, perhaps you are well past your estimated due date and have not gone into labor, or your amniotic sac has ruptured (your water broke) but labor is not starting on its own.

Under these circumstances, your provider may suggest delivering the baby via cesarean section. Even if you had not planned to have a c-section prior to this point, a c-section under these circumstances is not considered "emergency" as long as mother and baby are not in distress. A non-emergency c-section allows time to administer a spinal block (if the mother does not already have an epidural) so that the mother can remain awake and alert during the delivery. It allows the family and provider to prepare for a surgical birth. The risks of complications in a non-emergency c-section are lower than those associated with an emergency c-section.

An emergency c-section will be ordered if a situation arises in which the health or life of mother or baby are suddenly in danger. I detailed some possible emergency situations above. If one of these should occur, you will be quickly transported to the nearest operating room and prepped for surgery. If you already have an epidural, they will continue those medications to prevent you from feeling the pain of the surgery. If you do not, depending on the seriousness of the emergency, your doctors may be required to use general anesthesia to render you unconscious so the surgery can be performed quickly and safely. 

How is a C-Section Performed?

In a cesarean section, the surgeon (your obstetrician or an obstetrician on call at the hospital) cuts through the abdomen with a scalpel, makes an incision in the uterine wall, retracts (pulls back) the sides of the incision, suctions out the amniotic fluid, disengages the baby from the pelvis (if necessary), and delivers the baby head-first through the incision. When the head is out, the fluids are suctioned from the baby's mouth and nose to clear the lungs and airway, then the rest of the body is pulled free of the incision, and the umbilical cord is cut. The placenta is removed and examined to ensure it is intact. Then the uterus is sutured and the abdominal incision is closed up. The entire procedure typically takes about 45 to 60 minutes, with the first 5 to 10 minutes being delivery of the baby.

Depending on the practices of your particular doctor and hospital, it may be possible to hold your newborn on your chest during the second phase of the surgery, and even breastfeed him or her if desired. This is becoming more common and is something you may want to discuss with your provider prior to the surgery, if there is time. You may also want to research "family centered cesarean," in which the birth environment is set up to be as comforting and warm as possible for mother and baby. You may even be able to request to watch your baby's birth (if you want!). If possible, discuss cesarean section scenarios with your provider so that your wishes and needs can be heard and respected during the process. A c-section need not be traumatic or emotionally sterile just because it is not a "traditional" birth.

Risks of C-Section

The most common risk to the mother is post-surgical infection. Other risks for the mother include severe blood loss, reaction to anesthesia, and blood clots. Risks to the baby include lung or breathing problems and birth injury (such as being cut by the scalpel). Risks to the baby of a planned (scheduled) cesarean, as opposed to one that occurs during labor, also include premature delivery, which can carry many complications of its own. It should be noted that a planned cesarean does appear carry fewer risks to the mother than an emergency c-section.

There are also long-term risks of c-section, or multiple c-sections. These include increased risk of future placenta previa (which is when the placenta is blocking the cervix), future placenta accreta (which is when the placenta is too deeply attached in the uterine wall and cannot be expelled), uterine rupture, and risk of future emergency hysterectomy during birth. These risks increase exponentially with each additional c-section.

I want to stress here that in most cases, it is possible to have a vaginal delivery in a subsequent pregnancy even after one or two cesarean deliveries (vaginal birth after cesarean, VBAC). You can browse the "VBAC" tag on this blog for more on than, and investigate for great information about VBAC.

The Immediate Postpartum Time

I won't go into great detail about this in this series, since the focus is on pregnancy and birth. See this article for some tips for your postpartum hospital stay. During the first hours and days after your baby is born, you will spend time resting, learning to feed and care for your baby, and simply bonding. Spend time skin-to-skin with your baby (whether you're breastfeeding or not), enjoy being waited on, and get as much information from the doctors, midwifes, and nurses as you can. If you and your baby are healthy and you had a vaginal birth, you may be able to go home within 24 to 48 hours of the birth. In a c-section birth, you will stay three to four days to ensure you are healing properly.


Despite the length of this article and the Childbirth Choices Series, I cannot possibly have covered every question or every scenario you may encounter. I hope that I have given you some guidance, information you did not already have, and helped to organize your thoughts so that you can make evidence-based and informed choices as you navigate your way through pregnancy and childbirth. Do not be afraid to ask questions of your care provider, research on your own, and talk to friends who have had babies. You'll find a myriad of experiences, a plethora of opinions, but from all of this you should be able to figure out what you want out of the birth of your child.

I encourage you to browse the pregnancy and birth-related tags on this blog to learn more and to visit for evidenced-based articles on childbirth-related topics.

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