Childbirth

Definition

Childbirth is formally divided by the medical field into three stages. The first stage is labor, which has three phases: early, active, and transitional. The first stage ends with complete dilatation (opening) of the cervix. The second stage is delivery, which involves pushing and the actual birth of the baby. The third stage is delivery of the placenta or afterbirth.

Description

A full-term pregnancy is considered to be 280 days, nine calendar months or ten lunar months calculated from the first day of the last menstrual period. This is a fairly arbitrary number that may, in fact, vary with genetic differences and depends on a normal menstrual cycle, which varies considerably from woman to woman. The average actual length from conception to birth is estimated as 267 days. Childbirth is a natural process, and it, too, varies among women. Despite what the obstetrical texts say about what to expect, there are many variations that make each woman's experience hers alone. The whole process averages about 14 hours for first-time mothers and about eight hours for mothers in their subsequent pregnancies.

Labor can be described in terms of a series of stages.

First stage of labor

During the first stage of labor, the cervix dilates (opens) from 0 to 10 centimeters (cm). This stage has an early, or latent, phase, an active phase, and a transitional phase. The latent phase usually lasts the longest and is the least intense phase of labor. This phase is characterized by dilatation (opening) of the cervix to 3–4 cm along with the thinning out of the cervix (effacement). It can take place over a period of days without being noticed or over a period of two to six hours with distinctive contractions. Most women are relatively comfortable during the latent phase, and walking around is encouraged, since it naturally stimulates the process.

With the initiation of labor, the muscular wall of the uterus begins to contract causing the cervix to open (dilatation) and thin out (efface). For a first-time mother the cervix must completely efface before dilatation continues. Effacement is reported in percentages as 50 percent or 100 percent, which is completely thinned out. The amniotic sac may or may not break during labor, and the birth attendant may rupture the bag with an amnio-hook, which looks a little like a large crochet hook. There is no pain involved with the breaking the bag of waters, although the contractions may intensify. During a contraction, the infant experiences pressure that pushes it against the cervix to assist with the dilatation. During this first phase, a woman's contractions typically increase in frequency and duration. Periodic vaginal exams are performed by the physician or nurse to determine progress. As pain and discomfort increase, however, the woman may be tempted to request pain medication. The administration of pain medication or anesthetics should be delayed until the active phase of labor begins, at which point the medication will not act to slow down or stop the labor.

The active phase of labor is usually shorter than the first, lasting an average of two to four hours. The contractions are more intense and accomplishing more in less time. They may be three to four minutes apart lasting 40–60 seconds even though the pattern may not be regular. During the active phase, dilatation continues to 7 cm. Relaxing between contractions is essential for coping because these contractions are more intense. Breathing exercises learned in childbirth classes can help the woman cope with the discomfort experienced during this phase. Pain medication offered at this point consists of either a short-term medication, such as Nubain or Stadol, or long-term such as epidural anesthesia.

The transitional phase continues dilation 7–10 cm. It is the most exhausting and demanding phase of labor. The contractions become very strong, are two to three minutes apart, and last 60–90 seconds. It may feel as if the contractions never stop, and there is no time to relax between them. Dilatation of the final 3 cm to 10 cm takes, on average, 15 minutes to an hour. Strong rectal pressure, with or without an urge to push or move the bowels, may cause the woman to grunt involuntarily. If it is a natural labor and delivery, the laboring woman at this phase becomes very inwardly focused and can lose control. It is important to breathe with her through contractions as this keeps her attention on what she needs to do.

Second stage of labor

Up to this point, the woman may feels as if her participation is small, because all she has done is breathe. Active involvement can now begin along with some emotional relief that it is almost over. Without anesthesia, there is often an overwhelming urge to push, and the mother gets a second wind. The baby's head is through the cervix and on its way down the birth canal. The uterine contractions get stronger, and the infant passes along the vagina helped by contractions of the uterus and the mother's pushing. If an epidural anesthetic is being used, many practitioners recommend decreasing the dosage so the mother has better control of her pushing. Research has shown, however, that the contractions will continue to push the baby down the birth canal without mother's help. If a woman is numb from an epidural, she cannot push effectively, and it is usually better to let the contractions work alone. This is called "laboring down."

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum (the tissues between the vagina and the rectum). This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner suctions the baby's mouth and nose to ease the baby's first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

Many practitioners argue that it is better to cut the perineum than to let it tear. This cut is called an episiotomy. In reality, it is more difficult to repair a straight cut than a small tear in much the same way it is harder to put together a puzzle with straight edges; it is more difficult to match evenly and can result in vaginal discomfort once healed. Instead, the perineum can be massaged and gently stretched to prevent tearing as the baby's head crowns. There is also less pain associated with a tear than an episiotomy. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area for repair.

Third stage

In the final stage of labor, the placenta is expelled by the continuing uterine contractions. The placenta is pancake shaped and about 10 cm (25 cm) in diameter. During pregnancy, it is attached to the wall of the uterus and served to exchange needed nourishment from the mother to the fetus and simultaneously to remove waste products from the fetus. Generally, there is a rise in the uterus due to a contraction and a gush of blood as the placenta is expelled. The placenta should be examined to make sure it is intact. Retained placenta can cause severe uterine bleeding after delivery, and it must be removed.

Breech presentation

Approximately 4 percent of babies present in the breech position when labor begins. In this presentation, the baby's bottom is the presenting part instead of the head, which is called a vertex presentation. Using a technique called a version, an obstetrician may attempt to turn the baby to a head down position. This is only successful approximately half the time, and there are possible complications with the procedure, such as umbilical cord entanglement and separation of the placenta. However, some practitioners are very successful with versions, and it does make a vaginal delivery safer.

The risks of vaginal delivery with breech presentation are much higher than with a head-first (vertex) presentation. The mother and attending practitioner need to weigh the risks to make a decision on whether to deliver via a cesarean section or attempt a vaginal birth. The degree of risk depends to a great extent on which one of the three types of breech presentations it is. In a frank breech the baby's legs are folded up against its body. This is the most common breech presentation and the safest for vaginal delivery. The others include complete breech, in which the baby's legs are crossed under and in front of the body, and footling breech, in which one leg or both legs are positioned to enter the birth canal. Neither of these is considered safe enough for a vaginal delivery.

Even with a complete breech, there are other factors to consider for a vaginal birth. An ultrasound examination should be done to determine that the baby's head is not too large and that it is tilted forward (flexed) rather than back (hyperextended). Fetal monitoring and close observation of the progress of labor are also important. A slowing of labor or any indication of difficulty in the body passing through the pelvis should be an indication that it is safer to consider a cesarean section.

Forceps delivery

Although not used as much in the early 2000s as in earlier times, forceps can be used if the baby's head is very low in the birth canal. Also, if there is some sudden change in the maternal-fetal status, the doctor may opt for a forceps delivery if it would be faster than a cesarean section. Forceps are spoon-shaped devices that can be placed around the baby's head while the doctor gently pulls the baby out of the vagina.

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the mother's bladder and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur. The use of forceps can cause vaginal lacerations in the mother.

Half of the forceps are slid into the vagina and around the side of the baby's head to gently grasp the head. When both forceps are in place, the doctor pulls on them to help the baby through the birth canal during a uterine contraction. The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth while other obstetrical services do not use forceps at all. Complications from forceps deliveries can occur, such as nerve damage or temporary bruises to the baby's face. When used by an experienced physician, forceps can save the life of a baby in distress.

Vacuum-assisted birth

This method of delivering a baby was developed as a gentler alternative to forceps. Similar to forceps deliveries, vacuum-assisted births can only be used with a fully dilated cervix and a well-descended head. In this procedure, a device called a vacuum extractor is used by placing a large rubber or plastic cup against the baby's head. A pump then creates suction that gently pulls on the cup to ease the baby out the birth canal. The force of the suction may cause a bruise or swelling on the baby's head, but it resolves in a day or two.

The vacuum extractor is less likely to injure the mother than forceps, and it allows more space for the baby to pass through the pelvis. There can be problems in maintaining the suction during the vacuum-assisted birth, however, so forceps might be a better choice if the delivery needs to be expedited.

Cesarean sections

A cesarean section, also called a c-section, is a surgical procedure in which an incision is made through a woman's abdomen and uterus to deliver her baby. This procedure is performed whenever abnormal conditions complicate labor and vaginal delivery that threaten the life or health of the mother or the baby. The procedure is performed in the United States on nearly one in every four women resulting in more than 900,000 babies each year being delivered by c-section. The procedure is often used in women who have had a previous c-section, but if the incision on the uterus is not vertical, the woman can try a vaginal birth after cesarean (VBAC).

Dysfunctional labor is commonly caused by one of the three following conditions: maternal structural abnormalities; abnormal fetal presentations; failure to progress. Non-reassuring fetal heart rate tracings represent a condition in which the fetus may not be tolerating labor and oxygen deprivation can occur. Other conditions which might indicate a need for c-section include: vaginal herpes, hypertension (high blood pressure), and uncontrolled diabetes in the mother.

Causes and symptoms

Childbirth usually begins spontaneously, but it may be started by artificial means if the pregnancy continues past 41 weeks gestation. There are three signs that labor may be starting: rhythmical contractions of the uterus; leaking of the bag of waters (amniotic sac); and bloody show. The importance of the sign of contractions is in the rhythm and not the contractions. True labor contractions may start once every ten or 15 minutes or even at longer intervals, but gradually the interval decreases until they come every three to four minutes. The most important thing a woman can do at this phase is to remain relaxed. The bag of waters may leak slowly or may suddenly burst, and there is a gush of fluid. There is no pain when the water breaks, although it may be startling. If contractions are not ongoing prior to this, they are likely to start soon after. If they do not, it may be necessary to stimulate labor as the womb is now open to possible infection. The bloody show is a slight discharge of blood and mucus. It usually occurs after the cervix has started to dilate slightly and the mucus plug that keeps the cervix sealed from potential pathogens becomes dislodged.

Diagnosis

The diagnosis of true labor can only be determined by a vaginal exam to determine if the cervix has changed in dilatation (opening). True labor is determined by whether the contractions are, in fact, changing the cervix. If a woman is experiencing contractions and makes no cervical change, then this is false labor. Dilatation is measured in centimeters and it goes from zero to ten centimeters, which is complete dilatation. Although the woman having the contractions may feel like she is really experiencing labor, true labor is determined by cervical change. Many women may experience Braxton-Hicks contractions (practice contractions) in preparation for true labor, and these can become uncomfortable at times, which prevents the woman from resting. A warm bath or warm drink may help her to relax and sleep . Inevitably she will wake up in true labor with effective contractions. Palpating contractions as they occur can assist in determining whether they are strong. A very strong contraction cannot be indented and will feel as hard as the forehead. A moderate contraction will palpate like the feel of the chin and an easy contraction feels like the end of the nose. If the contractions can be indented, they probably do not constitute true labor.

Electronic fetal monitoring

Electronic fetal monitoring (EFM) involves the use of an electronic fetal heart rate (FHR) monitor to record the baby's heart rate. The FHR is picked up by means of an ultrasound transducer and the movement of the heart valves. Elastic belts are used to hold sensors against the pregnant woman's abdomen. The sensors are connected to the monitor and detect the baby's heart rate as well as the uterine contractions. The monitor then records the FHR and the contractions as a pattern on a strip of paper, called a tracing. Electronic fetal monitoring is frequently used during labor to assess fetal well-being. EFM can be used either externally or internally. Internal monitoring does not use ultrasound, is more accurate than electronic monitoring, and provides continuous monitoring for the high-risk mother. An internal monitor requires that the bag of waters be broken and that the woman is at least two to three centimeters dilated. It is used in high-risk situations or when it is difficult to obtain an accurate FHR tracing.

Telemetry monitoring has been available since the early 1990s but is not used in many hospitals as of 2004. Telemetry uses radio waves transmitted from an instrument on the mother's thigh, which allows the mother to remain mobile. It provides continuous monitoring and does not require the patient to be in bed continuously.

Besides EFM and telemetry, which is usually continuous, there is intermittent monitoring using a hand-held Doppler to assess the FHR. This method gives the mother freedom of movement during labor. Prior to electronic gadgetry a special stethoscope was used, called a fetoscope, which is rarely seen as of 2004 because it requires more skill to use. Research on the use of intermittent monitoring and continuous monitoring found no difference in fetal outcomes with intermittent monitoring. The use of continuous monitoring does result in a higher c-section rate partly because the tracing can be misinterpreted or because the mother usually requires more interventions when she cannot be mobile.

Treatment

Many women choose some type of pain relief during childbirth, ranging from relaxation and imagery to drugs. The specific choice may depend on what is available, the woman's preferences, her doctor's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

Regional anesthetics

Regional anesthetics include epidurals and spinals. With this procedure, medication is injected into the space surrounding the spinal nerves. Depending on the type of medications used, this type of anesthesia can block nerve signals, causing temporary pain relief or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is put in place that allows continuous doses of anesthetic to be given.

This type of anesthesia provides complete pain relief and can help conserve a woman's energy, since she can relax or even sleep during labor. This type of anesthesia does require an IV and fetal monitor. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia operates on the same principle as epidural anesthesia and is used primarily in cases of c-section delivery. It is administered in the same way as an epidural, but the catheter is not left in place following the surgery. The amount of anesthetic injected is large, since it must be injected at one time. Spinals provide quick and strong anesthesia and allow for major abdominal surgery with almost no pain.

Narcotics

Short-acting narcotics can ease pain and not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea , and vomiting . Narcotics cross the placenta and can affect the baby.

Natural childbirth and preparation for childbirth

There are several methods available to prepare for childbirth. The one selected often depends on what is available through the healthcare provider. Overall, family involvement is receiving increased attention by the healthcare systems, and the majority of hospitals now offer birthing rooms and maternity centers to accommodate the entire family.

Lamaze, or Lamaze-Pavlov, is the most commonly used method in the United States as of 2004. It became the first popular natural childbirth method in the 1960s. Various breathing techniques, cleansing breath, panting and blowing, are used for different phases together with the use of a focal point to enable the laboring woman to maintain control. A partner helps by coaching the mother throughout the birthing process.

KEY TERMS

Amniotic sac —The membranous sac that contains the fetus and the amniotic fluid during pregnancy.

Breech birth —Birth of a baby bottom-first, instead of the usual head-first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as does the head.

Cervix —A small, cylindrical structure about an inch or so long and less than an inch around that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo —In humans, the developing individual from the time of implantation to about the end of the second month after conception. From the third month to the point of delivery, the individual is called a fetus.

Gestation —The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum —The area between the opening of the vagina and the anus in a woman, or the area between the scrotum and the anus in a man.

Placenta —The organ that provides oxygen and nutrition from the mother to the unborn baby during pregnancy. The placenta is attached to the wall of the uterus and leads to the unborn baby via the umbilical cord.

Vertex —The top of the head or highest point of the skull.

The Read method, named for Dr. Grantly Dick-Read (who published his book Childbirth Without Fear in 1944) involves primarily remaining relaxed and breathing normally. Dr. Dick-Read promoted this method in the 1930s to help mothers deal with apprehension and tension associated with childbirth. He emphasized the practice of tensing and relaxing muscles so that complete relaxation occurs between contractions in labor. This action also serves to promote good oxygenation to the muscles.

The Bradley method is called father-coached childbirth, because it focuses on the father serving as the coach throughout the process. It encourages normal activities during the first stages of labor without interventions and focuses on breathing and relaxation.

HypnoBirthing is becoming increasingly popular in the United States in the early 2000s and has proven to be quite effective. Based upon the work of Grantly Dick-Read, it teaches the mother to understand and release the fear-tension-pain syndrome, which so often is the cause of pain and discomfort during labor. When people are afraid, their bodies divert blood and oxygen from non-essential defense organs to large muscle groups in their extremities. Unfortunately, the body considers the uterus to be a non-essential organ. HypnoBirthing explores the myth that pain is a necessary accompaniment to a normal birthing. When a laboring woman's mind is free of fear , the muscles in her body, including her uterine muscles, relax, thus facilitating an easier, stress-free birth. In many cases, first stage labor shortens, which diminishes fatigue during labor leaving the mother stronger for pushing. The founder of HypnoBirthing, Marie Mongan, promotes the philosophy that eliminating fear allows the woman's body to work like it is supposed to.

The LeBoyer method stresses a relaxed delivery in a quiet, dimly lit room. It strives to avoid overstimulation of the baby and to foster mother-child bonding by placing the baby on the mother's abdomen and having the mother massage him or her immediately after the birth. This is followed by the father giving the baby a warm bath.

See also Apgar testing; Electronic fetal monitoring; Cesarean section.

Resources

BOOKS

Murkoff, H. I., et al. What to Expect When You're Expecting, 3rd ed. New York: Workman Publishing, 2002.

Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Simkin, Penny, et al. The Labor Progress Handbook. Ann Arbor, MI: Blackwell Publishing, 2000.

Simkin, Penny. Pregnancy, Childbirth, and the Newborn, Revised and Updated: The Complete Guide. Minnetonka, MN: Meadowbrook Press, 2001.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. PO Box 5224, Sherman Oaks, CA 91413–5224. Web site: <www.bradleybirth.com/>.

Childbirth Enhancement Foundation. 1004 George Avenue, Rockledge, Fl 32955. Web site: <www.cefcares.org/>.

HypnoBirthing Institute. PO Box 810, Epsom, NH 03234. Web site: <www.joes.com/home/HYPNOBIRTHING/>.

International Association of Parents and Professionals for Safe Alternatives in Childbirth. Rte. 1, Box 646, Marble Hill, MO 63764. Web site: <www.napsac.org/default.htm>.

International Childbirth Education Association. PO Box 20048, Minneapolis, MN 55420. Web site: <www.icea.org/>.

Lamaze International. 2025 M Street, Suite 800, Washington DC 20036–3309. Web site: <www.lamazechildbirth.com/>.

Linda K. Bennington, MSN, CNS

Childbirth

Definition

Childbirth includes both labor (the process of birth) and delivery (the birth itself); it refers to the entire process as an infant makes its way from the womb down the birth canal to the outside world.

Description

Childbirth usually begins spontaneously, about 280 days after conception, but it may be started by artificial means if the pregnancy continues past 42 weeks gestation. The average length of labor is about 14 hours for a first pregnancy and about eight hours in subsequent pregnancies. However, many women experience a much longer or shorter labor.

Labor can be described in terms of a series of phases.

First stage of labor

During the first phase of labor, the cervix dilates (opens) from 0-10 cm. This phase has an early, or latent, phase and an active phase. During the latent phase, progress is usually very slow. It may take quite a while and many contractions before the cervix dilates the first few centimeters. Contractions increase in strength as labor progresses. Most women are relatively comfortable during the latent phase and walking around is encouraged, since it naturally stimulates the process.

As labor begins, the muscular wall of the uterus begins to contract as the cervix relaxes and expands. As a portion of the amniotic sac surrounding the baby is pushed into the opening, it bursts under the pressure, releasing amniotic fluid. This is called "breaking the bag of waters."

During a contraction, the infant experiences intense pressure that pushes it against the cervix, eventually forcing the cervix to stretch open. At the same time, the contractions cause the cervix to thin. During this first stage, a woman's contractions occur more and more often and last longer and longer. The doctor or nurse will do a periodic pelvic exam to determine how the mother is progressing. If the contractions aren't forceful enough to open the cervix, a drug may be given to make the uterus contract.

As pain and discomfort increase, women may be tempted to request pain medication. If possible, though, administration of pain medication or anesthetics should be delayed until the active phase of labor begins—at which point the medication will not act to slow down or stop the labor.

The active stage of labor is faster and more efficient than the latent phase. In this phase, contractions are longer and more regular, usually occurring about every two minutes. These stronger contractions are also more painful. Women who use the breathing exercises learned in childbirth classes find that these can help cope with the pain experienced during this phase. Many women also receive some pain medication at this point—either a short-term medication, such as Nubain or Numorphan, or an epidural anesthesia.

As the cervix dilates to 8-9 cm, the phase called the transition begins. This refers to the transition from the first phase (during which the cervix dilates from 0-10 cm) and the second phase (during which the baby is pushed out through the birth canal). As the baby's head begins to descend, women begin to feel the urge to "push" or bear down. Active pushing by the mother should not begin until the second phase, since pushing too early can cause the cervix to swell or to tear and bleed. The attending healthcare practitioner should counsel the mother on when to begin to push.

Second stage of labor

As the mother enters the second stage of labor, her baby's head appears at the top of the cervix. Uterine contractions get stronger. The infant passes down the vagina, helped along by contractions of the abdominal muscles and the mother's pushing. Active pushing by the mother is very important during this phase of labor. If an epidural anesthetic is being used, many practitioners recommend decreasing the amount administered during this phase of labor so that the mother has better control over her abdominal muscles

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum (the tissues between the vagina and the rectum). This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner suctions the baby's mouth and nose to ease the baby's first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

As the baby's head appears, the perineum may stretch so tight that the baby's progress is slowed down. If there is risk of tearing the mother's skin, the doctor may choose to make a small incision into the perineum to enlarge the vaginal opening. This is called an episiotomy. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area. Once the episiotomy is made, the baby is born with a few pushes.

Third stage

In the final stage of labor, the placenta is pushed out of the vagina by the continuing uterine contractions. The placenta is pancake shaped and about 10 inches in diameter. It has been attached to the wall of the uterus and has served to convey nourishment from the mother to the fetus throughout the pregnancy. Continuing uterine contractions cause it to separate from the uterus at this point. It is important that all of the placenta be removed from the uterus. If it is not, the uterine bleeding that is normal after delivery may be much heavier.

Breech presentation

Approximately 4% of babies are in what is called the "breech" position when labor begins. In breech presentation, the baby's head is not the part pressing against the cervix. Instead the baby's bottom or legs are positioned to enter the birth canal instead of the head. An obstetrician may attempt to turn the baby to a head down position using a technique called version. This is only successful approximately half the time.

The risks of vaginal delivery with breech presentation are much higher than with a head-first presentation. The mother and attending practitioner will need to weigh the risks and make a decision on whether to deliver via a cesarean section or attempt a vaginal birth. The extent of the risk depends to a great extent on the type of breech presentation, of which there are three. Frank breech (the baby's legs are folded up against its body) is the most common and the safest for vaginal delivery. The other types are complete breech (in which the baby's legs are crossed under and in front of the body) and footling breech (in which one leg or both legs are positioned to enter the birth canal). These are not considered safe to attempt vaginal delivery.

Even in complete breech, other factors should be met before considering a vaginal birth. An ultrasound examination should be done to be sure the baby does not have an unusually large head and that the head is tilted forward (flexed) rather than back (hyperextended). Fetal monitoring and close observation of the progress of labor are also important. A slowing of labor or any indication of difficulty in the body passing through the pelvis should be an indication that it is safer to consider a cesarean section.

Forceps delivery

If the labor is not progressing as it should or if the baby appears to be in distress, the doctor may opt for a forceps delivery. A forceps is a spoon-shaped device that resembles a set of salad tongs. It is placed around the baby's head so the doctor can pull the baby gently out of the vagina.

Forceps can be used after the cervix is fully dilated, and they might be required if:

• the umbilical has dropped down in front of the baby into the birth canal
• the baby is too large to pass through the birth canal unaided
• the baby shows signs of stress
• the mother is too exhausted to push

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the mother's bladder, and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur.

The obstetrician slides half of the forceps at a time into the vagina and around the side of the baby's head to gently grasp the head. When both "tongs" are in place, the doctor pulls on the forceps to help the baby through the birth canal as the uterus contracts. Sometimes the baby can be delivered this way after the very next contraction.

The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth. However, other obstetrical services do not use forceps at all.

Complications from forceps deliveries can occur. Sometimes they may cause nerve damage or temporary bruises to the baby's face. When used by an experienced physician, forceps can save the life of a baby in distress.

Vacuum-assisted birth

This method of helping a baby out of the birth canal was developed as a gentler alternative to forceps. Vacuum-assisted birth can only be used after the cervix is fully dilated (expanded), and the head of the fetus has begun to descend through the pelvis. In this procedure, the doctor uses a device called a vacuum extractor, placing a large rubber or plastic cup against the baby's head. A pump creates suction that gently pulls on the cup to ease the baby down the birth canal. The force of the suction may cause a bruise on the baby's head, but it fades away in a day or so.

The vacuum extractor is not as likely as forceps to injure the mother, and it leaves more room for the baby to pass through the pelvis. However, there may be problems in maintaining the suction during the vacuum-assisted birth, so forceps may be a better choice if it is important to remove the baby quickly.

Cesarean sections

A cesarean section, also called a c-section, is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.

Cesarean sections are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. In 2002, just over 26% of babies were born by c-section, an increase of 7% from the previous year. The procedure may be used in cases where the mother has had a previous c-section and the area of the incision has been weakened. Dystocia, or difficult labor, is the another common reason for performing a c-section.

Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; abnormalities in the labor, including weak or infrequent contractions.

Another major factor is fetal distress, a condition where the fetus is not getting enough oxygen. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus, or abnormalities in the birth canal, causing reduced blood flow through the placenta.

Other conditions also can make c-section advisable, such as vaginal herpes, hypertension (high blood pressure) and diabetes in the mother. Some parents choose to have a c-section because they fear the pain or unpredictability of labor or they want to avoid pelvic damage.

Causes and symptoms

One of the first signs of approaching childbirth may be a "bloody show," the appearance of a small amount of blood-tinged mucus released from the cervix as it begins to dilate. This is called the "mucus plug."

The most common sign of the onset of labor is contractions. Sometimes women have trouble telling the difference between true and false labor pains.

True labor pains:

• develop a regular pattern, with contractions coming closer together
• last from 15-30 seconds at the onset and get progressively stronger and longer (up to 60 seconds)
• may get stronger with physical activity
• occur high up on the abdomen, radiating throughout the abdomen and lower back

Another sign that labor is beginning is the breaking of the "bag of waters," the amniotic sac which had cushioned the baby during the pregnancy. When it breaks, it releases water in a trickle or a gush. Only about 10% of women actually experience this water flow in the beginning of labor, however. Most of the time, the rupture occurs sometime later in labor. If the amniotic sac doesn't rupture on its own, the doctor will break it during labor.

Some women have diarrhea or nausea as labor begins. Others notice a sudden surge of energy and the urge to clean or arrange things right before labor begins; this is known as "nesting."

Diagnosis

The onset of labor can be determined by measuring how much the cervix has dilated. The degree of dilation is estimated by feeling the opening cervix during a pelvic exam. Dilation is measured in centimeters, from zero to 10. Contractions that cause the cervix to dilate are the sign of true labor.

Fetal monitoring

Fetal monitoring is a process in which the baby's heart rate is monitored for indicators of stress during labor and birth. There are several types of fetal monitoring.

A special stethoscope called a fetoscope may be used. This is a simple and non-invasive method.

The Doppler method uses ultrasound; it involves a handheld listening device that transmits the sounds of the heart rate through a speaker or into an attached ear piece. It can usually pick up the heart sounds 12 weeks after conception. This method offers intermittent monitoring. It allows the mother freedom to move about and is also useful during contractions.

Electronic fetal monitoring uses ultrasound and provides a view of the heartbeat in relationship to the mother's contractions. It can be used either continuously or intermittently. It is often used in high risk pregnancies, and is not often recommended for low risk ones because it renders the mother immobile and requires interpretation.

Internal monitoring does not use ultrasound, is more accurate than electronic monitoring and provides continuous monitoring for the high risk mother. This requires the mother's water to be broken and that she be two to three centimeters dilated. It is used in high-risk situations only.

Telemetry monitoring is the newest type of monitoring. It uses radio waves transmitted from an instrument on the mother's thigh. The mother is able to remain mobile. It provides continuous monitoring and is used in high-risk situations.

Treatment

Most women choose some type of pain relief during childbirth, ranging from relaxation and imagery to drugs. The specific choice may depend on what's available, the woman's preferences, her doctor's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

Regional anesthetics

Regional anesthetics include epidurals and spinals. In this technique, medication is injected into the space around the spinal nerves. Depending on the type of medications used, this type of anesthesia can block nerve signals, causing temporary pain relief, or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is put in place that allows continuous doses of anesthetic to be given.

This type of anesthesia provides complete pain relief, and can help conserve a woman's energy, since she can relax or even sleep during labor. This type of anesthesia requires an IV and fetal monitor. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia operates on the same principle as epidural anesthesia, and is used primarily in cases of c-section delivery. It is administered in the same way as an epidural, but the catheter is not left in place. The amount of anesthetic injected is large, since it must be injected at one time. Because of the anesthetic's effect on motor nerves, most women using it cannot push during delivery. This is a disadvantage in labor, but not an issue during a c-section. Spinals provide quick and strong anesthesia and allow for major abdominal surgery with almost no pain.

Narcotics

Short-acting narcotics can ease pain and do not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea, and vomiting. Narcotics cross the placenta and may slow down a baby's breathing; they can't be given too close to the time of delivery.

Natural childbirth and preparation for childbirth

There are several methods to prepare for childbirth. The one selected often depends on what is available through the healthcare provider. Overall, family involvement is receiving increased attention by the healthcare systems, and many hospitals now offer birthing rooms and maternity centers to help the entire family. There are several choices available for childbirth preparation.

Lamaze, or Lamaze-Pavlov, is the most common in the United States today. It was the first popular natural childbirth method, becoming popular in the 1960s. Breathing exercises and concentration on a focal point are practiced to allow mothers to control pain while maintaining consciousness. This allows the flow of oxygen to the baby and to the muscles in the uterus to be maintained. A partner coaches the mother throughout the birthing process.

The Read method, named for Dick Read, is a technique of breathing that was originated in the 1930s to help mothers deal with apprehension and tension associated with childbirth. This natural childbirth method uses different breathing for the different stages of childbirth.

The LeBoyer method stresses a relaxed delivery in a quiet, dim room. It attempts to avoid overstimulation of the baby and to foster mother-child bonding by placing the baby on the mother's abdomen and having the mother massage him or her immediately after the birth. Then the father washes the baby in a warm bath.

The Bradley method is called father-coached childbirth, because it focuses on the father serving as coach throughout the process. It encourages normal activities during the first stages of labor.

KEY TERMS

Amniotic sac— The membranous sac that surrounds the embryo and fills with watery fluid as pregnancy advances.

Breech birth— Birth of a baby bottom-first, instead of the usual head first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as does the head.

Cervix— A small cylindrical organ about an inch or so long and less than an inch around that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo— The unborn child during the first eight weeks of its development following conception.

Gestation— The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum— The area between the thighs that lies behind the genital organs and in front of the anus.

Placenta— The organ that develops in the uterus during pregnancy and that links the blood supplies of mother and baby.

Resources

PERIODICALS

Stevens, Laura Roe. "Gimme a C: Is Choosing a Cesarean Section for a Nonmedical Reason Wise?" Fit Pregnancy April-May 2004: 40-42.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. P.O. Box 5224, Sherman Oaks, CA 91413. (800) 423-2397; in California (800) 422-4784.

American Society for Prophylaxis in Obstetrics/LAMAZE (ASPO/LAMAZE). 1840 Wilson Blvd., Ste. 204, Arlington, VA 22201. (800) 368-4404.

Childbirth Education Foundation. P.O. Box 5, Richboro, PA 18954. (215) 357-2792.

International Association of Parents and Professionals for Safe Alternatives in Childbirth. Rte. 1, Box 646, Marble Hill, MO 63764. (314) 238-2010.

International Childbirth Education Association. P.O. Box 20048, Minneapolis, MN 55420. (612) 854-8660.

Postpartum Support International. 927 North Kellogg Ave., Santa Barbara, CA 93111. (805) 967-7636.

Childbirth

Definition

Childbirth includes both labor (the process of birth) and delivery (the birth itself); it refers to the entire process as an infant makes its way from the womb down the birth canal to the outside world.

Description

Childbirth usually begins spontaneously, following about 280 days after conception, but it may be started by artificial means if the pregnancy continues past 42 weeks gestation, or if complications develop. Labor may also begin prematurely. The average length of labor is about 14 hours for a first pregnancy and about eight hours in subsequent pregnancies. However, many women experience a much longer or shorter labor.

Labor can be described in a series of phases.

First phase of labor

During the first phase of labor, the cervix dilates (opens) from 0–10 cm (0–4 in). This phase has an early, or latent, phase and an active phase. During the latent phase, progress is usually very slow. It may take quite a while and many contractions before the cervix dilates the first few centimeters. Contractions increase in strength and frequency as labor progresses. Most women are relatively comfortable during the latent phase.

As labor begins, the muscular wall of the uterus contracts and relaxes as the cervix thins and expands. As a portion of the amniotic sac surrounding the baby is pushed into the opening, it bursts under the pressure, releasing amniotic fluid (water breaking). Sometimes the amniotic sac breaks before labor begins.

During this first phase the birth attendant or nurse will do periodic pelvic exams to determine how the labor is progressing. If the contractions aren't forceful enough to open the cervix, a drug called oxytocin (Pitocin) may be given to make the uterus contract.

As pain and discomfort increase, women may be tempted to request pain medication or anesthetics. If possible, though, these should be delayed until the active phase of labor begins—at which point the medication will not slow down or stop the labor.

The active stage of labor is faster and more efficient. In this phase, contractions are longer and more regular, usually occurring about every two to three minutes. These stronger contractions are also more painful. Women who use the breathing exercises learned in childbirth classes find that these can help them cope with the pain experienced during this phase. Many women also receive some pain medication at this point—either a short-term narcotic or epidural anesthesia.

As the cervix dilates to 8–9 cm (3.15–3.54 in), the transition phase begins. This refers to the progression from the first phase, during which the cervix dilates, to the second phase, during which the baby is pushed out through the birth canal. As the cervix dilates completely and the baby's head begins to descend, women feel the urge to push or bear down.

Second stage of labor

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum. This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner may suction the baby's mouth and nose to ease its first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

As the baby's head appears, the perineum may be stretched so tightly that the baby's progress is slowed. If there is risk of tearing the mother's tissue, the doctor or midwife may make a small incision, called an episiotomy, into the perineum to enlarge the vaginal opening. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area. Once the episiotomy is made, the baby is born with a few pushes.

Third stage

In the final stage of labor, the placenta is pushed out of the vagina by the continuing uterine contractions. The placenta is pancake shaped and about 10 in (25.4 cm) in diameter. During the pregnancy it was attached to the uterine wall and conveyed nourishment from the mother to the fetus. Continuing uterine contractions release it from the uterus at this point. It is important that all of the placenta be removed from the uterus. If it is not, the uterine bleeding that is normal after delivery may be much heavier, and uterine infection may occur.

Breech presentation

Approximately 4% of babies are in what is called a "breech" position when labor begins. In breech presentation, the baby's bottom or legs press against the cervix and are positioned to enter the birth canal. An obstetrician may attempt to turn the baby to a head-down position using a technique called version before labor begins. This is only successful approximately half the time.

The risks of vaginal delivery with breech presentation are much higher than with a head-first presentation. In these cases the mother and attending practitioner will need to weigh the risks and decide whether to deliver via cesarean section or attempt a vaginal birth. The extent of the risk depends to a great extent on the type of breech presentation, of which there are three:

• Frank breech—the baby's legs are folded up against its body. This is the most common and the safest for vaginal delivery.
• Complete breech—the baby's legs are crossed under and in front of the body.
• Footling breech—one or both legs are positioned to enter the birth canal. Vaginal delivery with this presentation is considered unsafe.

Several factors should be considered before attempting a vaginal breech birth . An ultrasound examination should be done to be sure the baby's head is not unusually large, and that it is flexed (tilted forward) rather than hyperextended (tilted back). Fetal monitoring and close observation of the progress of labor are also important. If labor slows or there is any sign that it will be difficult for the baby to pass through the pelvis it may be safer to consider a cesarean section.

Forceps delivery

If the labor is not progressing as it should, the baby appears to be in distress, or the mother is too exhausted to push, the doctor may opt for a forceps delivery. A forceps is a spoon-shaped device that resembles a set of salad tongs. It is placed around the baby's head so the doctor can pull the baby gently out of the vagina. Forceps can be used after the cervix is fully dilated.

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the her bladder, and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur.

The obstetrician slides half of the forceps at a time into the vagina and around the side of the baby's head to gently grasp the head. When both halves are in place, the doctor pulls on the forceps to help the baby through the birth canal as the uterus contracts. Sometimes the baby can be delivered this way after the very next contraction.

When used by an experienced physician, forceps can save the life of a baby in distress. Complications from this type of delivery include nerve damage or bruises to the baby's face. The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth. Others don't use forceps at all.

Vacuum-assisted birth

This method of helping a baby out of the birth canal was developed as a gentler alternative to forceps. As with forceps, vacuum-assisted birth can only be used after the cervix is fully dilated and the head of the fetus has begun to descend through the pelvis. In this procedure, the doctor uses a device called a vacuum extractor, placing a large rubber or plastic cup against the baby's head. A pump creates suction that gently pulls on the cup to gently ease the baby down the birth canal. The force of the suction may cause a bruise on the baby's head, but it fades in a day or so.

The vacuum extractor is not as likely as forceps to injure the mother, and it leaves more room for the baby to pass through the pelvis. However, there may be problems in maintaining the suction with this method, and there is the potential for brain damage if repeated attempts are made, so forceps may be a better choice if it is important to remove the baby quickly.

Cesarean sections

A cesarean section, also called a C-section, is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby. The procedure is used to deliver nearly 25% of babies born in the United States; the rate can be as high as 60% for mothers who have had a previous C-section. Cesarean sections are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby.

Labor complications include: abnormalities in the mother's birth canal; abnormalities in the fetus's position; an unusually large baby; and abnormalities in the labor, including weak or infrequent contractions. Another complication is fetal distress, a condition in which the fetus does not get enough oxygen. This can lead to fetal brain damage. The mother's health can also influence the decision to deliver by C-section, especially if she has vaginal herpes, pregnancy-induced hypertension , or diabetes.

Causes and symptoms

One of the earliest signs of approaching labor is loss of the "mucous plug," the thick secretion that covers the cervix during the nine months of pregnancy to protect the fetus from infection. Another is the "bloody show," which is produced by broken capillaries in the cervix. Both the mucous plug and the bloody show appear as the cervix begins to expand and dilate in preparation for labor.

The most common indication that labor has begun is the onset of contractions. Sometimes women have trouble telling the difference between early contractions and and false labor pains, but the biggest distinction is that true labor pains develop a regular pattern, with contractions coming closer together.

Another less common sign that labor is beginning is the breaking of the amniotic sac that cushioned the baby during the pregnancy. When it breaks, it releases water in a trickle or a gush. Only about 10% of women actually experience this water flow in the beginning of labor, however. Most of the time, the rupture occurs sometime later in labor. If the amniotic sac doesn't rupture on its own, the birth-attendant may break it during labor.

A few women have diarrhea or nausea as labor begins. Others notice a sudden surge of energy and the urge to clean or arrange things right before labor begins; this is known as "nesting."

Diagnosis

The progression of labor can be determined by measuring how much the cervix has dilated. The degree of dilation is estimated by feeling the opening cervix during a pelvic exam. Dilation is measured in centimeters, from 0–10 cm (0–4 in). Contractions that cause the cervix to dilate are the sign of true labor.

Fetal monitoring

Fetal monitoring is a process in which the baby's heart rate is monitored for indicators of stress during labor and birth. There are several types of fetal monitoring.

A special stethoscope called a fetoscope may be used. This is a simple and noninvasive method.

The Doppler method uses ultrasound; it involves a handheld listening device that transmits the sounds of the heart rate through a speaker or into an attached ear piece. It can usually pick up the heart sounds 12 weeks after gestation. This method offers intermittent monitoring. It allows the mother freedom to move about and is also useful during contractions.

Electronic (external) fetal monitoring, in which a monitor is strapped to the mother's abdomen, uses ultra- sound to measure the fetal heartbeat in relation to the mother's contractions. It is often used in high-risk pregnancies, and is not always recommended for low-risk ones because it renders the mother immobile. External monitoring can be done intermittently, as needed.

Internal monitoring provides continuous monitoring for the high-risk mother. It requires the mother's water to be broken and that she be 2–3 cm (0.75–1.25 in) dilated. An electrode is attached to the baby, usually on the head, and a pressure catheter records the strength of uterine contractions. Internal monitoring is more accurate than external fetal monitoring, because external monitors are more likely to slip off. Internal monitoring is continuous.

Telemetry monitoring, the newest type, is similar to electronic monitoring, but uses radio waves beamed from a transmitter worn by the mother to measure the fetal heartbeat. The mother is able to remain mobile while still being monitored continuously.

FETAL MONITORING RESULTS. The results of internal and external fetal monitoring are both displayed and printed. Most interpretations are based on the printed tracing. The top tracing reflects fetal heart rate; the bottom tracing measures contractions. Baseline fetal heart rate is considered normal if it is between 120 and 160 beats per minute (bpm). Monitoring of contractions with an external fetal monitor gives the frequency and duration of the contractions. Internal monitoring of contractions can provide contraction intensity values.

Treatment

Childbirth options

Most women choose some type of pain relief during childbirth, ranging from relaxation and imagery to powerful drugs. The specific choice may depend on what's available, the woman's preferences, her doctor or midwife's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

REGIONAL ANESTHETICS. Regional anesthetics include epidurals and spinals. Depending on the type of medication used, these types of anesthesia can block nerve signals, causing temporary pain relief, or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two

vertebrae and through the tough tissue in front of the spinal column. A catheter is threaded through the needle and the needle is then removed. The anesthetic then drips continuously through the catheter.

Epidurals provide complete pain relief and can help conserve a woman's energy, allowing her to relax or even sleep during labor. This method requires an IV and fetal monitoring. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia is used primarily for C-section delivery. Unlike epidural anesthesia, which is administered continuously in the space around the spinal column, spinal blocks are one-time injections of anesthetic that go directly into the fluid that surrounds the spine. Although this method disables motor nerves, preventing women who use it from pushing during delivery, this is not an issue during a C-section. Spinals provide quick and strong anesthesia and permit major abdominal surgery with minimal pain.

NARCOTICS. Short-acting narcotics can ease pain and do not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea, and vomiting. Narcotics cross the placenta and may slow down a baby's breathing. For this reason they can not be given too close to the time of delivery.

METHODS OF PREPARATION. Health care providers often use psychoprophylaxis to help expectant mothers prepare for childbirth. These techniques use relaxation and breathing exercises along with other methods to diminish the discomfort and fear many women experience in childbirth. Although several distinct methods have evolved since the 1930s, when psychoprophylaxis first gained acceptance in the medical community, most doctors, nurses, and midwives today use a combination of approaches to instruct their patients.

The Read method is named for Dr. Grantly Dick- Read, the English obstetrician who developed it in the 1930s. This method aims to decrease the fear and tension surrounding childbirth by educating the mother about the birth process, and using relaxation and deep breathing techniques.

Lamaze, or Lamaze-Pavlov, is probably the best- known method in the United States today, although the pure Lamaze method is rarely used. It first became widely popular in the 1960s. The Lamaze method combines breathing exercises with concentration on a focal point to allow mothers to control pain while maintaining consciousness. This also allows the flow of oxygen to the baby and to the muscles in the uterus to be maintained. A partner coaches the mother throughout the birthing process.

The LeBoyer method stresses a relaxed delivery in a quiet, dim room that prevents overstimulation of the baby. Mother-child bonding is fostered by placing the baby on the mother's abdomen and by having the mother massage the baby immediately after delivery. Then the father washes the baby in a warm bath.

The Bradley method is called father-coached childbirth because it encourages the father to serve as coach throughout the labor. It encourages normal activities during the first stages of labor.

A newer method, called water birthing, allows mothers to labor and sometimes deliver—provided a doctor, nurse, or midwife is at hand—in a pool of warm water. The water supports and relaxes the mother, making labor more comfortable.

Prognosis

National U.S. health goals are to reduce the maternal mortality rate to no more than 3.3 deaths per 100,000 live births. The baseline in 1998 was 7.1 maternal deaths per 100,000 live births. The target for fetal and infant death reduction during the perinatal period (28 weeks of gestation to seven days or more after birth) is no more than 4.5 per 1,000 live births plus fetal deaths. The baseline in 1997 was 7.5 per 1,000.

Health care team roles

The nurse or nurse-midwife caring for the patient during labor and delivery will perform the following:

• Obtain an initial history and perform a physical examination upon admission.
• Determine the position of the baby.
• Assess for rupture of membranes.
• Determine the cervical dilation, effacement, and level of descent (station), and confirm presenting part through vaginal exam.
• Monitor vital signs.
• Monitor baby's heartrate and measure frequency and duration of contractions. Apply fetal monitoring apparatus if ordered. Observe tracing and record results in patient's record.
• Encourage involvement of the father and provide explanations to him as requested.
• Insert IV if ordered. Obtain laboratory specimens; evaluate results.
• Provide comfort measures through emotional support, changing pads, giving ice chips if allowed, giving back massages, assisting with breathing during contractions, administering pain medications, and assisting with regional anesthesia administration.
• Implement emergency measures if necessary.
• Assist with vaginal exams, rupturing the membranes (amniotomy) and other procedures as indicated.
• Prepare for delivery by setting up instruments, transporting to delivery room or readying birthing bed, and preparing equipment for initial newborn care.
• Provide coaching during pushing and delivery.
• Receive the baby after delivery and perform initial newborn care.
• Administer medications as ordered.
• Assess the mother and baby frequently after delivery.
• Provide perineal care for the mother.
• Monitor mother's and baby's vital signs.
• Assist mother with breastfeeding.
• Facilitate bonding of baby with mother, father, and other family members.

KEY TERMS

Amniotic sac —The membranous sac that surrounds the embryo and fills with watery fluid as pregnancy advances.

Breech birth —Birth of a baby bottom- or feet-first, instead of the usual head first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as the head.

Cervix —A small cylindrical organ, about an inch(2.54 cm) or so long and less than an inch around, that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo —The unborn child during the first eight weeks of its development following conception.

Gestation —The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum —The area between the thighs that lies behind the genital organs and in front of the anus.

Placenta —The organ that develops in the uterus during pregnancy and that links the blood supplies of mother and baby.

Resources

BOOKS

Cunningham, F. Gary, et.al. Williams Obstetrics. 20th ed. Stamford, CT: Appleton & Lange, 1997.

Pillitteri, Adele. Maternal & Child Health Nursing. 3rd ed. Philadelphia: Lippincott, 1999.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. PO Box 5224, Sherman Oaks, CA 91413. (800) 423-2397; in California (800) 422-4784. www.bradleybirth.com.

The American College of Nurse-Midwives. 818 Connecticut Ave. NW, Suite 900, Washington, D.C. 20006. (202) 728-9860. www.acnm.org.

Association of Women's Health, Obstetric, and Neonatal Nurses. 2000 L Street, NW, Suite 740, Washington, D. C. 20036. (800) 673-8499 U.S., (800) 245-0231 Canada. www.awhonn.org.

International Childbirth Education Association. PO Box 20048, Minneapolis, MN 55420. (612) 854-8660. www.icea.org.

OTHER

Burgess, Traci. "Benefiting from Childbirth Education." <http://www.spindlepub.com/emg/library/EBKed5.htm>.

Department of Health and Human Services. "Healthy People 2010" <www.health.gov/healthypeople/default.htm>.

Hargett, Dave, "Anesthesia and the Apnea Patient." <http://www.apneanet.org/anesthes.htm>.

McKesson HBOC Clinical Reference Systems: Adult Health Advisor. "Anesthesia."

<http://www.realage.com/Connect/healthadvisor/adulthealth/crs/anesthes.htm>.

Nadine M. Jacobson, R.N.

Childbirth

Definition

Childbirth includes both labor (the process of birth) and delivery (the birth itself); it refers to the entire process as an infant makes its way from the womb down the birth canal to the outside world.

Description

Childbirth usually begins spontaneously, following about 280 days after conception, but it may be started by artificial means if the pregnancy continues past 42 weeks gestation, or if complications develop. Labor may also begin prematurely. The average length of labor is about 14 hours for a first pregnancy and about eight hours in subsequent pregnancies. However, many women experience a much longer or shorter labor.

Labor can be described in a series of phases.

First phase of labor

During the first phase of labor, the cervix dilates (opens) from 0-10 cm (0-4 inches). This phase has an early, or latent, phase and an active phase. During the latent phase, progress is usually very slow. It may take quite a while and many contractions before the cervix dilates the first few centimeters. Contractions increase in strength and frequency as labor progresses. Most women are relatively comfortable during the latent phase.

As labor begins, the muscular wall of the uterus contracts and relaxes as the cervix thins and expands. As a portion of the amniotic sac surrounding the baby is pushed into the opening, it bursts under the pressure, releasing amniotic fluid. This is called "breaking the bag of waters" or "rupturing the membranes." Sometimes the amniotic sac breaks before labor begins.

During this first phase the birth attendant or nurse will do periodic pelvic exams to determine how the labor is progressing. If the contractions are not forceful enough to open the cervix, a drug called oxytocin (Pitocin) may be given to make the uterus contract.

As pain and discomfort increase, women may be tempted to request pain medication or anesthetics. If possible, though, these should be delayed until the active phase of labor begins—at which point the medication will not slow down or stop the labor.

The active stage of labor is faster and more efficient. In this phase, contractions are longer and more regular, usually occurring about every two to three minutes. These stronger contractions are also more painful. Women who use the breathing exercises learned in childbirth classes find that these can help them cope with the pain experienced during this phase. Many women also receive some pain medication at this point—either a short-term narcotic or epidural anesthesia.

As the cervix dilates to 8-9 cm (3.15-3.54 in), the transition phase begins. This refers to the progression from the first phase, during which the cervix dilates, to the second phase, during which the baby is pushed out through the birth canal. As the cervix dilates completely and the baby's head begins to descend, women feel the urge to push or bear down.

Second stage of labor

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum. This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner may suction the baby's mouth and nose to ease its first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

As the baby's head appears, the perineum may be stretched so tightly that the baby's progress is slowed. If there is risk of tearing the mother's tissue, the doctor or midwife may make a small incision, called an episiotomy, into the perineum to enlarge the vaginal opening. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area. Once the episiotomy is made, the baby is born with a few pushes.

Third stage

In the final stage of labor, the placenta is pushed out of the vagina by the continuing uterine contractions. The placenta is pancake shaped and about 10 in (25.4 cm) in diameter. During the pregnancy it was attached to the uterine wall and conveyed nourishment from the mother to the fetus. Continuing uterine contractions release it from the uterus at this point. It is important that all of the placenta be removed from the uterus. If it is not, the uterine bleeding that is normal after delivery may be much heavier, and uterine infection may occur.

Breech presentation

Approximately 4% of babies are in what is called a "breech" position when labor begins. In breech presentation, the baby's bottom or legs press against the cervix and are positioned to enter the birth canal. An obstetrician may attempt to turn the baby to a head-down position using a technique called version before labor begins. This is only successful approximately half the time.

The risks of vaginal delivery with breech presentation are much higher than with a head-first presentation. In these cases the mother and attending practitioner will need to weigh the risks and decide whether to deliver via cesarean section or attempt a vaginal birth. The extent of the risk depends to a great extent on the type of breech presentation, of which there are three:

• Frank breech—the baby's legs are folded up against its body. This is the most common and the safest for vaginal delivery.
• Complete breech—the baby's legs are crossed under and in front of the body.
• Footling breech—one or both legs are positioned to enter the birth canal. Vaginal delivery with this presentation is considered unsafe.

Several factors should be considered before attempting a vaginal breech birth. An ultrasound examination should be done to be sure the baby's head is not unusually large, and that it is flexed (tilted forward) rather than hyperextended (tilted back). Fetal monitoring and close observation of the progress of labor are also important. If labor slows or there is any sign that it will be difficult for the baby to pass through the pelvis it may be safer to consider a cesarean section.

Forceps delivery

If the labor is not progressing as it should, the baby appears to be in distress, or the mother is too exhausted to push, the doctor may opt for a forceps delivery. A forceps is a spoon-shaped device that resembles a set of salad tongs. It is placed around the baby's head so the doctor can pull the baby gently out of the vagina. Forceps can be used after the cervix is fully dilated.

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the her bladder, and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur.

The obstetrician slides half of the forceps at a time into the vagina and around the side of the baby's head to gently grasp the head. When both halves are in place, the doctor pulls on the forceps to help the baby through the birth canal as the uterus contracts. Sometimes the baby can be delivered this way after the very next contraction.

When used by an experienced physician, forceps can save the life of a baby in distress. Complications from this type of delivery include nerve damage or bruises to the baby's face. The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth. Others do not use forceps at all.

Vacuum-assisted birth

This method of helping a baby out of the birth canal was developed as a gentler alternative to forceps. As with forceps, vacuum-assisted birth can only be used after the cervix is fully dilated and the head of the fetus has begun to descend through the pelvis. In this procedure, the doctor uses a device called a vacuum extractor, placing a large rubber or plastic cup against the baby's head. A pump creates suction that gently pulls on the cup to gently ease the baby down the birth canal. The force of the suction may cause a bruise on the baby's head, but it fades in a day or so.

The vacuum extractor is not as likely as forceps to injure the mother, and it leaves more room for the baby to pass through the pelvis. However, there may be problems in maintaining the suction with this method, and there is the potential for brain damage if repeated attempts are made, so forceps may be a better choice if it is important to remove the baby quickly.

Cesarean sections

A cesarean section, also called a C-section, is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby. The procedure is used to deliver nearly 25% of babies born in the United States; the rate can be as high as 60% for mothers who have had a previous C-section. Cesarean sections are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby.

Labor complications include: abnormalities in the mother's birth canal; abnormalities in the fetus's position; an unusually large baby; and abnormalities in the labor, including weak or infrequent contractions. Another complication is fetal distress, a condition in which the fetus does not get enough oxygen. This can lead to fetal brain damage. The mother's health can also influence the decision to deliver by C-section, especially if she has vaginal herpes, pregnancy-induced hypertension, or diabetes.

Causes and symptoms

One of the earliest signs of approaching labor is loss of the "mucus plug," the thick secretion that covers the cervix during the nine months of pregnancy to protect the fetus from infection. Another is the "bloody show," which is produced by broken capillaries in the cervix. Both the mucus plug and the bloody show appear as the cervix begins to expand and dilate in preparation for labor.

The most common indication that labor has begun is the onset of contractions. Sometimes women have trouble telling the difference between early contractions and and false labor pains, but the biggest distinction is that true labor pains develop a regular pattern, with contractions coming closer together.

Another less common sign that labor is beginning is the breaking of the the amniotic sac that cushioned the baby during the pregnancy. When it breaks, it releases water in a trickle or a gush. Only about 10% of women actually experience this water flow in the beginning of labor, however. Most of the time, the rupture occurs sometime later in labor. If the amniotic sac does not rupture on its own, the birth-attendant may break it during labor.

A few women have diarrhea or nausea as labor begins. Others notice a sudden surge of energy and the urge to clean or arrange things right before labor begins; this is known as "nesting."

Diagnosis

The progression of labor can be determined by measuring how much the cervix has dilated. The degree of dilation is estimated by feeling the opening cervix during a pelvic exam. Dilation is measured in centimeters, from 0 to 10 (0 to 4 in). Contractions that cause the cervix to dilate are the sign of true labor.

Fetal monitoring

Fetal monitoring is a process in which the baby's heart rate is monitored for indicators of stress during labor and birth. There are several types of fetal monitoring.

A special stethoscope called a fetoscope may be used. This is a simple and noninvasive method.

The Doppler method uses ultrasound; it involves a handheld listening device that transmits the sounds of the heart rate through a speaker or into an attached ear piece. It can usually pick up the heart sounds 12 weeks after gestation. This method offers intermittent monitoring. It allows the mother freedom to move about and is also useful during contractions.

Electronic (external) fetal monitoring, in which a monitor is strapped to the mother's abdomen, uses ultrasound to measure the fetal heartbeat in relation to the mother's contractions. It is often used in high-risk pregnancies, and is not always recommended for low-risk ones because it renders the mother immobile. External monitoring can be done intermittently, as needed.

Internal monitoring provides continuous monitoring for the high-risk mother. It requires the mother's water to be broken and that she be 2-3 cm (0.75-1.25 in) dilated. An electrode is attached to the baby, usually on the head, and a pressure catheter records the strength of uterine contractions. Internal monitoring is more accurate than external fetal monitoring, because external monitors are more likely to slip off. Internal monitoring is continuous.

Telemetry monitoring, the newest type, is similar to electronic monitoring, but uses radio waves beamed from a transmitter worn by the mother to measure the fetal heartbeat. The mother is able to remain mobile while still being monitored continuously.

FETAL MONITORING RESULTS. The results of internal and external fetal monitoring are both displayed and printed. Most interpretations are based on the printed tracing. The top tracing reflects fetal heart rate; the bottom tracing measures contractions. Baseline fetal heart rate is considered normal if it is between 120 and 160 beats per minute (bpm). Monitoring of contractions with an external fetal monitor gives the frequency and duration of the contractions. Internal monitoring of contractions can provide contraction intensity values.

Treatment

Childbirth options

Most women choose some type of pain relief during childbirth, ranging from relaxation and imagery to powerful drugs. The specific choice may depend on what's available, the woman's preferences, her doctor or midwife's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

REGIONAL ANESTHETICS. Regional anesthetics include epidurals and spinals. Depending on the type of medication used, these types of anesthesia can block nerve signals, causing temporary pain relief, or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is threaded through the needle and the needle is then removed. The anesthetic then drips continuously through the catheter.

Epidurals provide complete pain relief and can help conserve a woman's energy, allowing her to relax or even sleep during labor. This method requires an IV and fetal monitoring. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia is used primarily for C-section delivery. Unlike epidural anesthesia, which is administered continuously in the space around the spinal column, spinal blocks are one-time injections of anesthetic that go directly into the fluid that surrounds the spine. Although this method disables motor nerves, preventing women who use it from pushing during delivery, this is not an issue during a C-section. Spinals provide quick and strong anesthesia and permit major abdominal surgery with minimal pain.

NARCOTICS. Short-acting narcotics can ease pain and do not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea, and vomiting. Narcotics cross the placenta and may slow down a baby's breathing. For this reason they cannot be given too close to the time of delivery.

METHODS OF PREPARATION. Health care providers often use psychoprophylaxis to help expectant mothers prepare for childbirth. These techniques use relaxation and breathing exercises along with other methods to diminish the discomfort and fear many women experience in childbirth. Although several distinct methods have evolved since the 1930s, when psychoprophylaxis first gained acceptance in the medical community, most doctors, nurses, and midwives today use a combination of approaches to instruct their patients.

The Read method is named for Dr. Grantly Dick-Read, the English obstetrician who developed it in the 1930s. This method aims to decrease the fear and tension surrounding childbirth by educating the mother about the birth process, and using relaxation and deep breathing techniques.

Lamaze, or Lamaze-Pavlov, is probably the best-known method in the United States today, although the pure Lamaze method is rarely used. It first became widely popular in the 1960s. The Lamaze method combines breathing exercises with concentration on a focal point to allow mothers to control pain while maintaining consciousness. This also allows the flow of oxygen to the baby and to the muscles in the uterus to be maintained. A partner coaches the mother throughout the birthing process.

The LeBoyer method stresses a relaxed delivery in a quiet, dim room that prevents overstimulation of the baby. Mother-child bonding is fostered by placing the baby on the mother's abdomen and by having the mother massage the baby immediately after delivery. Then the father washes the baby in a warm bath.

The Bradley method is called father-coached childbirth because it encourages the father to serve as coach throughout the labor. It encourages normal activities during the first stages of labor.

A newer method, called water birthing, allows mothers to labor and sometimes deliver—provided a doctor, nurse, or midwife is at hand—in a pool of warm water. The water supports and relaxes the mother, making labor more comfortable.

Prognosis

National U.S. health goals are to reduce the maternal mortality rate to no more than 3.3 deaths per 100,000 live births. The baseline in 1998 was 7.1 maternal deaths per 100,000 live births. The target for fetal and infant death reduction during the perinatal period (28 weeks of gestation to seven days or more after birth) is no more than 4.5 per 1,000 live births plus fetal deaths. The baseline in 1997 was 7.5 per 1,000.

Health care team roles

The nurse or nurse-midwife caring for the patient during labor and delivery will perform the following:

• Obtain an initial history and perform a physical examination upon admission.
• Determine the position of the baby.
• Assess for rupture of membranes.
• Determine the cervical dilation, effacement, level of descent (station), and confirm presenting part through vaginal exam.
• Monitor vital signs.
• Monitor baby's heartrate and measure frequency and duration of contractions. Apply fetal monitoring apparatus if ordered. Observe tracing and record results in patient's record.
• Encourage involvement of the father and provide explanations to him as requested.
• Insert IV if ordered. Obtain laboratory specimens; evaluate results.
• Provide comfort measures through emotional support, changing pads, giving ice chips if allowed, giving back massages, assisting with breathing during contractions, administering pain medications, and assisting with regional anesthesia administration.
• Implement emergency measures if necessary.
• Assist with vaginal exams, rupturing the membranes (amniotomy) and other procedures as indicated.
• Prepare for delivery by setting up instruments, transporting to delivery room or readying birthing bed, and preparing equipment for initial newborn care.
• Provide coaching during pushing and delivery.
• Receive the baby after delivery and perform initial newborn care.
• Administer medications as ordered.
• Assess the mother and baby frequently after delivery.
• Provide perineal care for the mother.
• Monitor mother's and baby's vital signs.
• Assist mother with breastfeeding.
• Facilitate bonding of the baby with the mother, father, and other family members.

KEY TERMS

Amniotic sac— The membranous sac that surrounds the embryo and fills with watery fluid as pregnancy advances.

Breech birth— Birth of a baby bottom- or feet-first, instead of the usual head first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as the head.

Cervix— A small cylindrical organ, about an inch (2.54 cm) or so long and less than an inch around, that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo— The unborn child during the first eight weeks of its development following conception.

Gestation— The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum— The area between the thighs that lies behind the genital organs and in front of the anus.

Placenta— The organ that develops in the uterus during pregnancy and that links the blood supplies of mother and baby.

Resources

BOOKS

Cunningham, F. Gary, et.al. Williams Obstetrics, 20th ed. Stamford, CT: Appleton & Lange, 1997.

Pillitteri, Adele. Maternal & Child Health Nursing, 3rd ed. Philadelphia: Lippincott, 1999.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. PO Box 5224, Sherman Oaks, CA 91413. (800) 423-2397; in California (800) 422-4784. 〈http://www.bradleybirth.com〉.

The American College of Nurse-Midwives. 818 Connecticut Ave. NW, Suite 900, Washington, D.C. 20006. (202) 728-9860. 〈http://www.acnm.org〉.

Association of Women's Health, Obstetric, and Neonatal Nurses. 2000 L Street, NW, Suite 740, Washington, D. C. 20036. (800) 673-8499 U.S., (800) 245-0231 Canada. 〈http://www.awhonn.org〉.

International Childbirth Education Association. PO Box 20048, Minneapolis, MN 55420. (612) 854-8660. 〈http://www.icea.org〉.

OTHER

Burgess, Traci. "Benefiting from Childbirth Education." 〈http://www.spindlepub.com/emg/library/EBKed5.htm〉.

Department of Health and Human Services. "Healthy People 2010" 〈http://www.health.gov/healthypeople/default.htm〉.

Childbirth

Definition

Childbirth, or parturition, is the process of labor that dilates the cervix, as well as the delivery of the baby and placenta through the birth canal.

Description

Most babies are born following approximately nine calendar months of pregnancy . Delivery between 37–42 weeks of gestation is considered normal and full-term. A baby born prior to 37 weeks of gestation is considered premature, or preterm. After 42 weeks, it is considered postterm. Each of the latter circumstances is considered a higher risk delivery.

Labor occurs in three stages. The first is the dilation of the cervix, the second is the delivery of the baby, and

the third is the expulsion of the placenta. However, approximately 25% of babies born in the United States are surgically delivered by Caesarean section. This can be a necessary and even life-saving procedure, but this percentage is probably much larger than it could be with better management of labor and more informed birthing consumers.

A 2001 report showed that older pregnant women are more likely to deliver via Caesarean and also may more likely required induced labor. At one time, "once a Caesarean, always a Caesarean" meant a woman could not deliver vaginally after having a Caesarean, but that is no longer true for everyone. Women who have had previous surgical deliveries are increasingly choosing vaginal birth after Caesarean (VBAC). Having a sympathetic, informed caregiver and preparation helps achieve this goal.

The first stage of labor is the time that is required for the cervix to reach full dilation. It includes latent (early), active, and transition phases. The latent phase of labor, when the cervix progresses from being closed to 3 cm open, may last for days or longer. For some women, latent labor is not a distinguishable phase, and for others it leads immediately into active labor. The latent phase is often exciting for the mother, who wonders if her baby is finally going to be born. Contractions during this phase are not very painful. Active labor ensues around the time the cervix reaches 3 cm dilation, and continues until approximately 7 cm dilation. At this stage, labor contractions are powerful, and require the mother's concentration. The length of this stage is also variable, and is usually longer for first-time mothers than for those having subsequent babies. Active labor is followed by transition. This is the shortest and most intense stage of labor, when many women express feelings of despair, or "not being

able to do it anymore." At the end of transition, the cervix is fully dilated to 10 cm, and pushing can begin.

The second stage of labor is pushing the baby out through the vagina (birth canal). Contractions are generally less frequent than in the first stage of labor, but are very strong and long lasting. Many women find it a relief to be able to push. In the unmedicated mother, pushing is reflexive and instinctual. The pressure of the baby's head on stretch receptors in the maternal pelvis triggers the urge to push. Pushing is another phase where nature gives credit to the woman who has had a previous birth. First-time mothers generally push for about 60 minutes; subsequent births require an average of only 15 minutes.

The third stage of labor is the delivery of the placenta, which often goes unnoticed by the mother who is attending to her newborn. After the baby is delivered, the uterus should continue to contract in order to push out the placenta. This organ functioned to bring the baby nourishment from the mother throughout the pregnancy, and return the child's waste products to the mother to be excreted. If contractions become sluggish or stop before the placenta is delivered, breastfeeding the baby can trigger the release of the hormone oxytocin to stimulate the uterus to contract again. Alternatively, artificial oxytocin (pitocin) can be given by injection.

Causes & symptoms

The onset of spontaneous labor may be marked by irregular contractions, not very different from the Braxton-Hicks contractions that are common throughout late pregnancy. In approximately 10% of spontaneous labors, rupture of membranes ("water breaking") may occur before the onset of contractions. Since prolonged rupture of membranes prior to delivery presents a risk of infection, the care provider for the mother should be contacted whether or not she is experiencing contractions.

Even experienced mothers sometimes have difficulty telling when labor begins, as prelabor may occur on and off for days or longer before settling into a regular pattern. In general, the contractions associated with labor will gradually get more frequent, more regular, longer, and stronger. Walking or changing activity will not alter them. These contractions are effective at changing the cervix, which will become appreciably lower, thinner, and more dilated. By contrast, contractions of prelabor stay about the same intensity and frequency. A change of activity will often make them disappear. These contractions may be uncomfortable, and may even cause some mild cervical changes, but there is not a change on an hourly basis.

Diagnosis

For women who choose to deliver in a hospital, a diagnosis of active labor is generally made if contractions are regular and strong, and the cervix is effacing and/or dilating noticeably on an hourly basis. A woman who arrives at the hospital reporting regular contractions who has no complicating factors is generally observed for at least an hour to see whether her labor will progress. Monitors that fit around the abdomen measure the fetal heart rate, and the nature of the contractions. A nurse will check the position and station of the baby, as well as the effacement, dilation, and position of the mother's cervix. Admission is generally made regardless of progress if the water has broken (rupture of membranes), or if there are complications, such as high maternal blood pressure, more than one fetus, fetal distress, abnormal fetal presentation, or excessive bleeding. Women delivering before 37 weeks or after 42 weeks of gestation are also well-advised to deliver in a hospital.

Treatment

For a routine, uncomplicated labor and delivery, the primary treatment required is assistance with comfort measures. What each mother finds comforting is very individual. At some point during the pregnancy, it is a good idea to make a list of things to try to relieve pain during labor, in the event that one or two favored techniques don't work. A mother who generally enjoys massage may suddenly discover that it is distracting to be touched during active labor; one who plans to rely on medication could have an epidural that does not take, or be laboring too quickly for it to be allowed. Having a list of comfort measures to refer to will be useful and reassuring for most laboring women. Reassurance is important, as relieving stress during labor allows it to progress more quickly and with less pain. Many women find it helpful to employ an experienced doula, or birth assistant, to provide comfort, reassurance, and information.

Fear of the unknown can certainly contribute to increased pain. Expectant parents should learn all they can about the process of childbirth. Many good reference books are available. Taking Lamaze classes lends a personal touch, and many couples enjoy the camaraderie of sharing the learning experience with other expectant families. Even though labor can take unexpected turns, being aware of the options at each stage will lend some perception of control. Making a list of birth preferences can be helpful in defining what the parents desire at the birth, but flexibility is important to avoid disappointment if every expectation is not met.

Acupuncture

A skilled acupuncturist may be able to offer some relief of labor pain, particularly for women who have previously found acupuncture to be helpful with other types of pain.

Massage therapy

Some women find massage or therapeutic touch to be quite relaxing during labor. Contractions are sometimes felt quite intensely in the back, and a combination of massage and counterpressure can offer relief. Foot massage may also be comforting, both during pregnancy and labor. There is a great temptation for the laboring woman to tense her abdomen against a contraction. The contraction will be more effective and less painful with effleurage (light stroking) of the area, and a verbal reminder to let the abdomen hang heavy and relax. The jaw area is also frequently clenched, and benefits from relaxation . Gentle touch and massage of any area that appears tense will help to relieve stress. This is a good technique to practice before labor begins.

Music

The sounds of a favorite piece of music can be an excellent aid to relaxation. Instrumentals are generally preferable to singing. Soothing sounds or tunes that evoke happy memories are helpful. Some women enjoy tapes of nature sounds.

Hydrotherapy

A warm tub or shower may be one of the most underestimated methods of relieving the pain of labor. Warmth encourages muscle relaxation, which in turn decreases anxiety . The water in a tub also supports the mother's body. In

a jetted tub, position and water pressure can be adjusted to soothe areas that are cramping or painful. This may be particularly comforting for back labor. In a birthing pool or large tub, the mother is free to move around and find a position that optimizes her comfort. The relaxation brought on by water can make for a shorter, more comfortable labor.

Aromatherapy

Some essential oils are particularly recommended during birth for those women who enjoy the scents. They can be added to a diffuser or a crock-pot of water in the birthing area, emitted from a scented candle, or concentrated drops of the scent can be placed on the pillow and bed linens. Clary sage and lavender are popular choices, but any scent that is pleasant to the mother may be used.

Visualization

The use of visualization, or guided imagery , can be powerful to promote relaxation and the progress of labor. One exercise that can be practiced in advance of labor is choosing a place or image that the mother associates with comfort, security, and serenity. This place can be imagined and explored at any time to help relieve stress. If the details of this visualization are shared with someone who will be present during labor, that person can help to evoke those feelings during times of pain or stress. Another popular visualization is that of a flower blooming. The cervix can be envisioned as a flower bud that gradually opens to allow the baby to descend. Other scripts for guided imagery can be practiced to relieve stress and reduce pain.

Increasingly, women (not in high-risk pregnancies) desire a more "low-tech" approach to labor and choose a nurse midwife to assist them rather than a physician. For thousands of years, midwives have given women support and care through the birthing process. In 1998, a nurse-midwife rather than a physician attended almost 9% of births, which is more than twice the number in 1989. Nurse-midwives committed to helping meet mothers' individual needs and to give them freedom of choice during birth. They work to provide a natural childbirth and to help the woman prevent complications before, during, and after the birth. Those wishing to use midwives should check with the obstetrician and also determine if the midwife is certified (CNM). More and more obstetrician practices also employ or work with nurse-midwives.

Allopathic treatment

Modern pain relief for childbirth generally involves the use of medication. Although medication has evolved from the days of mothers being put under "twilight sleep" for a normal vaginal birth, the use of chemical pain relief is not without risk.

Undoubtedly one of the most common pain relief methods during labor is the epidural. This technique involves the injection of anesthetic medication through a catheter into the epidural space in the back. Epidurals often provide excellent relief of pain from contractions, episiotomy, and perineal repair. They do not impair the mother's mental alertness, although she may sleep if labor to that point has been long and arduous. The disadvantages of epidurals include possible prolonging of labor, impaired ability to push, inability to move around, possible need for bladder catheterization and accompanying risk of infection or injury, maternal low blood pressure, maternal fever , spinal headache from inadvertent injection into the subdural space, and patchy or ineffective blocks. Low blood pressure can result in nausea and dizziness , as well as fetal distress. Supplemental oxygen may be given to the mother to alleviate this effect. Allergic reactions to the anesthetic agents occur rarely. The woman who wishes to have an epidural needs to have IV access, IV fluids in advance to help prevent low blood pressure, and fetal monitoring. The woman's inability to move around and change positions because of the tubes and wires can impede the progress of labor. If labor slows, it may be augmented by the injection of pitocin. Assisted delivery via forceps or vacuum extractor may be necessary if the mother finds herself unable to push effectively.

Injectable narcotic pain medications are also available. They can be given by either intramuscular (IM) or intravenous (IV) routes. When given intravenously, the effects are felt sooner and are shorter in duration. These medications are more likely to affect the fetus, and are generally not given late in labor. Some women say that their pain is not greatly diminished, but that they are better able to rest between contractions. Others experience side effects, such as nausea, vomiting , and dizziness that they feel negate any benefit that they get from the medication.

Prevention

Techniques that are used to prevent pregnancy are known as contraception. Some methods require a prescription, including those involving hormones, diaphragms, cervical caps, or intrauterine devices (IUDs). Hormonal birth control is available as a daily pill, an injection, or an implant. Consultation with a health care professional will determine the appropriateness of these methods. Conditions including clotting diseases, breast cancer , and liver disease will preclude hormonal forms of birth control. Significant side effects may occur even in women who are good candidates for these methods. Timing of taking the daily birth control pills is important, and back-up methods should be available if doses are missed. Diaphragms and caps are both barriers used next to the cervix along with a spermicide. For both methods, there is a pregnancy rate between 8% and 27% in the first year. The IUD is a uniquely long-term device. It is placed by a medical professional, and depending on the type, can retain effectiveness for as long as 10 years. It is not recommended for women who have ever had pelvic inflammatory disease , or for those who are not in a mutually monogamous relationship. The pregnancy rate in the first year for IUD users is around 3%.

Several popular forms of birth control are nonprescriptive. Barrier method materials, such as condoms, foam, and spermicides are available over the counter. Condoms have the distinction of being the only type designed for males. Used correctly, they are highly effective in preventing pregnancy. They have no side effects, and latex varieties have the additional advantage of providing some protection against sexually transmitted diseases. Average pregnancy rates are around 12%.

Periodic abstinence, sometimes called natural family planning, requires training and attentiveness to physical signs. A variety of methods are available, and may include monitoring of cycle days, basal body temperature, cervical mucus characteristics, and other symptoms related to the timing of ovulation. Effectiveness can be as great as 93%, but it requires significant commitment for the couple to faithfully monitor signs and abstain from intercourse for at least one week of every cycle. Women with irregular cycles or unreliable signs have the most unplanned pregnancies with these methods.

Resources

BOOKS

Levchuck, Caroline M., Jane Kelly Kosek, and Michele Drohan. "Certified Nurse-Midwife." In Healthy Living. UXL, 2000.

Sears, William, and Martha Sears. The Birth Book. Boston: Little, Brown and Company, 1994.

Stoppard, Miriam. New Pregnancy and Birth Book. New York: The Ballentine Publishing Group, 1999.

PERIODICALS

Ecker, Jeffrey L., et al. "Increased Risk of Caesarean Delivery with Advancing Maternal Age: Indications and Associated Factors in Nulliparous Women." American Journal of Obstetrics and Gynecology 185, no. 4 (October 2001): 883–885.

ORGANIZATIONS

Association of Labor Assistants and Childbirth Educators (ALACE) (formerly Informed Birth & Parenting). P.O. 382724. Cambridge, MA, 0228-2724. (617) 441-2500 or local (818) 358-2318.

International Childbirth Education Association (ICEA). P.O. Box 20048. Minneapolis, MN 55420-0048. (612) 854-8660. <http://www.icea.org>.

Judith Turner

Teresa G. Odle

KEY TERMS

Braxton-Hicks

—Mild, painless contractions of prelabor.