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Pregnancy Guide About Normal Labor and Delivery

The Duration Of Pregnancy

The “Due Date.” At the time of a woman's first visit to the obstetrician, she is given a date when the baby is “due.” This is known in medical parlance as the estimated date of confinement.” It is calculated by subtracting three months from the date of onset of the last normal menstrual, period and adding one year and a week. If his patients last period started on July 10, 2012, for example, the doctor would subtract three months (April 10), add a year and a week and tell her that her due date is April 17, 2013.'

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These dates are at best only rough calculations. Generally speaking, any birth which occurs as much as two weeks before or two weeks after the due date is regarded as a “term birth.” Only about one in twenty-five term births occurs precisely on the due date; at least a third occur more than ten days before or after.

Prematurity. If delivery takes place more than four weeks before term (or, more precisely, if the baby weighs less than 5 1/2 pounds), the baby will be premature. Needless to say, the closer the delivery is to term, the better are the baby's chances. Infants have been known to survive weighing as little as one pound, but this is extremely rare. As a matter of fact prematurity is the greatest single cause of infant mortality today.

Postmaturity. If, on the other hand, labor fails to start within two weeks after the due date, the baby will be regarded as “overdue” or “postmature.” The significance of postmaturity is far from clear. A large segment of European obstetricians feel that postmaturity may be harmful to the baby, but this conclusion has never been confirmed by United States doctors. Fortunately the vast majority of pregnancies do terminate at term, and so the problems of prematurity and postmaturity need not concern most of you.

It is understandable that pregnant women become increasingly anxious, during the last few weeks, to see what sort of baby they have been incubating for so long. But these last weeks are going to be unnecessarily trying for those who count on having their baby on the exact day that it is theoretically due. Greater peace of mind will be achieved by those who convince themselves that the baby is going to be late and are happily surprised if labor starts less than two weeks beyond their due date.

Premonitory Sensations

Lightening. Lightening is the term used to denote the dropping of the baby's head into the pelvis. With first pregnancies this is apt to occur sometime during the last few weeks. As the fetus descends, the entire womb and waistline seem lower, breathing is easier, and the feeling of enormity is diminished. Concurrently, however, there may be a feeling of increased pressure within the pelvis itself, a desire to void more frequently, and an exaggeration of the waddling pregnancy gait. This dropping is a gradual process, like everything else in Nature, so don't expect a sudden thud. The word is “lightening,” as in loads, not “lightning,” as in rainstorms. With subsequent pregnancies lightening may not occur before the onset of labor; by then the abdominal wall is usually so lax that any extra room the fetus needs may be found in a forward rather than a downward direction.

False Labor. Also during the last few weeks you are apt to notice that your uterus becomes quite firm every once in a while, although there is no discomfort associated with this change. This firmness signifies that the uterus is contracting. If you are unusually sensitive to pain, you may interpret this process as “false labor.” Actually the uterus contracts at irregular intervals throughout pregnancy, but since there is rarely any discomfort associated with these contractions until they develop into true labor, they usually pass unobserved. These contractions toward the end of pregnancy serve a definite purpose in softening the cervix and making it ready for the ultimate labor process.

Causes Of The Onset Of Labor

Why does a uterus which has harbored a pregnancy for nine months suddenly begin to contract and expel its contents? The simple truth of the matter is that no one knows the exact answer to this puzzle. We have identified most of the parts of the puzzle, but we have yet to discover the magic formula which will enable us to put the pieces together properly.

Hormones. We know, for example, that there is a hormone secreted by the pituitary gland (the oxytocic hormone) which is in some way concerned with the onset of labor. It is usually called Pitocin, and we can bring on labor artificially by giving it to pregnant patients who are at term. But we don't know definitely what triggers the secretion of this hormone by the pituitary.

Distention of Uterus. Secondly, we know that the onset of labor is somehow related to distention of the uterus. When the uterus is distended to a certain point by its contents, it reacts by beginning to contract in order to expel these contents. This is probably why, for example, multiple pregnancies generally terminate spontaneously in advance of term. But why, then, does labor sometimes start in the sixth or seventh month, when the fetus is quite small? No one knows.

Rupture of Membranes. A third known factor which often causes labor to start is rupture of the membranes. This usually occurs at term, but it can occur at any time. No matter when it happens, the escape of water from the womb causes the uterus to diminish suddenly in size and this is usually sufficient to initiate the labor process.

Other Factors. There are many other minor factors which are to varying degrees involved in this complex process. The size of the pelvis, the consistency of the cervix, and the presentation of the fetus (whether by vertex or breech) may all play a part, more in some cases than in others. There are occasional patients who have what is known as an incompetent cervix – that is, a cervix which is too weak to retain a pregnancy until term. In these cases every pregnancy may result in miscarriage or premature delivery until the defect in the cervix is repaired surgically.

In essence we know most of the factors which are responsible for the initiation of labor and we have sufficient control over some of these factors to be able to use them in starting labor artificially. But we don't know how these various factors are interrelated and, incidentally, once true labor starts we have no way of stopping it.

The Physiology Of Labor

The basic concept of what labor is and how it brings about delivery of the baby is not too difficult to understand. And, generally speaking, the better a patient understands it the less she is afraid of the whole process and hence the easier her labor is apt to be. This is one of the fundamental tenets of natural childbirth.

The Uterus During Pregnancy. For all practical purposes the uterus may be regarded as being composed of two distinct parts: the fundus, which contains the products of conception, and the cervix, which prior to labor prevents the fetus from descending into the vagina. It is the fundus, composed principally of muscle tissue, which contracts rhythmically during labor and thereby pushes the baby down through the birth canal. The cervix, on the other hand, is composed predominantly of fibrous tissue which is incapable of contracting. Throughout pregnancy the cervical canal remains tightly closed; during labor it begins to dilate as the baby's bead is pushed down through it. This dilatation is accomplished by the action of the fundus, which pulls the cervix up and over the baby's head.

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The Uterus During Labor. Hence for nine months the fundus plays a passive role, permitting itself to be distended by the growth of the fetus, whereas at the same time the cervix plays the comparatively active role of resisting the pull of gravity upon the fetus and thereby preventing its untimely descent into the vagina. During labor these roles become reversed; it is the fundus which actively contracts and the cervix which passively permits its canal to become dilated. The pregnant uterus can be compared to a balloon which has been filled with water and then tied at its neck. When the tie is broken the elastic walls of the balloon contract and force the water out.

The Stages of Labor. When the cervix becomes completely dilated, it no longer provides an obstacle to further descent of the baby. The cavities of the uterus and the vagina are now continuous. The interval between the onset of labor and full dilatation of the cervix is known as the first stage of labor. With first babies this stage usually takes from six to eighteen hours; with subsequent babies it may take only two to six hours.

The interval between full dilatation of the cervix and actual delivery of the baby is called the second stage of labor. With first babies this stage usually takes one or two hours; with subsequent births it may take five minutes or an hour. The time between delivery of the baby and delivery of the placenta is known as the third stage of labor. This stage usually takes less than five minutes, regardless of the number of previous pregnancies.

The Second Stage. During the second stage of labor, after the cervix is completely dilated, further descent of the baby through the birth canal is impeded only by the resistance of the vagina itself and the muscles which surround it. It is at this stage that it is usually necessary to call into play a second force of labor, beyond the involuntary contractions of the uterus – namely, the forceful, voluntary, bearing-down efforts which the patient can exert by tightening her abdominal muscles. Of this, more later.

The Third Stage. As soon as the baby escapes from the uterus the uterus contracts violently, and there is nothing now to prevent these contractions from reducing the size of the uterus itself. Now its only contents are the placenta and membranes, which it promptly tries to expel by continuing to contract. But since these contractions, even when aided by the patient's expulsive efforts, are usually inadequate to effect complete separation and delivery of the afterbirth, the obstetrician almost invariably has to apply pressure upon the fundus through the abdominal wall to terminate the third stage within a reasonable measure of time.

Subjective Sensations Of Labor

Bloody Show. The earliest signs and symptoms of labor are somewhat variable. Oftentimes the very first sign is the passage of some bloody mucus (“bloody show”) from the vagina. This signifies the extrusion of the mucus plug from the cervical canal and usually means that labor is imminent.

Ruptures of Membranes. Sometimes the onset of labor is heralded by a sudden gush or by a slow leakage of clear fluid (several ounces to a cupful or more) from the vagina, which means that the membranes have ruptured or “the waters have broken.” If this happens at any time during pregnancy, you should call your doctor right away. The membranes rupture first m about 10 per cent of cases slightly more often with first babies.'

Contractions. In the majority of cases the characteristic contractions of labor precede the bloody show or rupture of the membranes. Invariably with the first baby, and often with later pregnancies, women are concerned that they will not recognize these contractions because they have never experienced them or have forgotten what they feel like. Don't worry. You will instinctively recognize them. Every woman does.

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Labor Pains. The sensations caused by the contractions of labor may begin with a dull, intermittent, low backache, or they may begin with intermittent feelings of discomfort down low in the abdomen, not dissimilar from the cramps many women feel at the time of a menstrual period. These sensations occur at periodic intervals; they last from twenty to forty seconds – never longer than a minute. After a few hours they may disappear or they may become more frequent. When they disappear this is known as false labor and has no special significance. True labor may not begin in these cases for several days or weeks, and during the interim several other episodes of false labor may supervene.

Timing the Pains. If these early, mild, irregular contractions become increasingly frequent and more noticeable, true labor is probably about to begin It is at this time that you should have your watch handy and actually time the exact interval between the beginning of one contraction and the beginning of the next.

Contractions can be recognized either by the discomfort they cause or by the hardening and actual rising up of the uterus which can be felt abdominally by either you or your husband. If you lie on your back you will notice that the uterus becomes tense during a contraction, much as your arm becomes tense when you contract your biceps.

Frequency of Contractions. Sometimes the contractions begin at regular four- or five-minute intervals. More often they are irregular at first, every ten to thirty minutes; and then, as the interval between them decreases, they become as regular as clockwork – perhaps every fifteen minutes at first, then every ten, every five, and so forth. If you live within an hour of the hospital, your doctor will probably want you either to call him or to go to the hospital when the contractions are coming at about five-minute intervals if it is your first baby – sooner if you have had a baby before. Don't feel, however, that there is any great urgency in your racing to the hospital at this stage, especially if this is your first, for good labor is usually associated with regular contractions every two minutes and, as noted above, the first baby usually takes between six and eighteen hours to arrive.

One important word of advice: once you begin to feel contractions, do not eat or drink.

Arrival at the Hospital. After you have arrived at the hospital, a pelvic examination by the doctor or nurse on duty will very promptly tell them how far your labor has progressed. Generally speaking, with first babies the patient is apt to feel that her labor is farther along than it actually is, so it is a good policy not to be overly optimistic. If you are, indeed, in early but definite labor, the next step is known in labor room lingo as the “prep and enema”: the nurse will shave your perineum and then give you an enema. The purpose of the enema is two-fold: emptying the rectum and stimulating labor. The purpose of the “prep” is hygienic.

The Duration of Labor. The duration of the first stage of labor depends on the strength and frequency of your contractions, the size of your baby, the size and shape of your pelvis, the consistency of your cervix, the amount of medication you receive and the timing of its administration, and many other things. Above all, of course, it depends upon whether or not this is your first baby. If it is your first, you are a nullipara (nullus meaning “none” in Latin and parere meaning “to bring forth”) and, as intimated above, the whole process takes about two or three times as long the first time. If a woman's first labor lasts eight hours, for example (and this is about par for the course), her labors with subsequent babies will last in the neighborhood of four hours. And remember that labor begins when the contractions become regular. The early, irregular pains don't count.

The Intensity of the Pain. How much pain is associated with labor? In truth, it varies tremendously, for the threshold to the perception of pain varies from individual to individual. There is a small minority of women – some of whom are blessed with extraordinary powers of relaxation or insight or some such magic quality, some of whom have profited to the fullest from a natural-childbirth program – who would say that, although labor is an uncomfortable experience, the pain is far from unbearable and the whole process is so wonderfully miraculous that whatever discomfort they did feel was well worth it and soon forgotten. And undeniably there is another small minority who will tell you that it is the most excruciatingly painful ordeal that one could conceivably experience. But the vast majority, when questioned soon after their babies are born, while the memory is still fresh in their minds, will quite honestly say, yes, it is painful, more so than their modem books on natural childbirth had led them to believe, but certainly less so than the many old wives' tales had implied. And yes, they did feel the need for some medication to take the edge off the pain, but the medication did help and at no time did they suffer unbearably.

It is unwise to face the prospect of labor with the conviction that it is going to be either painless or unbearable. After all, not even the most ardent natural-childbirth enthusiasts (those of them who have had a baby, at any rate) claim that childbirth is painless. And obviously labor couldn't be as horrible as some old wives say or there wouldn't be so many mothers so anxious to go through it again (and again). If you expect pain without fearing it you will probably not be adversely surprised. Perhaps it is a little like the difference between pinching yourself, which almost never hurts much for you know that this pain stimulus is under your own control, and being pinched by someone else which almost invariably hurts more for it is unexpected and out of your control. Most women in the midst of labor are both surprised and relieved by the reassurance that their pains will not become perceptibly more severe, for it is natural to expect the worst and this fear does seem in turn to increase the pain. Doesn't the pain caused by a dentist's drill seem more bearable when he informs you that he is almost finished?

The Second Stage. The pains associated with the second stage of labor are a little more severe than those of the first stage - not much, but a little. This is due to the fact that the pain of the first stage is due almost solely to the stretching of the cervix, whereas in the second stage it is due to distention of the vagina, a somewhat more sensitive organ. It is at this stage, when the baby's head (or buttocks) descends so far down into the birth canal that it actually presses on the rectum, that most women feel the urge to move their bowels. This is a normal, understandable sensation, for it is caused by the same stimulus which is ordinarily responsible for a bowel movement, namely, pressure on the rectum. And this coincidence is, of course, fortuitous, for it stimulates the same bearing-down efforts which are associated with a bowel movement and it is these efforts which are essential to the final descent of the baby through the vagina. Sometimes women who do not understand this phenomenon feel that bearing down will cause injury to themselves by overstretching the vagina, but this is obviously not true. If it seems remarkable to you that the vagina can be stretched to such an extent as to permit the delivery of a seven- or eight-pound baby, this never ceases to surprise doctors who have delivered thousands of babies, and yet it happens and the vagina is just about the same size after childbirth as before. It might console you to remember that a newborn calf weighs 100 pounds.

Actually the walls of the vagina in its collapsed state, before labor, are pleated, like the sides of an accordion. This explains how the vagina tolerates so much expansion without injury.

Labor Room Routine

Appearance of the Rooms. Labor rooms vary from hospital to hospital. Some accommodate more than one patient, others are single. Most are sparsely furnished, for reasons of efficiency - a bed, chair, table, and sink constituting the only furniture. In some private hospitals the patient is left in her own room until her labor is well advanced before she is taken to the labor room.

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Examinations. A nurse will visit you at frequent intervals during the beginning of your labor and she will normally stay with you after your labor has become active. It is she who will shave you, give you an enema, administer your medications, time your contractions, and attend to your needs of the moment. Most labor room nurses are dedicated souls whose experience, judgment, and empathic powers are vast. A house physician, bedecked in white, may also check you occasionally. He may put an intravenous in your arm, so that medicine can be given to you through the tubing. Your blood pressure will be checked periodically. The nurse will listen to your baby's heart beat either with a stethoscope or, in some instances, with an electronic amplifier which renders the sound audible to everyone in the room. And pelvic exams will be done – more frequently as your labor progresses - in order to determine the dilatation of your cervix and the level of the baby's head in your pelvis. All of this information will be relayed to your doctor, who will appear at intervals to examine you. During one of these exams he may rupture your membranes (if they haven't ruptured spontaneously) – a painless procedure that speeds up the labor process.

Your Appearance. You will wear a hospital gown while you are in labor and your jewelry will be taken from you. Don't plan to have your hair done in preparation for this event. Vanity and modesty are instinctively shed by the woman in labor. The excitement of experiencing the miracle of childbirth supersedes the mundane emotions of other-day life.

Your Behavior. Vomiting, defecating, urinating, and bleeding are all, in varying degrees, associated with the labor process. Don't be surprised by them or worried about them. Labor-room personnel are accustomed to these events and they are inexhaustibly prepared to deal with them. It is important that the bladder, rectum, and stomach be empty during labor. Hence the enema; hence, also, you will be catheterized if you cannot void. You will not be allowed to eat or drink, for the stomach must be empty in order to prevent the regurgitation of its contents during anesthesia. No smoking either, because of the proximity of explosive anesthetic gases.

You may be allowed to walk in the corridors of the labor suite if you are very early labor, but soon thereafter you will be confined to bed. Many women find that lying on their side is the most comfortable position in labor.

Invariably the laboring woman is as fearful of making a fool of herself as she is fearful of the pain itself. Invariably on the day following delivery she apologizes to her obstetrician for her “performance” during labor. This is nonsense. A woman is entitled to behave in labor in whatever manner her spirit tells her to. Most women behave with admirable restraint and stoic pride. But if you want to scream, go right ahead. You won't be the first or the last or the loudest.

It is invariable, too, that women (men, too, for that matter fear that they will reveal some awful intimacy when they are anesthetized – that they may bare their souls and shock their doctor. Such revelations are never made, and if they were they would not shock the doctor. While you may not scream, the lady down the hall may. Brace yourself for this; labor rooms are usually soundproofed, but no soundproofing system yet devised has met this test.

Medication During Labor

Drugs Commonly Used. Since the discovery of morphine in pre-Christian days, a vast variety of drugs have been used to allay the pain of labor. For many years morphine and scopolamine were used together to produce “twilight sleep,” which was much in demand in the 1920s. The combination seemed ideal for morphine is a very strong narcotic and scopolamine acts with it to produce a dreamy state; but it soon became obvious that morphine was so powerful that, upon entering the blood stream of the fetus (as most drugs do) , it would also narcotize the baby, so that it would be born sluggish and difficult to resuscitate.

In the 1930s, Demerol (a synthetic narcotic) was discovered to have almost the same effect as morphine upon the mother but considerably less effect upon the baby. It soon became the most popular drug for use in labor in this country and it has remained so ever since. Various combinations of Demerol, scopolamine, and barbiturates are most often used. But it must be borne in mind that these drugs, admirable as they are, have at least two main drawbacks. First, if they are given too soon, before labor becomes really well-established, they will slow down labor or actually stop it. And, secondly, even these medications must be given in moderation lest they adversely affect the baby. If given in unduly large or oft-repeated doses, they will act upon the respiratory center in the baby's brain and interfere with his ability to breathe after birth. This is especially true of the premature infant, which is apt to be affected by the smallest amounts of medication.

There are literally hundreds of other drugs which have gained variable reputations in this field. Chief among them is the whole stable of tranquilizers, which have earned a niche in the labor-room pharmacy for their ability, when given in combination with narcotics, to reduce the patient's need for these latter drugs and hence spare the baby the relatively more dangerous side effects of the narcotics. The vast variety of drugs now available for use in obstetrics enables the doctor to choose those which are best suited to the needs of each individual patient.

Caudal Anesthesia. And, finally, there is the subject of caudal anesthesia. This will be mentioned below with the other types of anesthesia, but it bears mention here because it is often used during the first stage of labor. As opposed to the drugs mentioned above, caudal is a true anesthetic and hence it will completely abolish all of the pain of labor. Why, then, is it not given routinely? Well, this is a complicated issue, but suffice it to say that it involves injection of a drug into the caudal canal (not the spinal canal) at the base of the spine, that this injection may be difficult and in some cases impossible, that its use requires some training and skill, and that if it is given too soon or in too large a quantity it will slow or stop labor. It is, in short, an excellent agent under the proper conditions, but it is best for the obstetrician to decide when the conditions are proper.

Anesthesia

“In sorrow thou shalt bring forth children.” Thus did God admonish Eve (Genesis 3:16) and this indeed was the accepted fate of womankind until the discovery of chloroform and ether in the 1840s. So firmly was this philosophy entrenched, in fact, that there were many women and their obstetricians in those days who refused to use these agents in the belief that they were contrary to God's will.

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It wasn't long, however, before complete narcosis was the rule in childbirth and women were demanding at least partial narcosis throughout the labor process as well. And now that a whole battery of analgesic and anesthetic drugs have been perfected for this purpose is it not ironical that the cry is for less and less of them? Sensible as this general tendency may be, there will always be a need for anesthesia in obstetrics and it is important for you to know something about it.

Your Preference. There is now such a variety of anesthetics available to the pregnant woman that it has become fashionable, in these days of wanting to know the how and the why of everything, to ask one's obstetrician what anesthetic agents he employs. This is a generally healthy attitude, of course, especially with regard to such matters as ovulation, labor natural childbirth, and rooming-in, and it is worth while learning in advance whether your doctor will grant your wish to be awake or asleep if all goes well during delivery; but this is one sphere of obstetrics which the patient cannot dictate too strongly.

Assuming that several types of anesthesia are available at the hospital at which you are going to deliver - and this is usually the case - it is impossible for your doctor to tell you in advance which particular anesthetic will be best for you. So much depends on the size of your baby, the quality of your labor, the size of your pelvis, the possibility of unforeseeable complications, and many other unpredictable factors, that it would not behoove him to promise that you have such-and-such a type of anesthesia. Your doctor will surely take your wishes into consideration in making his final decision, but by and large you must realize that this is one matter in which your personal feelings may have to be sacrificed in the best interest of yourself and your baby and in deference to your doctor's judgment.'

Gas. Any drug or anesthetic which makes the mother sleepy or puts her to sleep will, after a short while, have a similar effect upon the baby. For this reason ether and chloroform are no longer widely used in obstetrics. These agents have been largely superseded by two types of gas, nitrous oxide and cyclopropane both of which are faster-acting and therefore safer' for the baby than ether or chloroform. So if you are to be put asleep during your delivery, one of these gases will probably be used. Both are pleasant, safe, and free of serious aftereffects.

Pentothal. If you have had a minor operation recently the chances are that a needle was put into your arm, you were asked to count while a liquid was being injected through the needle, and you were asleep before you counted to ten. Or at least you have probably heard of this type of anesthetic, which is called Pentothal. After Pentothal has been given to induce sleep it is usually supplemented with gas and/or a drug which causes muscle relaxation. These techniques are sometimes used in obstetrics.

Spinal and Caudal. For the growing segment of American women and obstetricians who believe that there are advantages to both mother and baby in having the mother awake during the delivery process, there are several means of achieving this with complete obliteration of all pain involved. Chief among these means are the spinal and caudal anesthetics. Both permit the mother to be wide awake and cooperative, relaxed and free of pain; neither has any narcotizing effect upon the baby. There is a lot to be said for using these agents in conjunction with or as a substitute for natural childbirth, for the advantages of conscious childbirth are retained without the element of pain.

Caudal anesthesia can be administered during the latter part of the first stage of labor, thus abolishing the discomfort of the contractions as well as that of the delivery itself. It involves injecting a solution, similar to or identical with the Novocaine used in dentistry, into the caudal canal, which is located at the very end of the spinal column. This canal is easy to locate in most women, impossible in others. If it cannot be located with ease the anesthetist may decide to enter the same space higher up in the lower part of the back. Skill is required in the administration of this anesthetic and in the timing of its administration, for if it is given too soon or in too large amounts it can cause slowing of the labor. Once the needle is placed in the caudal canal it can be replaced with a narrow plastic tube, through which additional anesthetic may be injected periodically. In this way the effect of the anesthesia may be prolonged until after delivery has taken place.

Spinal anesthesia is usually given not in the midst of the first stage, but rather immediately prior to delivery, in the delivery room. The only other significant difference between spinal and caudal anesthesia is that the former is injected into the spinal rather than the caudal canal. If properly administered, both methods produce complete pain relief with complete safety. Spinal anesthesia in obstetrics is sometimes referred to as “saddle block” anesthesia since the nerves are blocked from that area of the body which comes in contact with a saddle. Stories are rampant to the effect that spinal anesthesia is dangerous. It is not – at least no more so than general anesthesia.

Local. The last type of obstetrical anesthesia in fairly common use today is local anesthesia. Here Novocaine or a similar drug is injected just prior to delivery in the area of the vagina in order to block the nerves which carry pain sensations from the lower pelvis.

Obstetrical Factors. If used with skill and experience, any one of the above methods of anesthesia is adequate and proper. Some obstetrical situations will demand the use of one type of agent rather than another. It is preferable, for example, to avoid general anesthesia in the delivery of a premature baby; but, on the other hand, it may become mandatory to use a general anesthetic in the delivery of twins. Then, too, it is quite likely that your doctor has worked with certain combinations of drugs and anesthetics that are most familiar to him. He has gained a great deal of experience in his particular methods because he has used them often. For this reason it will be to the advantage of all concerned - you, your baby and your physician - if you let him use his judgment - his own methods - rather than insist on getting the same anesthetic that your sister's doctor gave her.

The Delivery

The Delivery Room. If this is your first baby you probably will not be wheeled into the delivery room until the baby's head is actually visible at the opening of the vagina. With subsequent pregnancies you will more probably make this move at the end of the first stage of labor. You may be moved in your bed or by stretcher; but at any rate you will ultimately be transferred onto a delivery table. Most delivery tables these days are as shiny and complex as a modem automobile, each wheel and lever enabling the delivery room staff to add to your protection and comfort. Overhead there is a small operating room lamp so that the doctor can see what he is doing. And scattered here and there are tables for the doctors' gowns, for the sterile delivery equipment, for the episiotomy repair; an anesthesia machine; large bowls of antiseptic solution; a bassinet for the baby; a resuscitation apparatus for reviving sleepy infants; stools for the doctors to sit on; and the inevitable glass cabinets full of instruments which look ominous but are rarely used.

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Position of the Patient. If you are to have spinal anesthesia, it will be given as soon as you move over to the delivery table. And the next step, regardless of the type of anesthesia you are to receive, is that the nurses put your legs up “in stirrups” and remove or lower the foot of the table so that your buttocks are resting upon the very edge and your legs are up in the air. Braces may be placed against your shoulders so that you won't move upward on the table, and your wrists will be confined by your side in leather bracelets. At this point you will be unable to move your arms or your legs. Although this may seem medieval it is done during any kind of operation; its purpose is to prevent you from inadvertently disturbing the “sterile field” in which the doctor must work in order to protect you from infection.

Preparations for Delivery. While you are being thus positioned on the table your doctor will probably be scrubbing his hands and donning his sterile gown and gloves. He or his assistant will now paint your buttocks and perineal area with an antiseptic solution, and perform another pelvic examination in order to determine, among other things, the position of the baby's head. If the baby's head is not down far enough he may ask you to bear down during the next few contractions, during which time you may inhale gas from an anesthesia mask if you so desire. Up until this point you will probably be awake, no matter what type of anesthesia you are going to get.

Delivery of the head. Now, whether you are having your first baby or your fourth, whether you are to be awake for the delivery or not, the baby is at last ready to be born. If you are to be awake, with caudal, spinal, local, or no anesthesia, it is usually possible for a mirror to be set up so that you can see the entire delivery process. If you are to be put to sleep, now is the time; you will be given an injection or asked to take some deep breaths from a black rubber mask which covers your mouth and nose. Many babies these days are delivered by forceps. The forceps are applied to the baby's head, the episiotomy is then performed, and the baby's head is delivered, face downward, as the obstetrician exerts gentle traction on the forceps. Forceps are never applied without some form of anesthesia. If forceps are not used, it will be necessary for you to continue to bear down with each contraction until the baby's head is born; or the obstetrician or his nurse may supply the same expulsive force by pushing on the top of the uterus through your abdominal wall.

If you are to deliver the baby yourself by the natural-childbirth method, you will be asked to push the baby out without anesthesia. This is, no matter how well-prepared or stoic the patient, a momentarily painful experience, counteracted by the joy of conscious participation and accomplishment. There are, as always, compromise solutions for the mother who wants relief of the pain and yet does not want to be totally unconscious. Partial relief may be obtained at this stage by inhaling just enough gas to take the edge off the pain but not enough to effect deep or lasting anesthesia. And, of course, spinal, caudal, and local anesthesia permit the patient to be pain-free and wide awake. Sometimes patients with these latter types of anesthesia can deliver the baby by themselves; usually forceps are necessary.

The Use of Forceps. If you have seen or heard of a baby's being permanently scarred or disabled in some way by a forceps delivery, you have probably seen or heard of a baby who was delivered by an incompetent obstetrician. Forceps are no longer used to deliver babies from high up in the birth canal. They are used only to bring the baby's head over the mother's perineum, a maneuver which, if properly performed, will not hurt the baby. It often permits the obstetrician to shorten the second stage of labor by as much as an hour or more, thereby sparing the mother that much pain and preventing a number of spontaneous accidents which might occur to the baby at this crucial stage of the labor process.

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The Final Moment. After the head is delivered the shoulders are next. Delivery of the shoulders usually requires a further bearing-down effort by the patient or, if she is asleep and unable to bear down, pressure upon the abdomen by the nurse. The body and legs follow spontaneously and at last you can learn whether it's a boy or a girl. The baby is held by the ankles, upside down, so that the mucus and blood which may be in its mouth will drain out. Two metal clamps are placed on the umbilical cord, the cord is 'cut between the clamps, and the baby is on its own. If you were not given large amounts of analgesic drugs or anesthetic gases, the baby will probably be crying by now.

The Baby. If you are awake you can see your baby briefly before it is taken to the bassinet, where any remaining mucus is suctioned from its throat, its umbilical cord is shortened, and it is cleaned up a little. Unless you are prepared for it, you may be a little shocked by the appearance of a newborn baby, for it may be covered with a thick white slippery substance known as vernix, which has much the same consistency as cold cream; it may also be covered with blood from the episiotomy; and its head is apt to have become temporarily elongated in its trip through the birth canal. The vernix and blood are promptly removed and the head returns to its normal shape within a few days. The baby will be examined by the obstetrician before leaving the delivery room but it probably will not be weighed until it arrives in the nursery. (As part of the natural-childbirth program the baby is sometimes put to breast immediately upon delivery.)

Delivery of the Placenta. Once the baby is delivered, the third stage of labor is in progress. Within a few minutes usually the placenta has separated from the uterine wall and it is expelled by the obstetrician's applying pressure on the uterus through the abdomen. An injection is now given which causes the uterus to contract further, thereby preventing any unnecessary loss of blood. After the placenta is delivered, don't be surprised if a nurse burrows her hand into your newly flat and flaccid abdominal wall in order to massage the uterus. Although not the most pleasant experience in the world, it is an important measure to assure that the uterus contracts well so that you will not bleed.

Other Types of Delivery. About eighty out of every hundred deliveries follow the above sequence. Twin deliveries occur one at a time, of course, and are not significantly different from other deliveries except that it sometimes becomes necessary to put the mother to sleep in order to extract the second baby. As a matter of fact, twins are usually easier to deliver than single babies because they tend to be smaller.

The Episiotomy

The Rationale. An episiotomy is an incision made at the opening of the vagina just before the delivery of the baby's head. It is usually made with scissors and it may extend for one or two inches onto the skin of the perineum and for the same distance into the vagina. Episiotomies are performed in roughly three quarters of all deliveries in the United States these days, and the reasons for them are these: Without an episiotomy the perineum and vagina often become tom. If these tears are visible they must be-repaired with sutures, and it is easier to repair a clean cut than a jagged tear. But oftentimes these tears are not visible; they involve only the deep fascia and muscles which surround the vagina and support the bladder and rectum. This type of tear cannot be repaired, and the eventual result of such a disruption of these fascial and muscular supports is that the bladder and rectum become loosened from their normal moorings and protrude into the vagina. The full effect of these injuries may not become apparent for many years. You have probably heard of old ladies whose vaginas turned inside out or who could no longer retain their urine; this is why. The episiotomy is also done to protect the baby's delicate head from being injured by undue pressure from the intact perineum; this is especially true in the case of the doubly delicate head of a premature infant. So you can see that these incisions protect the mother and the baby from hidden injuries which might otherwise occur.

The Method. Episiotomies can be done in two different ways. The incision may extend in a straight line from the vagina toward the anus, or it may be curved away from the anus toward the right or left leg. They are repaired with catgut sutures (the word “catgut” being a misnomer since this suture material is actually made from the intestinal lining of sheep). Within a week or two these sutures dissolve and the superficial ones fall out. Women often ask how many stitches were taken, but the answer to this question is meaningless. The doctor may have taken numerous stitches with the same piece of thread or he may have taken a series of individual stitches, some of which may be in the muscles, some in the skin. The stitches may be close together or far apart. Furthermore, the doctor is too busy to count them.

The Induction Of Labor

When the doctor initiates the labor process rather than waiting for it to begin spontaneously, this is referred to as the induction of labor.

When Ifs Done. During the last week or two of pregnancy, the cervix usually starts to dilate. This dilatation of the cervix is one of the principal indices by which the obstetrician can tell that labor is imminent. If this dilatation progresses to a sufficient extent (two centimeters or more) and if all other conditions, such as the position of the baby, are propitious to the easy onset of labor, the doctor may then suggest that your labor be induced.

How it's Done. Usually this entails rupture of the membranes (which is often done in the course of spontaneous labor) and the administration of a drug which causes the uterus to contract (the same hormone responsible for the onset of spontaneous labor). This drug, called Pitocin or “Pit,” may be given into the vein in the muscle or under the tongue. There is often a latent period of half an hour or more when nothing happens. Then the contractions begin. As with spontaneous labor the contractions are apt to be mild and irregular at first.

Why It's Done. What are the advantages of the induction of labor? In the first place, labor is shorter. Second, you know that your obstetrician is going to be with you from the beginning. There will be no need to find him or to share his attention with another patient he may have in labor at another hospital. Third, the delivery will occur in the daytime, when the entire hospital staff and its facilities are most readily available, and when both you and your doctor are also operating at peak efficiency. Fourth, you will be going into labor, as you should, with an empty stomach and rectum, for you will be told not to eat breakfast and you will be given a cleansing enema. Fifth, the advantages for those of you who do not live near the hospital are self-evident. And, finally, you will be able to plan in advance for the welfare of the family you are leaving behind and for the arrival of whoever is to help you out when you return home.

Whether It's Done. It is by no means possible to predict the propitious moment to induce labor in every case. It is actually feasible to do so in a maximum of about one half of patients. In the others the cervix may ripen rapidly and labor ensue between office visits, or the membranes may rupture before the cervix dilates at all, or labor may simply begin before these signs of readiness appear. It is especially difficult to find the right moment during a first pregnancy, in which the cervix often fails to dilate at all before labor begins.

No obstetrician is going to induce your labor without your permission. But if your obstetrician suggests it, I would advise you to say Yes. Paradoxical as it may seem, if you are planning to have your baby by the natural-childbirth method this is no argument against the induction of labor – rather the opposite, since induced labors are shorter and they can be planned for a time when both your doctor and your husband are free.

As one last indication that there is nothing terribly unnatural about the induction of labor, it might be mentioned that if the doctor selects his candidates for induction properly, about one third of them will go into labor spontaneously during the twenty-four-hour waiting period between the inception and the execution of the idea.

Natural Childbirth

Natural childbirth is a term coined in the 1940s by Grantly Dick Read, a British doctor who wrote a book on the subject entitled Childbirth Without Fear. It was his observation that women who lose their fear of having a baby will have less pain in labor. And this is generally true. The fear may be lessened by learning what labor is all about – through attending classes, reading books, and talking to your doctor. In addition, natural childbirth entails performing certain exercises during pregnancy and in labor, which help to relax the body, control the muscles, and distract the mind. The doctor, nurse, and husband play important supportive roles through exhortation, encouragement, and massage.

When natural childbirth was first introduced it was regarded by many women as a sort of substitute for modern obstetrical management. They felt impelled to experience the entire labor and delivery process without medication, anesthesia, forceps, or episiotomy. This was unfortunate for two reasons: most women simply cannot succeed in this without considerable pain; and there are definite medical advantages to be derived from modern obstetrical methods. Furthermore, many of the women who needed pain relief, after having been led to believe that they would need none, felt that they had failed, that they had somehow not measured up to the mark of normal, motherly women.

The principles underlying natural childbirth are nonetheless sound – so sound, in fact, that they have been known to the obstetrical profession for a hundred years. The pain of labor is intensified by the tension which results from fear, and hence this pain can be reduced through education and relaxation. But the degree of relief necessarily varies from individual to individual, just as the individual perception of pain varies. Some women have totally painless labors without ever having heard of natural childbirth; others go to all the classes, read all the books, practice all the exercises, and still ask to be put to sleep.

Prepared Childbirth

When it became apparent that most women cannot or should not go through labor and delivery without the benefits of modem medicine, the concept of natural childbirth became slightly altered and a more moderate approach was introduced, called prepared childbirth. The basic principles of education and exercise remain the same, but women are not led to believe that these measures will lead to totally painless labor, they are encouraged to ask for medication when they need it, and they are urged to accept their doctor's advice with regard to anesthesia, forceps, and episiotomy.

This compromise has worked very well. Because these women are “prepared” with regard to what to expect, they are less afraid, they have less pain, and they actually require less than half of the usual amounts of medication. Whenever possible, regional (rather than inhalation) anesthesia is used, so that the patient is wide-awake and able to participate in the delivery. And whenever forceps and/or episiotomy are indicated, the mother and the baby profit from their use.

Some fortunate women, with high pain thresholds and rapid labors, are able to undergo the entire experience without any analgesia or anesthesia, but at least those who can't are not led to believe they have failed. Of course, most of the women in prepared-childbirth programs are about to have their 'first labor, which is apt to be the most prolonged, so some pain relief is usually in order. Preparation and medication have proved to be a good combination in these cases.

There are several natural-childbirth “schools.” The most popular in this country are the English school based on Grantly Dick Read's teachings, and the French school based upon “I'accouchement sans douleur” principles of “Lamaze.” Though the techniques taught by these schools are quite different the end results are objectively the same. The over-all success of natural or prepared childbirth seems to depend far more upon the woman's personality, her pain threshold, and her confidence in the doctor.

The Husband. One of the features of every natural or prepared-childbirth program is inclusion of the husband. The husband is expected to attend some of the classes so that he too will learn about the physiology of pregnancy, labor, and delivery. So informed, he is better able to help his wife throughout pregnancy and to stand by her during labor. If he has attended his share of the classes (usually only two or three of them, which are usually held in the evening for his convenience), he is permitted to remain with his wife during at least the first stage of her labor. His mere presence often serves as a source of strength to her and renders the experience a memory which both of them can cherish.

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The desire on the part of a wife for her husband to attend her in labor may stem from several sources. Ideally she wants him near during such a supreme moment in their lives. Sometimes she feels that he will bolster her courage if it falters. And occasionally she wants him there to witness her suffering. It is important, therefore, for you to examine your motives in this regard and to be sure that they are straightforward and unselfish. Husbands vary, too, in their desires to share this experience. Many feel adamantly that there is nothing “natural” about their getting into the act at this stage. Surely, they argue, the aboriginal male was never found in the same tent with his laboring spouse. So examine your husband's feelings too. If he is obviously enchanted by the idea, fine; but if he seems at all leery, don't push him.

The husband is expected under these circumstances:

(1) to help time the labor contractions,

(2) to massage his wife's back during contractions, and

(3) to provide moral support.

If it becomes apparent as labor progresses that he too is showing signs of needing a doctor or of becoming unexpectedly squeamish, this is the time for true altruism: let him off the hook; let him go home. Some husbands, on the other band, want to stay on through the delivery itself. Not all hospitals permit this. When it is permitted, the husband is expected to don a gown, cap, and mask; to remain at the head of the delivery table; and to leave the room if any complication arises.

Comment. Most women find that the contractions of labor are painful. There is no doubt that this pain is intensified by fear and ignorance. The very fact that you are reading this article demonstrates your healthy desire to dispel this fear and ignorance. Further steps should include:

(1) choosing an obstetrician you will have confidence in and, if possible,

(2) enrolling in a prepared-childbirth school.

You will then have done all you can to reduce the discomfort of having your baby. Let your doctor do the rest.

Health | Reproduction | Pregnancy


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