NORMAL LABOR AND BIRTH
Labor is defined as regular contractions, which result in dilation (opening) and effacement (thinning) of the cervix. Labor is usually divided into four stages:
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Stage 1 starts with the onset of regular contractions and ends when the cervix is completely effaced and dilated. Voluntary pushing with the abdominal muscles is not helpful and may result in tearing the cervix.
Stage 2 starts with complete dilation of the cervix and ends when the baby is delivered. It involves the movement of the baby through the birth canal and is completed with the delivery of the baby. Birth is aided by voluntary bearing down, using the abdominal muscles. |
LABOR BIRTH GRAPH
(Friedman labor curve)
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Stage 3 refers to delivery of the placenta. The uterus will deliver the placenta on its own; no bearing down is required.
Stage 4 refers to the first few hours after the delivery of the placenta, when the uterus shrinks in size and you become acquainted with your baby.
Although all labors have these same four stages, each labor is unique. Labors differ from one woman to the next and even from one labor to the next in the same woman. Some of the factors that affect the course of labor include general states of health and nutrition, emotional behavior, preparation for childbirth, size and shape of the pelvis, size and presentation of the baby, and medical interventions.
The cause of the onset of labor is not completely known. The following factors are thought to contribute to the start of labor:
1. The uterus reaches a critical point of distention
2. The placenta ages, and levels of the hormone progesterone drop, causing the uterus to become irritable
3. Hormones from the baby stimulate uterine contractions
4. The mother’s pituitary gland releases oxytocin, a hormone that causes the uterus to contract
5. Hormones called prostaglandins are released from the wall of the uterus, stimulating contractions of the uterine muscle
6. Stretching of the cervix sets up reflexes in the nervous system that stimulate more contractions
There is no conscious action on the part of the mother that can start or stop contractions. However, anxiety, fatigue, physical activity, and sexual stimulation may affect the contractions. Rides over bumpy roads do not seem to start labor.
Throughout the last two-thirds of your pregnancy, the uterus has mild, intermittent contractions without pattern. These are referred to as Braxton-Hicks contractions. The contractions are exercises that condition the uterus for labor, and they are felt as a tightening in the lower abdomen that lasts from a few seconds to a few minutes. They have no rhythmical pattern. You may notice that the uterus feels hard during these contractions.
The Braxton-Hicks contractions gradually become stronger and occur more frequently as you near the end of your pregnancy. Often these contractions cause very gradual, intermittent softening, thinning, and opening of the cervix. Since these changes are not steadily progressive, they are not considered labor.
The contractions of labor are made up of three parts: the build-up, the peak, and the tapering off. Between contractions, there are periods of relaxation so that the body can rest and the uterus will be re-oxygenated.
The frequency of a contraction is timed from the beginning of one contraction until the beginning of the next. Duration is timed from the beginning of a contraction to the end of the same contraction.
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Approach of Labor
Labor usually begins between 37 and 42 weeks after the first day of the last menstrual period. Several weeks before labor, there may be signs of its approach.
Lightening, or dropping, refers to the settling of the baby’s head into the pelvis. If and when this occurs, you may notice greater ease in breathing, less heartburn, increased pressure in the pelvic area, greater frequency of urination, and awkwardness when walking. You may also have more lower backaches and difficulty sleeping.
This may occur two to four weeks before labor in first pregnancies, but it may not occur until labor actually begins in second or later pregnancies.
Vaginal secretions increase during the last weeks of pregnancy. If changes in the cervix occur, you may note brown, pink, or blood-tinged mucous. This is also commonly noted after the examinations of the cervix done in the last few weeks of pregnancy. This is called loss of the mucous plug or bloody show.
Weight change, either a loss or leveling off of weight, is often noted shortly before labor begins.
Some women experience energy changes shortly before labor begins such as a sudden urge to clean the entire house, wash the walls, rearrange the furniture, and so forth. Resist the urge! Save your energy for labor.
The baby’s movement will decrease just prior to labor.
Braxton-Hicks contractions may increase in frequency. This is false labor, though sometimes the contractions are sufficiently strong and frequent enough to be confused with true labor.
The false labor, or pre-labor, may go on for many hours or even several days, causing extreme fatigue. It may be necessary to give a safe, mild sedative to help you rest. Following this rest, it is common for true labor to begin.
Ruptured membranes can occur when a membrane stretches, develops a weak spot, then opens up and releases amniotic fluid. The sac or membrane that contains the amniotic fluid protects the baby and serves as a barrier to infection from the vagina.
The rupture may occur as a sudden gush of watery fluid or as an uncontrollable continuing trickle. Rupture of membranes usually occurs during labor, but in 10% of cases it happens before labor has begun.
Two complications occasionally result. If the head is not engaged in the pelvis, the cord may fall into the vagina and then be compressed between the baby’s head and the pelvic walls, which could deprive the baby of oxygen. The other possibility is that with the passage of time, infection of the uterus and its contents may develop.
If you suspect that your membranes have ruptured, you should be evaluated by your physician or nurse midwife. If you are at term, labor usually begins within 12–24 hours. If labor does not begin on its own, it may need to be induced.
If the membranes rupture before 37 weeks, it may be better for the baby to have more time before labor begins. When the membranes rupture, do not place anything into the vagina. Do not use tampons, douche, or have sexual intercourse in order to avoid introducing infection.
As mentioned earlier, it is common to have a bloody show in late pregnancy or after examination of the cervix, but passage of blood like a period is not normal and could represent a problem with the placenta. You should notify your care provider immediately if this occurs.
In summary, you need to be seen when the following occur:
• Regular rhythmical contractions with intervals of five minutes or less
• Suspected rupture of membranes
• Any bleeding more than a bloody show
If any of these occur during office hours, please call the office and come in to be examined. If any of these occur outside office hours, please go to the hospital to be examined.
Please phone the office at (970) 493-7442 before going to the hospital and the answering service will put you in contact with your physician or nurse midwife.
| True
Labor |
False
Labor |
• Contractions often felt more in the back
• Contractions become progressively stronger, longer, and closer together over time
• Intensity increases with activity changes
• Bloody show often present
• Progressive effacement and dilation of cervix |
• Contractions felt more in the abdomen
• Contractions remain variable in interval, duration, and intensity
• Intensity decreases with change in activity
• No bloody show
• No progressive effacement and dilation of the cervix
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| The false labor or pre-labor may go on for many hours or even several days, causing extreme fatigue. It may be necessary to give a safe, mild sedative to help you rest. Following this rest, it is common for true labor to begin. |
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The Hospital
The health care facility for your delivery is Poudre Valley Hospital, located at 1024 South Lemay. Several times a month, the Obstetric Department invites expectant parents to a Parents-To-Be Preview, a slide presentation and tour of the PVH Birth Center. In addition, they will describe their philosophy of family-centered maternity care. We urge you to attend this Preview about one month before you are due to deliver. Our office will provide you with pre-admission forms that should be completed and mailed or taken to the Admission Office of the hospital.
The labor and delivery area consists of several private birthing suites where you will labor, deliver, and recover. All of these suites are equipped with birthing beds and infant resuscitation equipment. There are also two high-risk rooms, two conventional delivery/operating rooms for cesarean sections and high-risk vaginal deliveries, and a two-bed recovery room. A large Jacuzzi-like tub is available for early labor and back discomfort.
The hospital staff shares our philosophy of a family-centered birth experience. A support person, or persons, of your choice may be with you at all times. Your children may attend the birth if you feel that they are mature enough for this to be a good experience for them. Young children need to have an adult, other than the labor coach, supervising them.
Although the hospital can supply most of your clothing and personal hygiene items, you will feel more comfortable if you bring your own. You will need a robe, slippers, gown, and a good supportive bra. The bra is recommended whether you nurse or use formula to feed your baby.
The hospital will provide sanitary pads, lotion, soap, tissues, and shower caps after your delivery. If you forget your toothbrush, toothpaste, mouthwash, or breast pads, these can be provided upon request.
You will also need a complete set of clothes for your baby to wear home.
Your arrival time will determine which entrance you should use at Poudre Valley Hospital. For specific instructions, please consult your information booklet from
PVH.
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Admission Procedures
When you arrive at the labor and delivery area, you will be assigned to an appropriate birthing suite. After answering several of the nurse’s questions, you will be asked to change into a hospital gown.
The nurse will then monitor your pulse and blood pressure and the baby’s heart beat. The nurse will also record the frequency and duration of your contractions and check the cervix for effacement and dilation. The nurse will then notify the on-call physician or nurse midwife of your presence in the delivery area and ask for further directions.
Enemas are not routine since many women experience frequent bowel movements, which are associated with the onset of labor. If you have not had a bowel movement within the eight hours before coming to the hospital, you will be offered a Fleets enema since a full rectum may be uncomfortable for you and may slow your progress in labor.
Electronic fetal heart rate monitoring is usually performed to ensure that your baby is doing well during the stresses of labor. If a baby is experiencing some distress during labor, the electronic monitors make us aware of developing problems at a much earlier stage than the monitoring provided by a stethoscope.
The prevailing opinion is that monitoring is in the best interest of your baby. If early distress is detected, appropriate measures can be instituted to avert more serious problems. Many women find that it is helpful for them to know when a contraction is beginning, and they also like the assurance of seeing the baby’s heart rate at all times.
There are two types of monitoring: external and internal.
With external monitoring, two belts are placed around the abdomen. One belt contains a device that detects the uterine contractions; the other belt detects the fetal heart rate by means of a Doppler ultrasound, similar to the one used in our office.
If you are in early labor, an initial 15- to 20-minute monitoring strip will be obtained to assure that the baby is doing well. Intermittent monitoring for 15–20 minutes out of each hour will typically be performed until you are in the active phases of labor.
One objection raised to external monitoring is that it restricts the ability of the laboring mother to move about. This is easily overcome by the intermittent monitoring of early labor, when you wish to be up and walking. The monitor can be easily disconnected if you need to go to the restroom.
As you enter the more active phases of labor, it is common to begin monitoring continuously and to switch to
internal monitoring. With internal monitoring, a small clip is attached to the baby’s scalp to detect the baby’s heart rate. Internal monitoring provides a more accurate reading of the baby’s heart rate and allows the laboring woman to move about more freely than she can with external monitoring.
Many people are concerned that the electrode on the baby’s scalp may be painful; however, the discomfort is probably minimal compared to the sensations the baby experiences with contractions. An infrequent complication of internal monitoring is that an infection may occur where the electrode is applied to the baby’s scalp. This is easily treated if it does occur.
We strongly believe that the minor inconveniences and risks posed by both forms of monitoring are offset many times over by the increased safety they provide your baby during the birthing process.
Another safety measure that we believe is necessary is a buffalo cap. The buffalo cap is a small, plastic tubing that is inserted into the vein in the forearm and capped off with a small amount of medication called heparin, which prevents a blood clot from forming in the tube. Although obstetrical emergencies occur infrequently, when they do occur, they may arise suddenly. The buffalo cap provides a means of responding to these emergencies effectively and quickly. Medications or blood can be given through the intravenous catheters. In the event of prolonged labor, a solution of water and dextrose can also be administered through the buffalo cap to provide energy and to prevent dehydration.
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First Stage of Labor
During the first stage of labor, the contractions of the uterus will cause the cervix to efface and dilate.
Effacement refers to the shortening and thinning of the cervix. This is expressed as a percentage, from 0% (long and thick) to 100% (completely thinned out).
Dilation, or dilatation, refers to the opening of the cervix. This is expressed in centimeters, 0 (closed) to 10 (complete dilation).
Station is another term used to indicate the progress of labor, and it refers to the position of the baby’s “presenting part” in relation to the ischial spines in the pelvis. A zero station means the presenting part (usually the baby’s head) is level with the spines. A minus number refers to the number of centimeters the baby’s head is above the spines, and a plus number refers to the number of centimeters the baby’s head is below the spines. The head is usually considered to be engaged when it reaches the level of the ischial spines.
Your progress in labor is determined by vaginal examinations, which measure the effacement and dilation of the cervix and the station of the baby. Your physician, nurse midwife, and labor and delivery nurse will perform your examinations, helping you assess your progress in labor.
The first stage of labor is divided into three phases: early, active, and transition.
Early Phase
The early phase of labor extends from the onset of labor until the cervix is dilated approximately four centimeters. During this phase, the contractions are regular, every 5–10 minutes, and they usually last for about 30–45 seconds. They are usually of mild to moderate intensity.
The contractions result in the effacement of the cervix and dilation up to four centimeters. This process usually takes about six to twelve hours.
If you think you may be in labor, it is best to avoid eating solid foods. The intake of water, clear liquids, or ice chips is encouraged.
Generally, your labor will progress more rapidly and you will be more comfortable if you continue light activities such as walking.
During this phase, you may want to begin practicing the relaxation techniques you learned during your pregnancy. You may also wish to practice the breathing patterns during your contractions when other efforts are no longer effective. Your coach will help you by timing your contractions and by providing you with physical comfort and emotional support.
Active Phase
The active phase is when the cervix becomes four centimeters dilated, and contractions usually increase in intensity and become somewhat longer, lasting 45–60 seconds. The contractions then remain regular, usually two to five minutes apart.
During this stage, the cervix dilates at the rate of approximately one centimeter per hour for first pregnancies. For subsequent pregnancies, the process usually occurs more rapidly unless the baby is larger in size or is in an unusual position.
It is common to experience nausea or vomiting and trembling of the legs during the active phases. Your coach will continue to support you physically and emotionally.
Transition Phase
During the transition phase, the cervix goes from approximately eight centimeters dilation to complete dilation. It is the shortest but most intense part of labor. Contractions are usually every two to three minutes; they last 60–90 seconds and are very intense. As complete dilation approaches, you may develop pressure sensations in the rectum and an urge to push.
Nausea, vomiting, chills, tremors, difficulty in maintaining relaxation, and discouragement are also common during this phase. Your coach will continue with physical and emotional comfort measures.
You should not begin pushing down with the abdominal muscles until you are told to do so, since it could result in the tearing of the cervix.
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Second Stage of Labor
The second stage of labor begins with the complete dilation of the cervix and ends with the birth of the baby.
During this stage, the baby descends through the pelvis and enters the outside world. This work is accomplished by contractions of the uterus and is aided by your voluntary pushing efforts. This stage gave the name “labor” to the birthing process.
It is common to experience the sensation of fullness in the vagina and pressure in the rectum during this stage, but the urge to push seems to vary from one woman to another. During your prenatal classes, you will be taught to push from a variety of positions including semi-reclining, lying on your side, kneeling, and squatting. You should use the position that is most comfortable and most effective for you. As you push with your abdominal muscles during the contraction, it is important to allow the perineum to relax. You should also relax completely between contractions so that you can refresh yourself.
Crowning refers to the baby’s head appearing at the vaginal opening. When crowning occurs, preparations are made for delivery.
If you are using a birthing room, the bed will be made ready for delivery, and necessary equipment will be brought into the room. You will find that the birthing bed provides you with a variety of options for positions during delivery. Choose one that is most comfortable for you.
If the delivery is to be done in a delivery room, you will be transferred to a delivery table, and your legs will be supported by stirrups. You can hold onto the handles on the sides of the delivery table as you push.
Wherever you deliver, your coach will remain at your side during birth and is welcome to take photographs. High-speed color film produces excellent photographs without the use of a flash.
When the baby’s head is delivered, you will feel a momentary decrease in the pressures you have been experiencing. During this time, the baby’s mouth and nose will be suctioned to remove mucus and amniotic fluid. When this is completed, you will be asked to push down again, and the shoulders, followed by the baby’s body, will be delivered.
The baby is then usually placed on the mother’s abdomen, and further suctioning of the mouth and nose is performed. The baby is then carefully dried to prevent chilling.
Two clamps will be placed across the umbilical cord. Fathers are welcome to cut the umbilical cord if they wish to do so.
You will then be given your baby to hold.
It is very important to prevent the loss of heat in a newborn, so a cap will be placed on the baby’s head, and both you and the baby will be covered by warm blankets.
You will most likely be very eager to inspect your newborn baby. After counting the fingers and toes, you may notice that the baby has a somewhat bluish appearance. This is perfectly normal since it takes a few minutes to oxygenate the blood when making the transition from the uterus to the outside world.
You may also notice some blood on the baby, which comes from the mother’s birth canal. A white material called vernix caseosa covers many babies; this protects the baby while in the uterus.
Often, the baby’s head may appear elongated because of molding that occurs during the passage through the birth canal. This molding gradually disappears over the first two to three days following birth.
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Third Stage of
Labor
The third stage of labor begins with the birth of the baby and ends with the delivery of the placenta. The rhythmical contractions that you have been experiencing temporarily cease. The contractions gradually return and cause the placenta to be expelled. There is nothing you need to do to hasten the process.
After the placenta has been delivered, the hormone Pitocin may be injected into the buffalo cap to hasten the contraction of the uterus and to prevent unnecessary bleeding.
The birth canal will be inspected for any tears and, if necessary, a few skillfully placed sutures may be required to return the tissues to their normal position.
During this time, the lighting in the room may be dimmed since the baby’s eyes are very sensitive.
Your baby will be carefully monitored following the delivery. At one and again at five minutes following the delivery, the baby’s heart rate, respiratory effort, color, muscle tone, and reflexes will be evaluated and given a score, which is referred to as the
Apgar score. Scores of seven to nine at five minutes are considered normal. A score of 10 is very unusual since few babies have pink hands, fingers and toes within five minutes of delivery.
After you have inspected your baby, the nurse will place an identification band on the baby’s wrist and ankle and a matching band on your wrist. The baby will be weighed and measured, and the baby’s footprints will be taken.
|
THE APGAR
SCORING CHART |
| Sign |
Score
0 |
Score
1 |
Score
2 |
| 1. Heart rate |
Absent |
Below 100 beats/minute |
Over 100 beats/minute |
| 2. Breathing Effort |
Absent |
Slow, irregular |
Good, crying lustily |
| 3. Muscle Tone |
Limp |
Some bending of arms, legs |
Active motion |
4. Reflex Irritability
(Baby's reaction when soles of feet are flicked) |
No Response |
Cries, some motion |
Vigorous cry |
| 5. Color |
Blue, pale |
Pink body, blue hands & feet |
Completely pink |
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Fourth Stage of Labor
During the first few hours following birth, the uterus will contract in size, and bleeding will gradually subside. During this time, you may eat or drink as desired and should rest to refresh yourself.
Both you and your baby will be carefully monitored by the nursing staff for one to two hours. The nursing staff will teach you to massage the uterus to keep it contracted.
Afterpains, or contractions of the uterus, are more noticeable after second and subsequent births.
Lochia is the normal flow of blood, excess tissue, and fluid from the uterus. It will be monitored for amount and consistency.
Phones are available so that you can notify family and friends of this long-awaited event.
Bonding
Getting to know your baby and incorporating this new little stranger into your family is a process that is referred to as
bonding. The first few hours following the delivery seem to be very important to this process. The baby is usually very alert and receptive during this time, making it an excellent opportunity for you to become acquainted. Feel free to touch and hold your baby, look into the baby’s eyes, talk to the baby and, if you wish, nurse.
From two to 24 hours following birth, your baby will often be very sleepy, and most babies do not seem to be as receptive to the bonding process during that time.
| The Postpartum Area |
| Approximately two hours after birth, you will be transferred to your room in Women’s Care. Your baby will be taken to the nursery at this time for a brief exam, bath, and photo.
During your stay, your baby may either stay with you in your room or be in the nursery. Do not feel that your baby must be with you all of the time. It is very important for new mothers to get plenty of rest.
Your doctor or nurse midwife will normally examine
you baby in the nursery between 7:00 a.m. and 9:00 a.m. |
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After the Birth of the Baby
Following the birth of the baby, the uterus will continue to contract in order to squeeze out extra blood and tissue, and contractions usually increase while you are nursing your baby. The contractions are often much more noticeable with second or subsequent births. Pain medication is available, but you must notify the nursing staff that you want it to be brought to you.
Following your delivery, fluid retained during pregnancy begins to be eliminated. Because of the soreness in the perineal area, sensations associated with urination may be altered. You should frequently empty your bladder so that it does not become overextended. If you are unable to urinate, it may be necessary to insert a catheter to drain the bladder.
Throughout recovery time, you should frequently contract the pelvic floor muscles (Kegel exercise). This increases blood flow to the area, reduces swelling, and speeds healing of the tissues. It also helps restore muscle tone to your pelvic floor.
The nursing staff will instruct you about how to care for the perineal area following your delivery in order to prevent infection and promote healing. To relieve soreness, any or all of the following are available:
• Ice packs to apply to the area for six hours following birth
• Sitz baths (soaking in a warm tub) three times a day
• Warm water washes using a peri- bottle after each bathroom use
• Anesthetic sprays
• Tucks medicated pads
• An inflatable ring on which to sit
Because of the relaxation of the abdominal muscles, soreness of the perineum, and perhaps hemorrhoids, you may have some difficulty in moving your bowels. A stool softener will be prescribed throughout your hospital stay.
You should also drink sufficient fluids and eat a diet that is high in fiber throughout the postpartum period.
If you are an Rh negative mother, your baby’s blood type will be tested. If the infant is Rh positive, you will receive an injection of RhoGAM within 72 hours of birth. This injection prevents your body from producing antibodies that could endanger subsequent babies during pregnancy.
If your baby is a male, you will be asked whether or not you would like to have a circumcision performed. Proponents of the procedure state that it prevents cancer of the penis, infection of the foreskin, and phimosis (inability to retract the foreskin). They also point out the psychological benefits of having a penis that looks like his father’s or his peers’, most of whom have been circumcised.
Opponents of circumcision argue that cancer of the penis, infection of the foreskin, and phimosis can all be prevented by good personal hygiene. They also point out that the procedure carries a risk of bleeding at the time of surgery as well as a delayed scarring of the urinary opening, which may require correction at a later date.
If you have further questions, please discuss them with your pediatrician.
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