Labor and Delivery

While it takes nine months to grow a full-term baby, labor and delivery occurs in a matter of days or even hours. However, it’s the process of labor and delivery that tends to occupy the minds of expectant parents the most, with questions and concerns around the signs and length of labor, and how to manage pain.

Signs of Labor

Symptoms such as increased pressure in the uterus, a change of energy levels, or a bloody show (mucus streaked with blood) can all mean that labor has started or is coming soon. When contractions become regular and are painful, it most likely means real labor has arrived. 

Braxton Hicks Contractions

Many women experience irregular contractions sometime after the 20th week of pregnancy. Known as Braxton Hicks contraction, they are typically painless or, at most, uncomfortable and are irregular. Braxton Hicks contractions can sometimes be triggered by an increase in activity of either mother or baby or a full bladder. No one fully understands the role Braxton Hicks contractions play in pregnancy. They may promote blood flow or play some role in maintaining uterine health during the pregnancy or preparing the uterus for childbirth. Braxton Hicks contractions do not cause the cervix to dilate. Painful or regular contractions are not likely to be Braxton Hicks and should lead you to call your doctor.

Stages of Labor

Labor and delivery are divided into three stages:

First Stage

The first stage of labor incorporates the onset of labor through the complete dilation of the cervix. This stage is further subdivided into three stages.

  • Early Labor:  This is normally the longest and least intense phase of labor. Early labor is also called the latent phase of labor. This period includes the thinning of the cervix and dilation (opening) of the cervix to 3-4 cm. It can occur over several days, weeks or just a few short hours. Contractions vary tremendously during this phase and can be mild to strong and occur at regular or irregular intervals. Other symptoms during this phase include backache, cramps, and a bloody show. Most women will be ready to go to the hospital at the end of early labor although many women will arrive at the hospital or birthing center when they are still in early labor.
  • Active labor:  The second phase of labor (also called the active phase) as the cervix dilates from 3-4 cm to fully dilated (10 cm). Contractions become stronger and other symptoms may include backache and bloody show.·           
  • Transitional Labor:  This is the most intense phase of labor with a sharp increase in contractions. They become strong and occur about two to three minutes apart, and average 60 to 90 seconds. The last three centimeters of dilation (to the full 10 cm) usually occur in a very short period of time.

Second Stage

  • Delivery:  During the second stage, the cervix is fully dilated. Some women may feel the urge to push right away or soon after they are fully dilated (10 cm), for other women the baby may still be high up in the pelvis and it may take some time for the baby to descend with the contractions so it is low enough for the mother to start pushing. Women who do not have an epidural typically have an overwhelming urge to push or significant rectal pressure when the baby is low enough in the pelvis. Women with an epidural may still have an urge to push and they may feel rectal pressure, although typically not as intense. Burning or stinging in the vagina as the baby’s head crowns is also common. It’s important to try and stay relaxed and rest between contractions; this is where your labor coach and/or doula can be very helpful.

Third Stage

  • Delivery of the placenta:  After the baby has been born, the placenta, which has been the baby’s life support for the last nine months, will be delivered. Mild contractions will help to separate the placenta from the uterine wall and move it down towards the vagina. After the placenta is delivered, any necessary stitching (if you had a tear or episiotomy) will occur.

Pain Relief

Modern medicine can provide a variety of options to manage pain and complications that can occur during labor and delivery. Some of the medications available include:

Narcotics:  Narcotic medications are used frequently for pain relief during labor.  However, their use is limited to the early stages because of their tendency to cause excessive maternal, fetal, and neonatal sedation. Narcotics are generally given to women in labor by intramuscular injection or through an intravenous line. Some centers offer patient controlled administration. This is an attractive method to laboring women because they can choose when to receive the drug. 

Some of the most common narcotics include:

  • Morphine
  • Meperidine
  • Fentanyl
  • Butorphanol
  • Nalbuphine

Nitrous oxide:  Inhaled analgesic medications are sometimes used during labor.  Of these, nitrous oxide, often called laughing gas, is most commonly used.  When used intermittently, it can provide adequate pain relief particularly in the early stages of labor for some women.

Epidural:  The most commonly employed method of pain relief during labor and delivery is the epidural blockade.  It is used to provide anesthesia during labor and delivery as well as anesthesia for a caesarean section.  The blockade results from injecting a locally acting anesthetic drug into the epidural space, located just outside the lining covering the spinal cord.  The drug effectively blocks the transmission of pain sensations through the nerves that pass through that portion of the epidural space before connecting with the spinal cord. 

The use of combined spinal-epidurals or a walking epidural has gained popularity in recent years. This technique involves passing a very small pencil-point needle through the epidural needle prior to placement of the epidural anesthetic. The smaller needle is advanced into the space adjacent to the spinal cord and a very small dose of either a narcotic or local anesthetic is injected into the space. This affects only sensory function which enables the patient to walk and move about during labor. This technique is normally used during the early stages of labor.

Natural Pain Relief Options

For women who are seeking a nonmedical pain relief for labor and delivery there are many options that focus on reducing the perception of pain without the use of medication. Some of these include:

  • patterned breathing
  • Lamaze
  • hydrotherapy
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • hypnosis
  • acupuncture
  • massage

Induction of Labor

Labor can be artificially induced in several ways. The method chosen will depend on several factors including how ready your cervix is for labor, if this is your first baby or not, how far along you are in the pregnancy, if your membranes have ruptured, and the reason for the induction. Induction may be recommended when a pregnancy has gone into the 42nd week, if the mother’s water breaks and labor doesn’t begin shortly thereafter, or if there are complications with the mother (such as high blood pressure) or with the baby (such as a delay in growth). Induction of labor is usually not recommended when a woman has had a previous c-section or if the baby is breech (bottom down).

If the cervix is long and has not softened or started to dilate, either a hormone medication called prostaglndin, a medication called misoprostol, or a device may be used to soften and open the cervix (this is called cervical ripening).

Stripping the membranes may induce labor for some women. This is a procedure in which your doctor checks your cervix and manually inserts a finger between the membranes of the amniotic sac and the wall of the uterus. By separating or stripping the lower part of the membranes from the uterine wall, natural prostaglandins are released, which may soften the cervix and cause contractions. Stripping the membranes can only be accomplished if the cervix has dilated enough to allow your doctor to insert their finger and perform the procedure.

Medications, such as oxytocin or misoprostol can be used to induce labor. Oxytocin is given in the intravenous, and misoprostol is a tablet placed in the vagina.

Fetal Position

The position of your baby is regularly monitored by your doctor during prenatal visits. Most babies turn into a head-down position between the 32nd and 36th weeks, but some don’t turn at all, and others turn into a feet-first, or bottom-first position. Most doctors will try to turn a breech fetus into a head-down position using external cephalic version (ECV). During an ECV, a doctor will try to gently shift the fetus by applying his/her hands to the mother’s abdomen. Using an ultrasound as guidance, the baby will be monitored during the procedure. ECV’s are successful 60-70 percent of the time and can reduce the likelihood for a caesarean delivery.

Cesarean Sections (C-section)

The national average of births by cesarean section (C-section) has gone up dramatically over the last few decades. At nearly 31 percent, about one mother in three will give birth by cesarean section in the United States every year. In difficult deliveries, or when complications occur, cesarean sections are often the safest and quickest delivery option.

C-sections are considered major surgery. The baby is delivered through an incision in the abdomen wall and uterus rather than the vagina. Before surgery, the patient will be given an anesthetic (general, spinal, or epidural) which will numb the area from the abdomen to below the waist. Amost always the incision is horizontal along the lower portion of the abdominal wall, although in some situations the incision may go up and down the midline below the belly button. The incision in the uterus is also horizontal, except in certain complicated scenarios. If the incision in the uterus is vertical, this is called a classical c-section and leaves the uterine muscle less able to tolerate contractions in a future pregnancy.

After the baby is delivered, the mouth and nose will be suctioned so that the baby can take his/her first breath and the placenta will be delivered.

Most women won’t know whether or not they will have a cesarean before labor begins. C-sections may be scheduled in advance if there are complications with mother or baby. Some other reasons for needing a C-section include:

  • A previous cesarean with a classical, vertical incision.
  • A fetal illness or birth defect.
  • Mother with diabetes and the baby is estimated to weigh more than 4,500 g.
  • Placenta previa.
  • HIV infection in the mother and high viral load. 
  • Breech or transverse fetal position.

Vaginal Birth after Caesarean (VBAC)

It was once thought that once you’ve had a C-section, then you will always need a C-section to deliver any subsequent babies. Today, however, it is recognized that repeat cesarean sections are not always necessary, and that vaginal birth after cesarean (VBAC) can be a safe option for many.

Women who have had a low-transverse uterine incision (horizontal) from a C-section will have a good chance at delivering a baby vaginally, while those who have had a classic vertical incision should not be allowed to attempt a VBAC. A vertical incision increases the risk of a uterine rupture during a vaginal birth.

It is important to discuss your previous pregnancies and medical history with your doctor who can assess whether you are a candidate for a VBAC.

Assisted Delivery

There are times towards the end of the pushing stage where a woman may need a little extra help in delivering her baby. A vacuum extractor or forceps may be used to assist in delivery.

Episiotomy

An episiotomy is a downward cut at the base of the vagina and perineal muscle to make the opening for the baby to come out larger. It was once believed that every woman needed an episiotomy to deliver a baby.  However, episiotomies are now most definitely not performed routinely and are only done if the baby is distressed and needs help getting out fast, or if there is a condition called shoulder dystocia, where the baby’s head delivers but the shoulders get stuck. An episiotomy may also be performed if a woman has been pushing for a very long time and cannot push the baby past the very lower part of the vaginal opening. Episiotomies are generally avoided, if possible, although the skin and sometimes muscles may tear instead. However, skin tears are less painful and heal faster than an episiotomy.

Cord Blood Banking

In recent years, several commercial companies have advertised a service that banks "leftover" umbilical cord blood after birth for potential use by the baby or other family members for a possible future illness that could require stem cell transplantation. There is a significant cost associated with processing and cryopreservation of this.

The American College of Obstetrics and Gynecology (ACOG) considers this a speculative investment that cannot be supported with scientific data. It is not known what happens to the blood after long-term storage or if the amounts of blood saved would be enough to treat someone.