You can choose who you would like to be with you during labor and delivery-of course, you will need to take into consideration the guidelines of your hospital or birthing center. Most hospitals and birthing centers encourage women to have a support person or persons. Your birth assistant should be focused on helping you by guiding you through relaxation and comfort techniques during labor. Your partner or support person should also know how you feel about the use of medications and invasive procedures, so your wishes can be communicated even if you are too preoccupied to speak for yourself. During the birth, you may appreciate having your support person encourage you, sponge your forehead, or support your legs or shoulders.
A nurse will be your primary caretaker for the whole time you are in the hospital or birthing center, and your doctor or midwife usually arrives when you go into active labor. So that you will know what to expect, you should talk with your midwife or doctor about when they will be with you during labor and birth. In some hospitals, there are also student nurses and doctors who may ask to help with the birth. You can let your nurse or doctor know if this is okay with you.
Once your cervix is completely dilated (open to 10 cm), you will be encouraged to start pushing. If you have not received pain medication, the urge to push is usually strong. Pushing will give you a burst of energy. For most women, it feels better to push than not to push. Pushing is done instinctively and as hard as the mother feels necessary.
If you have had an epidural, you will be numb. You will not have the urge to push and your muscle coordination will be a little more difficult to organize into effective pushing. You may have to rely on your nurse, nurse-midwife, or doctor to help guide your pushing efforts. Most women with epidurals push very effectively and will not need the assistance of forceps or a vacuum extractor to deliver their babies. If you are very numb, sometimes the nurse or doctor will encourage you to rest comfortably while the uterus continues to push the baby downward. After a while, the epidural will be a less powerful, you will feel more able to push, the baby will be further down the birth canal, and delivery can proceed nicely.
To push effectively, you will need to take a deep breath and hold it in your lungs, put your chin on your chest, and pull your legs toward your chest while bearing down. The same instructions apply, only in an upright position, if you are squatting. Women use the same muscles to push out a baby as they do to push out a bowel movement. Those particular muscles are very strong and effective in helping deliver a baby. If they are not used, it can take considerably longer to deliver.
Some women are afraid of accidentally passing some stool if they use these muscles to push. This is a frequent occurrence and you should not be embarrassed if it happens. The nurse will quickly clean it up. After all, everything else has to get out of the way to allow the birth of the baby.
The time it takes to push the baby through the birth canal, under the pubic bone, and to the vaginal opening depends on a number of factors. On average, a woman's first vaginal delivery takes about an hour of pushing during a "natural" birth and two hours during an "epidural" birth. Of course, this varies depending on the factors discussed below.
The first variable is whether this is your first vaginal delivery (even if you have had a cesarean section before). Your pelvic muscles are tight when they have never been stretched to accommodate the birth of an infant. The process of your muscles stretching to accommodate the birth can be slow and steady. It usually will not take as long to push the baby out during subsequent deliveries. Some women who have had a few babies may push only one or two times to deliver the baby because the muscles have been stretched before.
The second factor is the size and shape of the mother's pelvis. Pelvic bones can vary quite a bit in size and shape. A nice, large round opening is ideal. Some pelvic openings may be large and some small, but infants can navigate most of them well. Some openings are too narrow for even a small infant to get through, but this is rare. If you have been told you have a small pelvis, you will be encouraged to labor and give your pelvis a chance to stretch as the infant starts the descent to the pelvic opening.
The third factor is the size of the infant. Infants have skull bones that are not fixed in a permanent shape. These bones are able to shift and overlap during the delivery process. When this happens the infant will be born with a somewhat elongated head, affectionately referred to as a "cone-head." The head will return to a round shape within a day or two. An infant's head may be larger than the mother's pelvis can accommodate, but this is not usually apparent until vaginal delivery has been attempted. Every mother is given the opportunity to delivery vaginally first.
A fourth factor is the position of the baby's head within the pelvis. For normal vaginal delivery, the baby should be in position to exit the womb headfirst. Facing back toward the tailbone is the ideal situation-this is called an anterior position. When the baby is facing up toward the pubic bone (called a posterior position), the labor may be slower and the mother may feel more back pain. Babies can sometimes be delivered facing upward, but sometimes they need to be rotated to an anterior position. Pushing usually takes longer when the baby is in a posterior position.
The fifth factor is the force of the labor. Force refers to how strong the contractions are and how hard the mother pushes. Contractions help the cervix to dilate and if they have been strong enough to dilate the cervix completely, they should be strong enough to help you birth your baby. With good pushing and a good balance of the other factors, the infant will most likely deliver within an hour or two of pushing. It can happen sooner and it can take quite a bit longer. Don't be discouraged-keep working!
Sometimes, the baby needs extra help in getting out. Even though you may be pushing with all the strength you can muster, your energy may have waned, and because of fatigue, your pushing may not be strong enough to deliver the baby. Alternatively, it may be a tight fit or the baby may need to be rotated to a better position in order to squeeze out. After two to three hours of good pushing, your nurse or doctor may opt to guide the baby out with an instrument while you continue to push.
The instruments that may be used in these situations are the forceps and the vacuum extractor. They should not be used unless the baby can be seen and reached easily. Your doctor will not "pull" the baby out. The baby will be guided while you continue to push.
No one can predict whether you will need an episiotomy. There are some things you can do to help decrease the chances that you will need an episiotomy. However, there are certain factors you cannot control.
An episiotomy is a cut at the base of the vagina to make the opening for the baby larger. In the past, doctors believed that every woman needed an episiotomy to deliver a baby. At present, episiotomies are performed only in certain cases, including the following:
- when the baby is having distress and needs help getting out fast;
- when there is tearing of the tissues upward into sensitive areas such as the urethra and clitoris; and
- if after pushing for a long time, there is no progress in stretching or toward delivery.
Small skin tears are less painful and heal faster than an episiotomy; therefore, an episiotomy may not be performed, but the mother may still need a few small stitches.
For repair of an episiotomy or tears, doctors use sutures that dissolve so that they won't need to be removed. As you are healing, you may notice them at times; you may also notice intermittent itching as the skin heals.
A couple of things you can do to improve your chances of not needing an episiotomy include (1) eating a well-balanced diet and (2) periodically stretching the vaginal area during the four weeks before your due date. Things that you cannot control include (1) the elasticity of your skin and (2) the size of your baby.
If your baby is in a stable condition, you can start nursing shortly after the baby is born. If the baby is breathing too fast, he or she may choke on the breast milk if you begin breast-feeding. The nurse will let you know if there are any problems that would require a delay in breast-feeding; otherwise it is good to start soon after the birth.
Most babies are wide-awake during the first hour after delivery. It is a wonderful time to start breast-feeding. Be patient and realize that the baby has never nursed before. You will need to get acquainted with your new baby and the baby needs to learn how to latch on. Don't get frustrated if you and the baby don't master breast-feeding right away. The nurses will work with you until you and your baby have established a good pattern.