10.8: Labor and Birth

Labor is defined as contractions and cervical change, contractions alone are not labor.

Pre-Labor Signs: as your body is preparing for labor, there are a few things that should be expected to happen within four to six weeks of labor.

1. Pressure on the pelvic area
2. Occasional brownish discharge
3. Energy level is noticeably increasing or decreasing
4. Loss of the mucus plug (does not always exist)/increasing discharge
5. Braxton Hicks contractions (painless contraction of the uterus)
6. Movement of the baby into the pelvis

False Labor Signs: there are a few signs that indicate false labor.

1. Timing of the contractions are irregular and do not become more frequent or more intense
2. Contractions stop during rest, stopping what the mother is doing, walking, or changing position
3. Inconsistent in strength (strong one minute then weak the next)
4. Location of pain is in the front only

True Labor

1. Pain in the lower back, radiating towards the front abdomen, possibly also the legs
2. Contractions increase in strength and are closer together; coming now on a regular basis, 30 to 70 seconds apart
3. The mucous plug is detached, showing bloody discharge
4. The water breaks (often this does not break until the doctor or nurse midwife does it), when this happens, contractions become much stronger
5. Some women have the sudden need to go to the bathroom, diarrhea is common
6. Contractions continue despite movement
7. The cervix is thinning and dilating

When the contractions of labor begin, the walls of the uterus start to contract. They are stimulated by the release of the pituitary hormone oxytocin. The contractions cause the cervix to dilate (open) and efface (thin out) . As labor progresses the amniotic sac can rupture causing a slow or a fast gush of fluids. Labor usually begins within a 24 hour period after the amniotic sac has ruptured. As contractions become closer and stronger the cervix will gradually start to dilate. The first stage of labor is broken into three parts:

• Early Phase: First is the early phase of labor, when the cervix dilates from 1-4 centimeters, this can be the longest and most exhausting part for the mother.
• Active Phase: The cervix dilates on average 1 cm per hour in the active phase of labor dilating from 4-7 centimeters. If an epidural is requested, it is usually given in this phase.
• Transition: This is often considered the most intense part of labor with contractions lasting longer and having shorter rest periods in between them. Dilation from 8-10 centimeters occurs during transition. Some women experience nausea and vomiting during this phase as well as rectal pressure and an urge to push.

At this point the labor enters the second stage, or the birth of the baby. The mother begins pushing to aid in the birth of the baby, this part of labor can last minutes, or even hours. A fetus is usually delivered head first. 'Crowning' is the term used when the fetus' head can be seen between the mothers labia as it emerges. At this point, the birth attendant may perform an episiotomy if necessary, which is a small surgical incision on the perineum. This procedure is usually done to deliver the baby more quickly, in response to fetal distress.

Diagram showing an episiotomie. Licensed under CC BY-SA 4.0

The third stage of labor is the delivery of the afterbirth (placenta). Oxytocin continues to be released to shrink the size of the uterus and aid in the limiting of blood loss from the site of the placenta. As the uterus shrinks the attachment site blood vessels, some of which can be as large as an adult finger, shrink also. The average blood loss in a routine vaginal delivery is 400-500 cc.

There are times when a mother may need outside aid in the delivery of the baby, some of these methods include:

• Forceps, an instrument used to cradle the fetus' head and manipulate the head under the pubic bone to more easily pass through the birth canal.
• Vacuum Extraction, a suction cup is applied to the baby's head, and a plunger is used to suck any air from between the suction cup and the head to create a good seal. The baby's head is then manipulated through the birth canal. This usually leaves a baby's head bruised, but the mark fades within weeks after birth.

C-section Birth. Licensed under CC BY-SA 4.0

• Cesarean section, also known as C-section, is the delivery of a baby through a surgical abdominal incision (Abdominal delivery - Abdominal birth - Cesarean section). A C-section delivery is performed when a vaginal birth is not possible or is not safe for the mother or child. Surgery is usually done while the woman is awake but anesthetized from the chest to the legs by epidural or spinal anesthesia. An incision is made across the abdomen just above the pubic area. The uterus is opened, and often brought through the incision after delivery for better visualization. The amniotic fluid is drained, and the baby is delivered. The baby's mouth and nose are cleared of fluids, and the umbilical cord is clamped and cut.

After delivery, a Newborn Intensive Care Unit (NICU) nurse, nurse midwife, nurse practitioner, neonatologist or pediatrician checks to make sure that the baby is breathing and responding. Due to a variety of medical and social factors, C-sections have become fairly common; around 25% of births are performed by C-section. C-sections carry some risks to mother and baby. Compared to a vaginal birth, the risks to mother include increased risk of death, surgical injury, infection, postpartum depression, and hemorrhage, although these are rare. Babies born by c-section are more likely to be admitted to the NICU for breathing problems. Mothers are advised to carefully weigh the risks of C-section versus vaginal birth.

"New Born Baby at the hospital" by Lizadeborah03 is licensed under CC BY-SA 4.0

Delivery Options

Hospital Births

The chances of having a natural, uncomplicated birth are optimized by carefully selecting your obstetrician and hospital. Doctors who work with midwives have lower Cesarean section rates because midwives handle less complicated pregnancies. Delivering babies by abdominal surgery has been steadily rising in America over the past two decades, so that now 22-30% of births in American hospitals are by Cesarean section. The U.S., despite having the most advanced technology and highly trained medical personnel, ranks 23rd in infant mortality and 18th in perinatal mortality.

Medical interventions such as epidural anesthesia, pitocin augmentation of labor, vacuum extraction of the fetus, episiotomy and separation of newborn and mother are common in American hospitals. There are circumstances where medical procedures such as these are necessary, but many parents and professionals now question the routine use of such interventions. In some cases, the routine use of these procedures have led to further complications. For example, the epidural anesthetic, while providing pain relief, has shown to increase the operative vaginal delivery rate (i.e. forceps and vacuum extraction rates slightly), especially in first time mothers. Epidurals have not been shown to increase the cesarean section rate in recent well documented studies.

Freestanding Birth Centers & Water Birth

"Freestanding" Birth Centers are not inside of or affiliated with a hospital. They are run by a collaboration of midwives and/or physicians. This is an alternative choice for the woman who does not wish to give birth in a hospital environment, yet is not comfortable giving birth at home. Birth centers do not provide any additional measure of safety than most planned home births with qualified midwives; they may provide the expectant couple with the physiological comfort necessary to enable the mother to relax.

Out-of-hospital birth centers are designed for women having low-risk pregnancies, who want drug-free birth with minimal intervention in a home-like environment. Family members may participate in the birth. C-sections rates are lower than most hospitals because the pregnancies are low risk. Freestanding Birth Centers are an alternative choice for a woman who has had a previous cesarean and wishes to maximize her chances of a vaginal delivery. However, vaginal birth attempts after a prior cesarean section have a 1-2% risk of uterine rupture. Health insurance may cover costs. Many birth centers offer birthing tubs where one can give birth in water.

Homebirth

Birth at home provides parents with intimacy, privacy, comfort and family-centered experience. Childbirth at home may be a safe option for healthy women having normal pregnancies. It is for those who have a very strong desire for natural childbirth, and who are willing to take a high degree of responsibility for their health care and baby's birth. At home, the parents and midwife are in control of the birthing environment, and strict time perimeters for length of labor are not imposed, or routine medical interventions such as IVs done. In choosing the comfort of, home parents are also choosing to be further away from lifesaving measures, should complications arise.

Homebirth midwives provide complete prenatal care including monthly visits, laboratory tests, screening for infections. They provide nutritional counseling and support for psycho-social issues. There is a chance that a rare, but critical emergency might occur during the birth where hospital services may not be able to be obtained quick enough. Home birth midwives are trained to know when an emergency requires a medical interface, and can provide stabilizing measures until critical care can be obtained.

"Homebirth" by SignijalP is licensed under CC BY-SA 4.0