Labor and Birth
Labor and Birth
Soon, you'll experience the amazing process of childbirth! Find out the signs of labor and learn about your options for giving birth.
Prepare for Labor and Birth
Once you reach the third trimester, you should talk to your doctor or midwife about labor and delivery. Learn your options for pain relief. Find out how to reach her if you go into labor. And ask her at what point in labor should you call.
Before you reach the last few weeks of pregnancy,you and your partner should visit the hospital or birthing center. Make sure you know how to get there, whereto park and where to check-in. Find out if you can pre-register so that your insurance information is already in the computer when you arrive.
Signs of Labor
Many women, especially with their first babies, think they are in labor when they're not. This is called false labor. So don't feel embarrassed if you go to the hospital thinking you're in labor, only to be sent home!
If you think labor has begun, you should call your doctor or midwife. They can decide if it's time to go to the hospital or if you should be seen at the office first. Learn the signs of labor so you will know when the time has come.
Call your doctor if you experience any of the following:
- Contractions that come at regular and increasingly shorter intervals. Contractions should also become stronger over time.
- You have lower back pain that doesn't go away. You might also feel premenstrual and crampy.
- Your water breaks (can be a large gush or a continuous trickle).
- You have a bloody (brownish or red-tinged) mucous discharge. This is probably the mucous plug that blocks the cervix. Losing your mucous plug usually means your cervix is dilating (opening up) and becoming thinner and softer (effacing). Labor could start right away or may still be days away.
Choosing Where to Deliver
Many women carefully choose the kind of environment in which to deliver her baby. You will need to contact your health insurance to find out what options are available. Not all companies will cover care given at a birth center and fewer will cover planned home births. In general, women can choose to deliver at a hospital, birth center or at home. Nowadays, most hospitals and birth centers offer birthing classes like Lamaze and breastfeeding support.
Women with health problems, pregnancy complications or those who are at risk for problems during labor and delivery should give birth in a hospital. Hospitals offer the most advanced medical equipment and highly trained doctors for pregnant women and their babies. In a hospital, doctors can do a cesarean section if you or your baby is in danger during labor. Women can get epidurals or many other pain relief options.
Only certain doctors and midwives have admitting privileges at each hospital. So before you choose your doctor or midwife learn about their affiliated hospital. When choosing a hospital you might consider:
- Is it close to your home?
- Is an anesthesiologist at the hospital 24-hours a day?
- Do you like the feel of the labor and delivery rooms?
- Are private rooms available?
- How many support people can you invite into the room with you?
- Does it have a neonatal intensive care unit (NICU) in case of serious problems with the baby?
- Can the baby stay in the room with you?
- Does it have an on-site birth center?
More and more hospitals are adding on-site birth centers. At these hospitals you can choose to deliver your baby in the comfortable, intimate setting of a birth center. If something goes wrong, you and your baby have the added security of already being in a hospital.
Birth Centers - Healthy women who are at low-risk for problems during pregnancy, labor and delivery may choose to deliver at a birth or birthing center. Birth centers give women a "homey" environment in which to labor and give birth. They try to make labor and delivery a special, warm, family-focused process. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers.
Birth centers do not do any "routine" medical procedures. So, you will not automatically be hooked up to an IV. Likewise, you won't have an electronic fetal monitor around your belly the whole time. Instead, the midwife or nurse will check in on your baby from time to time with a handheld machine. Once the baby is born, all examinations and care will occur in your room. By doing away with most high-tech equipment and routine procedures, labor and birth remain a natural and personal process.
Women can not receive epidurals at a birth center although some pain medicines may be available. If a cesarean section becomes necessary, women must be moved to a hospital for the procedure. Basic emergency care can be done on babies with problems while they are moved to a hospital.
Many birthing centers have showers or tubs in their rooms for laboring women. They also tend to have comforts of home like large beds and rocking chairs. In general, birth centers allow more people in the delivery room than do hospitals.
Birth centers can be inside of hospitals, affiliated with a hospital or completely independent, separate facilities. If you are interested in delivering at a birth center, make sure it is accredited by the Commission for the Accreditation of Birth Centers. Accredited birth centers must have affiliated doctors at a nearby hospital in case of problems with the mom or baby.
Healthy pregnant women with no risk factors for complications during pregnancy, labor or delivery can consider a planned homebirth. Some certified nurse midwives and physicians will deliver babies at home. If you are considering this choice you should ask your insurance company about their policy on homebirths. Some health insurance companies cover the cost of care for home births and others don't.
Homebirths are common in many countries in Europe. But in the United States, planned homebirths are still a controversial issue. The American College of Obstetricians and Gynecologists (ACOG) is against homebirths. ACOG states that hospitals are the safest place to deliver a baby. In case of an emergency, says ACOG, a hospital's equipment and highly trained physicians can provide the best care for a woman and her baby.
If you are considering a homebirth, you need to weigh the pros and cons. The main advantage is that you will be able to experience labor and delivery in the privacy and comfort of your own home. Since there will be no routine medical procedures, you will have control of your experience.
The main disadvantage of a homebirth is that in case of a problem, you and the baby will not have immediate hospital/medical care. It will have to wait until you are transferred to the hospital. Plus, women who deliver at home have no options for pain relief.
To ensure your safety and that of your baby, you must have a highly trained and experienced midwife along with a fail-safe back-up plan. You will need fast, reliable transportation to a hospital. If you live far away from a hospital, homebirth may not be the best choice. Your midwife must be experienced and have the necessary skills and supplies to start emergency care for you and your baby if need be. Your midwife should also have access to a physician 24 hours a day.
Who Should Deliver Your Baby?
Women can also choose what type of health care provider they would like to deliver their baby. An obstetrician-gynecologist (OB) is a medical doctor who specializes in the care of pregnant women and in delivering babies. Obstetricians also have special training in surgery so they are capable of doing episiotomies and cesarean sections. Women who have health problems or pregnancy complications should see an obstetrician.
A certified nurse-midwife (CNM) and a certified professional midwife (CPM) specialize in prenatal care, labor, and delivery. Both can be a good option for healthy women at low-risk for problems during pregnancy, labor, or delivery. A CNM does not need experience delivering babies in home settings and most practice in hospitals and birth centers. A CPM is required to have experience delivering babies in home settings because most practice in homes and birthing centers. Both should have a back-up arrangement with an obstetrician in case of a problem or emergency.
Some women also choose to have a doula assist with labor and delivery. A doula is a professional labor coach who gives physical and emotional support to women during labor and delivery. They offer advice on breathing, relaxation, movement and positioning. Doulas also give continuous emotional support and comfort to women and their partners during labor and birth. Doulas and midwives often work together during a woman's labor. Check with your health insurance company to find out if they will cover the cost of a doula. When choosing a doula, find out if she is certified by Doulas of North America (DONA) or a comparable group.
Managing the Pain
Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for everyone. So no one can predict how you will feel. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, and the strength of the contractions.
Natural Pain Relief
Many women choose to deliver their babies without using medicine for pain relief. Some of these women use other techniques to help them cope. Things women do to ease the pain include:
- use breathing and relaxation techniques
- take warm showers or baths
- receive massages
- have the supportive care or a loved one, nurse, or doula
- find comfortable positions while in labor (stand, crouch, sit, walk, etc)
- use a labor ball
- listen to music
Building a positive outlook on childbirth and managing fear may also help some women cope with the pain. It is important to realize that labor pain is not like pain due to illness or injury. Instead, it is caused by contractions of the uterus that are pushing your baby down and out of the birth canal. In other words, labor pain has a purpose.
Try the following to help you feel positive about childbirth:
- Take a childbirth class. Call the doctor, midwife, hospital or birthing center for class information.
- Get information from your doctor or midwife. Write down your questions and talk about them at your regular visits.
- Share your fears and emotions with friends, family and your partner.
More and more women in the United States are using water to find comfort during labor and delivery. In waterbirthing, laboring women get into a tub of water that is between 90 and 100 degrees. Some women get out of the tub to give birth. Others remain in the water for delivery.
The water helps women feel physically supported. It also keeps them warm and relaxed. This eases the pain of labor and delivery for many women. Plus, it is easier for laboring women to move and find comfortable positions in the water.
Waterbirthing is relatively new in this country. So there is very little research on its benefits. Even so, some women say giving birth in the water is faster and easier. Plus, women may tear less severely and need fewer episiotomies in the water.
Waterbirthing may be gentler for your baby too. It may ease the baby's transition from the womb to the new world. The baby is born into an environment that is similar to the womb. Plus, the water dulls the lights, sound and feel of the new world. Once the baby is born, it is brought to the surface of the water and wrapped in blankets.
Ask your doctor or midwife if you are a good candidate for waterbirthing. Water birth is not safe for women or babies who have health issues.
Medical Pain Relief
While you're in labor, your doctor, midwife or nurse should ask if you need pain relief. It is her job to help you decide what option is the best for you. There are many different kinds of pain relief. Not all options are available at every hospital and birthing center. Plus your health history, allergies, and any problems with your pregnancy will make some options better than others.
Types of pain relief used for labor and delivery include:
Intravenous or intramuscular analgesic - A doctor gives you pain medicine through a tube inserted in a vein (intravenous) or by injecting the medicine into a muscle (intramuscular). These medicines go into your blood and help ease the pain. Opioids including morphine, fentanyl and nalbuphine are usually used for this type of pain relief. This option does not get rid of all the pain. Instead it usually just makes the pain bearable. After getting this kind of pain relief, you can still get an epidural or spinal pain relief later.
Some disadvantages of getting intravenous or intramuscular analgesics include:
A doctor injects medicine into the lower part of your backbone or spine. The medicine blocks pain in the parts of the body below the shot. During a contraction, the feeling of pain travels from the uterus to the brain along nerves in the backbone. Epidurals block the pain of contractions by numbing these nerves.
Epidurals allow most women to be awake and alert with very little pain. Many women who get epidurals do not feel any pain during contractions and childbirth. Medicines used in epidurals include novocaine-like drugs that block the pain in that region combined with opioids like fentanyl.
Some disadvantages of getting an epidural include:
- It can make you shiver.
- It can lower your blood pressure.
- It can make you feel very itchy.
- It can cause headaches.
- It many not numb the entire painful area. So women continue to feel pain in an area of the abdomen and back.
A doctor injects numbing medicine into the vagina and a nearby nerve called the pudendal nerve. This nerve carries sensation to the lower part of your vagina and vulva. This is only used late in labor, usually right before the baby's head comes out. With a pudendal block, you have some pain relief but remain awake, alert and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages.
A doctor injects a medicine into the lower part of your backbone. This medicine numbs the body below where the medicine was injected. Spinal anesthesia gives immediate pain relief. So they are often used for women who need an emergency Cesarean section. Spinal anesthesia uses numbing medicines similar to novocaine combined with opioids like fentanyl.
Some disadvantages of spinal anesthesia include:
- It numbs the body from the chest down to the feet.
- It makes you feel short of breath.
- It can lower your blood pressure.
- It can cause headaches.
Most healthy pregnant women with no risk factors for problems during labor or delivery have their babies vaginally. Still, the rate of babies born by cesarean section (c-section) in the United States is on the rise. In 2004, 29.1 percent of babies were born by c-section in this country. This is an increase of more than 40 percent since 1996.
Many experts think that up to half of all c-sections are unnecessary. Thus, the U.S. government is trying to reduce the rate. So it is important for pregnant women to get the facts about c-sections before they deliver. Women should find out what c-sections are, why they are performed, and the pros and cons of this surgery.
What is a C-section?
During a c-section, the doctor makes a cut in the mother's abdomen and uterus and removes the baby. So, the baby is delivered through surgery instead of coming out of the vagina. Most women get spinal or epidural anesthesia during a c-section. This allows her to stay awake without feeling pain. But sometimes general anesthesia is needed. With general anesthesia the woman is asleep during the procedure.
A c-section can save the life of a baby or mother. If health problems come up before or during labor and delivery, a c-section can get the baby out very quickly. Most c-sections result in a healthy mother and baby.
Still, a c-section is major surgery. And all surgeries have risks. These include infection, dangerous bleeding, blood transfusions and blood clots. Women who have c-sections stay at the hospital for longer than women who have vaginal births. Plus, recovery from this surgery takes longer and is often more painful than that after a vaginal birth. So, c-sections should only be done when the health or the mother of baby is in danger.
When do Doctors Recommend C-sections?
Doctors recommend c-sections when the health of the baby or mother is in danger. Even so, there are risks of delivering by c-sections. Limited studies show that the benefits of having a c-section may outweigh the risks when:
- the mother is carrying more than one baby (twins, triplets, etc.)
- the mother has health problems including HIV infection, herpes infection, and heart disease
- the mother has dangerously high blood pressure
- the mother has problems with the shape of her pelvis
- there are problems with the placenta.
- there are problems with the umbilical cord
- there are problems with the position of the baby (e.g. breech presentation)
- the baby shows signs of distress (e.g. slowed heart rate)
- the mother has had a previous c-section
Elective C-Sections: Can Women Choose?
A growing number of women are asking their doctors for c-sections when there is no medical reason. Some women want a c-section because they fear the pain of childbirth. Others like the convenience of being able to decide when and how to deliver their baby. Still others fear the risks of vaginal delivery including tearing and sexual problems.
But is it safe and ethical for doctors to allow women to make medical decisions? The answer is unclear. Only more research on both types of deliveries will provide the answer. In the meantime, many obstetricians feel it is their ethical obligation to talk women out of elective c-sections. Others believe that women should be able to choose a c-section if they understand the risks and benefits.
Experts who believe c-sections should only be performed for medical reasons point to the risks. C-sections can be dangerous for the mother and baby. This major surgery increases the risk of infection, bleeding and pain in the mother. C-sections also increase the risk of problems in future pregnancies. Women who have had c-sections have a higher risk of uterine rupture. If the uterus ruptures, the life of the baby and mother is in danger. Babies born by c-section have more breathing problems right after birth and are very rarely cut during the surgery.
Supporters of elective c-sections say that this surgery may protect a woman's pelvic organs, reduces the risk of bowel and bladder problems, and is as safe for the baby as vaginal delivery. The American College of Obstetricians (ACOG) is not opposed to elective c-sections. ACOG states that "if the physician believes that (cesarean) delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing" a c-section.
Can I Try a Vaginal Birth if I've had a C-Section (VBAC)?
Some women who have delivered previous babies by c-section would like to have their next baby vaginally. This is called vaginal delivery after c-section or VBAC. Women give many reasons for wanting a VBAC. Some want to avoid the risks and long recovery of surgery. Others want to experience vaginal delivery.
Studies show that VBACs are more risky for the woman and baby than a repeat c-section. The most serious danger of VBACs is the chance that the c-section scar on the uterus will open up during labor and delivery. This is called uterine rupture. While very rare, uterine rupture is very dangerous for the mother and baby. Less than 1 percent of VBACs lead to uterine rupture. Even so, uterine rupture can lead to life-threatening bleeding for the mother and brain damage or even death for the baby.
The biggest and best study on VBACs was published in the New England Journal of Medicine in 2004. The researchers studied more than 30,000 women who had had a c-section and were pregnant again. Some of these women chose to have a VBAC. Others decided on a repeat c-section. The doctors compared the health of the women and babies after both types of delivery.
Almost three-quarters (73%) of women had a successful VBAC. The other 27% of women who tried to deliver vaginally ended up having another c-section. While rare, problems with the woman and baby were more common among VBACs compared with repeat c-sections. Only 0.8% of women had a uterine rupture. Women who tried VBACs had more blood transfusions and a greater risk of endometriosis than those who had repeat c-sections. Babies born by VBAC had a higher risk of brain damage than those born by repeat c-section.
The percent of VBACs is dropping in the United States for many reasons. Women, doctors and hospitals are worried about the rare, yet possible problems of VBACs. A growing number of doctors and hospitals are banning VBACs. They are afraid of lawsuits that might follow VBACs that go wrong. In 2004 the American College of Obstetricians and Gynecologists recommended that hospitals have a surgical team "immediately available" whenever a woman is having a VBAC. In other words, ACOG suggests that a surgeon, nurses and an anesthesiologist be standing by in case an emergency c-section is needed. Guaranteeing this stand-by team is just too expensive for many hospitals.
Doctors are also discouraging or flat out refusing to perform VBACs. Sometimes this is because their affiliated hospital does not allow them. In other cases, doctors can not get malpractice insurance to cover claims related to VBACs. And some doctors admit they are afraid of getting sued if a VBAC goes wrong.
Choosing to try a VBAC is a difficult decision for many women. If you are interested in a VBAC, talk to your doctor and read up on the subject. Only you and your doctor can decide what is best for you. VBACs and planned c-sections both have their benefits and risks. Learn the pros and cons and be aware of possible problems before you make your decision.
The American College of Obstetricians and Gynecologists (ACOG) recommends that doctors consider VBACS when:
- a woman has had 1 previous planned c-sections done with a low, horizontal cut or incision ("bikini" incision)
- a woman has no other uterine scars (aside from the prior c-section) or problems
- a woman has no known problems with her pelvis
- a doctor is present during all of labor and delivery and can perform an emergency c-section if needed
- an anesthesiologist and other members of a surgical team are standing by in case an emergency c-section is needed
Source: The National Women's Health Information Center
U.S. Department of Health and Human Services
Office on Women's Health
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