Labor and Vaginal Delivery
In 2014 the American College of Obstetricians and Gynecologists (ACOG) released new guidelines on how we diagnose prolonged or arrested labor. These guidelines are meant to help us avoid unnecessary C sections. I would hasten to emphasize that they are guidelines, not rules, since labor is a complex thing, encompassing numerous important variables from both mom and baby. Certain authorities in the field are raising concerns about the mathematical and statistical methods used in this new 2014 study which may have skewed the results. These concerns pertain more the the latter phases of labor, during pushing, and how we monitor and evaluate that phase. The basic concern is that not enough factors (variables) were taken into consideration. The health and characteristics of the mother, the health and characteristics of the unborn baby, the knowledge the doctor possesses of her patient, her experience, judgment and management choices all enter into the course of labor.
Given the complexity of labor and the difficulty in predicting how it will go, I will tell you my two bits about labor plans. I think all women should have one. Having one means the patient has learned all about labor and considered factors where she has a choice. However it should not be long, detailed and definite. That would be a recipe for disappointment. The labor plan should not be too short, and it should not be too long. It should be, "just right".
There are two main types of laboring women:
Primiparous women ( primips) - those who are having their first baby
Multiparous women ( multips) - those who have having a second or greater baby
Labor has phases:
Latent phase
Contractions may or may not produce slow cervical change. Latent phase may last over 20 hours in primips, and 14 hours in multips. We do not perform C sections for labor arrest in the latent phase , since active labor hasn't even started. We used to think latent phase ended at 4 cm, but now the data shows it is closer to 6 cm.
About 1 in 5 women start labor by breaking their bag of waters before contracting.
Active phase
First stage ( before 10 cm)
This generally begins after about 6cm, though there is a fair amount of important individual variation. There should be regular contractions and regular progress to diagnose the first stage of active labor.
Primips- Were felt to dilate 1.2 cm/hr, but with the new data only 0.5-0.7 cm /hr.
Multips- Were felt to dilate 1.5 cm/hr, but with the new data only 0.5-1.3 cm /hr.
New recommendations indicate C sections for labor arrest should be reserved for those who are more than 6 cm, with ruptured membranes, who fail to progress after 4 hours of adequate uterine activity, or 6 hours of inadequate uterine activity despite pitocin augmentation. However, many authorities feel that labor arrest can be diagnosed well before this time and to press on increases risk of complications.
Second stage ( after 10 cm and pushing)
Primips- Were felt to be allowed at least 3 hours but now get 3 or more hours to push.
Multips- Were felt to be allowed at least 1 hour but now get 2 or more hours to push.
Those with epidurals are allowed an extra hour for pushing.
SOME progress needs to be made to allow pushing to continue. No progress AT ALL in even a couple hours is concerning for a serious problem with fit. Quality of contractions, quality of pushing, weight of the mother, and size and position of the baby all factor in. We do not want to go so long in the second stage that we face a difficult C section, a difficult forceps or suction delivery, or the shoulders getting stuck ( shoulder dystocia).
In all cases, the continuation of labor requires that both mother and baby are tolerating it well. Generally mother's issues like high blood pressure or infection can be managed during labor. If baby show signs of stress, there are measures such as oxygen, repositioning and IV fluid which we use to help, but if they are not adequate, C section may be necessary.
Labor is painful but not unmanageable.
We use a buffet of different measures to manage labor pain.
Strong personal support from friends, family, doctor, nurse or doula makes labor more tolerable.
Breathing patterns such as those taught in Lamaze are very helpful.
Laboring in warm water is beneficial.
Position changes are helpful in managing labor pain.
IV medication like fentanyl can be used to take the edge off , but are often withheld in the last parts of labor due to transit to the baby and potentially causing the baby to have trouble breathing when born.
Nitrous oxide can help with labor pain.
Intrathecal blocks can provide a sensory block, but patients can still move. They last about 2-3 hours.
Epidural blocks with catheters produce a seniority and a motor block from the belly down, and thus patients can no longer get out of bed. Epidurals last as long as medicine is flowing through the catheter.
Medicine in epidurals and intrathecal is of such a tiny quantity that it has little to no effect on baby.
Anesthesia places these blocks and can answer questions about these right on labor and delivery.
Crowning and Beyond
Crowning refers to the actual emergence of the babies head. Ideally this is a slow, controlled process so the skin can stretch and not tear. However tears happen, especially with primips, but they are generally easy to repair and heal well.
These days, we do NOT routinely do episiotomy, though if one is felt to be beneficial, it may be in the midline or off to the side. The goal is keeping the perienum intact and to prevent injury to the rectal sphincter. The goal of the episiotomy is often to prevent a bad tear, but episiotomies are also done to allow big shoulder to deliver.
Babies first moments
Best practices include presentation of the baby to the mother's chest with assistance from the nurse. We generally delay cord clamping to allow extra blood flow to the baby. Baby will need to be kept dry and warm, ideally next to mom. Some moms prefer their infants to be dried first then brought back to them, and this is fine too. Either way, we prefer to get the baby to breast ASAP.
The placenta
The majority of blood loss with delivery is when the placenta separates. At this time, the uterus hopefully contracts down firmly and expels it whole. Sometimes the placenta separation is a bit gradual, resulting in excess blood loss, and so the doctor will instruct the patient to push and will help it along herself. We also use several methods and medications to help the placenta deliver and to prevent excess blood loss.
Repairs and Recovery
If you need a repair it will be done just after the delivery of the placenta. You may receive additional pain medication for this. At the same time, you will have a series of frequent vital signs taken. Your nurse will watch you closely to make sure your bleeding slows, and that you are not lightheaded. Before long, you will be able to move about, eat, and present the baby to family. Post partum mothers feel elated initially, then tend to " crash " after a few hours. Knowing that you will need to rest will help ease into it. Try to shower or jacuzzi a little if you can. Life becomes a dreamy cycle of eating, resting and nursing every 2-4 hours. What's next ?
The Postpartum Period
Click HERE to learn more.