Our Bodies, Ourselves (87 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
© Jada Shapiro, Birth Day Presence
When we went for a walk, we ran into friends. “What are you doing up? I thought you were in labor.” It was fun changing people's image of a woman in labor
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For many first-time mothers, it can take a day or more to get to about 4 centimeters dilation, which signals entry into the active phase of labor. When you feel painful, wavelike, regular,
rhythmic contractions that last forty-five to sixty seconds and that are so intense you can't talk or walk while you are having one, you are likely in active labor. The contractions may begin in your back, you may feel them only in the front, or you may feel them in both the back and front. Your uterus feels hard to the touch.
Your water may break at any time before or during labor. Some women will notice their water break before labor or during early labor. If you start active labor and your water hasn't broken yet, it most likely will during transition or while pushing.
Though you may have heard that labor will get more and more painful as it progresses, this is not necessarily true. Some women say the active phase of labor was the most painful, some say the transition phase, and others say pushing was the most painful. In general, women feel the most pain during periods when the cervix is dilating fast or when the baby is descending quickly. These events can happen at different phases of labor for different women.
I spent most of the night laboring alone in the dark, like a cat. It was marvelous. Not easyâit's hard work; that's why it's called LABOR. It was intense. Not painfulâI can't call it painful. But it's . . . inevitable. Inescapable. Uncontrollable. You can't get away. I kept thinking of that kids' game “Going on a bear hunt”: “Can't go over it, can't go around it, have to go through it!”
This is the time to gather your support people, to call your provider if you are having a home birth, or to prepare to go to the birth center or hospital. If you are not sure if you are in active labor yet, your care provider can help you know for sure. A careful phone consultation, a home visit, or a visit at the office can help determine your progression. Staying home or in another familiar, comfortable setting until active labor is well established is an important strategy for reducing your chance of interventions. Studies show that being admitted to a hospital in early labor increases the chances of having medications to speed up your labor or a cesarean section.
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Travel can be an uncomfortable challenge during active labor, but you can regain your rhythm once you are settled in your chosen birth setting.
Progress in the active phase of labor, both for first-time mothers and for women who have given birth before, is widely variable. In many hospital birth settings, expectations for labor progress are based on outdated studies that showed average dilation rates in women with medically managed labors (known as the “Friedman curve”) or driven by financial incentives to get labor done more quickly and make room for the next patient to be admitted. The traditions of natural or expectant management and current evidence show that normal labor can be significantly longer than previous studies suggested, and “plateaus”âwhen the woman's cervix doesn't actively dilate for several hoursâare common.
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As long as the mother and baby are doing well, labor should be allowed to progress on its own.
One woman describes her experience of getting “stuck” temporarily at a certain point in active labor:
I got stuck at about 8 to 9 centimeters for a really long time. I wasn't aware how long, except that it was hours. [The doctor] who was on call suggested Pitocin to speed things up, but I refused. Part of my concern was that the contractions were already so intense that I felt if they were
stronger and closer together I wouldn't be able to cope, and I did not want to do anything that put me at risk for a C-section â¦
© Elana Hayasaka
Cervical dilation shown in actual size (in centimeters). When you reach about 10 centimeters, you will be ready to push.
⦠In the end, I realized that though it was hard, it was never more than I could take, and I had been prepared to keep pushing for even longer if necessary. I had not reached the end of my strength. We never would have been able to do it without our doula's helpâshe was worth her weight in gold
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The last few centimeters from 8 cm to complete dilation (about 10 cm) can be the hardest, most intense phase of labor, but it is also usually the shortest. In first pregnancies, this period generally lasts no more than a couple of hours. The transition is when many women get discouraged and feel that they have hit a wall and can't go on. Excellent labor support from a loved one or doula can help you discover deep wells of strength to finish birthing. If you experience challenges at this time, keep in mind that this is the home stretch. Your body has already accomplished most of the difficult work. Do whatever makes you feel more comfortable and helps you handle the intensity of labor. When transition is over, you will be pushing your baby out. One woman recalls how she shed her usual inhibitions during transition:
The hospital's birthing pavilion was like a good hotel. But I didn't get to kick back with a book and some room service. All through the night, I heaved around on the floor in a variety of positionsâon my side Jane Fonda aerobics style, on all fours with ass and yoni to the wind, on the floor, and then up on the bed. I was desperate for comfort, relief and a baby in my arms
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MEDICAL APPROACHES TO SPEEDING UP LABOR
Active labor may be over in several hours, or it may take a day or longer. As long as the mother and baby are doing well, there is no reason for concern. Efforts to stimulate labor should be used only if they reduce the likelihood of a poor outcome such as infection or a cesarean section or prevent exhaustion and suffering. The two most common methods used in hospitals for stimulating labor arguably achieve neither of these outcomes reliably.
Artificial Rupture of Membranes
If you are in active labor with a bulging sac of water in front of your baby's head and the baby is deep in your pelvis, your doctor or midwife may recommend rupturing the membranes to strengthen contractions or to speed up a prolonged labor. This procedure, known as amniotomy, is performed during a vaginal exam using a small tool that looks like a crochet hook. Breaking the membranes is thought to release chemicals and hormones that stimulate contractions, and the direct pressure of the head rather than a cushion of fluid on the cervix is thought to assist dilation. However, a systematic review of the better-quality published research on routine amniotomy found that it is ineffective at speeding labor and may increase the likelihood of cesarean surgery.
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None of the studies assessed pain, but women commonly report increased pain after membranes are broken. Amniotomy may also predispose a woman to infection and increases the chance that the umbilical cord will be compressed enough to temporarily reduce oxygen flow to the baby.
Amniotomy is required if internal fetal monitoring is planned. Some women very late in labor find that amniotomy provides relief if a large pocket of fluid is bulging in front of the baby's head. Most women's membranes release spontaneously during pushing, if they haven't broken earlier in labor.
Pitocin
Pitocin (synthetic oxytocin) is sometimes used to make labor progress more quickly. It is given through an IV and makes contractions more frequent and forceful. Pitocin is on a small list of high-alert medications (drugs that have a high risk of causing injury when they are misused) identified by the Institute for Safe Medication Practices, and the use of Pitocin requires continuous fetal heart rate monitoring. Pitocin is begun at a low dose, which is gradually increased to achieve contractions that are close enough together to continue opening the cervix and moving the baby forward into the birth canal.
Negative consequences of having labor augmented with Pitocin include being attached to an IV and the electronic fetal monitor, which may limit your freedom to move into different positions. With Pitocin, contractions may reach their peaks more rapidly. If this occurs, the contractions may be more painful.
In addition, you may get too much medication for a short time, and this can cause contractions that come too close together. As a result, the baby may get less oxygen between contractions than she or he would with typical contractions. Turning the Pitocin off, lying on your side, and/or receiving extra IV fluids can quickly remedy this situation.
Since using Pitocin requires continuous fetal heart rate monitoring, fetal heart rate changes that appear alarming but are nonetheless tolerated by the baby may result in other interventions. Research is mixed on whether and under what circumstances Pitocin augmentation affects the likelihood of cesarean section.
Pitocin also interferes with the production of a woman's own natural oxytocin. Oxytocin is the hormone that regulates the emotional responses of connection and bonding. It is crucial for giving birth, breastfeeding, and attachment. More research is needed to understand whether the use of Pitocin in labor affects the emotional health and behavior of women and babies.
Pitocin may be used if labor progress slows and other efforts are not effective. Because epidurals disrupt a woman's own oxytocin levels, Pitocin is often needed to keep labor progressing after an epidural is placed.
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Some hospitals have a low-dose Pitocin protocol based on the peak action time of the drug. In this case, Pitocin is increased very slowly and over a longer period of time. This mimics natural labor more closely and makes the contractions easier to deal with.
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In Childbirth Connection's 2006 Listening to Mothers II survey, 59 percent of women had their bag of water artificially ruptured and 55 percent received intravenous Pitocin to speed up or strengthen contractions after labor started.
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When more than half of women receive interventions to treat “abnormal” labor, there may be something wrong with the definition of abnormal. Choosing a care provider and setting in which these interventions are used infrequently and arranging to have excellent labor support are good strategies for ensuring you will not be exposed to them unnecessarily. (For more information, see
Chapter 15
, “Pregnancy and Planning for Birth.”)
Shift changes were going on, and people were coming and going. It was like Grand Central Station. . . . They asked me if I minded having a nursing student watch the birth. By this time, I didn't care if the security guard from the parking lot brought in popcorn and Raisinettes to watch the event
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Another woman says:
The peak of each contraction was such that I needed to close my eyes and really concentrate
on the number of deep breaths I was taking, knowing that at the count of five or eight, depending on the length of the sensation, it would start to ease up. There's a sureness in numbersâthe logic overwhelmed the raw wildness of the sensation. I knew time was my only ally in dealing with the pain. With time each contraction would be over, with time the baby would be born
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DIFFERENCES BETWEEN PERIODIC AND CONTINUOUS FETAL MONITORING
The baby's heart rate and rhythm provide information that care providers can interpret to make a judgment about the baby's health. The baby's heartbeat can be assessed periodically (intermittent monitoring or intermittent auscultation) or continuously throughout labor. Intermittent auscultation involves using a handheld fetoscope (an instrument like a stethoscope) or, more commonly, a handheld ultrasound (Doppler) to record the baby's heart rate.
Hospitals generally use continuous external fetal monitoring, which produces a continuous electronic record of the baby's heart rate. This provides more data about the baby, but more data do not necessarily lead to better ability to make judgments about the baby's well-being. In fact, in healthy women without labor complications, and even in some higher-risk labors, continuous electronic fetal monitoring dramatically increases the likelihood of a cesarean section.
If you have an epidural, are receiving Pitocin for induction or augmentation, or have health problems such as high blood pressure, you will be required to use continuous electronic fetal monitoring. Many hospitals now have wireless units that allow you to stay reasonably mobile even while your baby's heartbeat is continuously monitored.
In healthy women without labor complications, intermittent monitoring is associated with equally good infant outcomes and reduced likelihood of cesarean surgery, compared with continuous monitoring.
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Intermittent auscultation allows the woman to remain mobile and keeps the attention of staff and labor support companions on the woman herself rather than machines.
Unfortunately, intermittent monitoring is very infrequent in hospitals, due to staffing issues, liability concerns, and the frequent use of other interventions that necessitate continuous monitoring. In a nationally representative survey of women who gave birth in U.S. hospitals in 2005, just 6 percent were monitored intermittently throughout labor.
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