Parenting - Prenatal to preschool/Parenting_PrenatalToPreschool.bin/dp/0044/00443.txt

Text File | 1993-06-14 | 47KB | 758 lines

$Unique_ID{PAR00443}
$Pretitle{}
$Title{Pregnancy:  Labor and Delivery}
$Subtitle{}
$Author{
Editors of Consumer Guide
Ellis, Jeffrey W
Ellis, Maria}
$Subject{Labor Delivering uterus placenta amniotic sac delivered rhythmic
contractions pelvis vagina dilate cervix vaginal delivery effacement Braxton
Hicks contractions effaced dilated dilation Contractions Baby Size
Presentation head-first cephalic position breech transverse positions Pelvis
Size Shape Stages Timing False labor doctor call fluid Arrival admitting
office policy policies procedures Enema Shaving pubic hair bed Restriction
Vaginal exam examination examinations Electronic fetal monitor monitoring
breathing method methods push pushing lithotomy episiotomy mediolateral
Variation Variations complication complications Forceps Artificial Rupture
Membranes Induction Stimulation oxytocin Cesarean Section catheter anesthesia
spinal epidural anesthetic}
$Log{
Contraction Chart*0044301.tab
Labor Contractions (Caption)*0044301.tif
Labor Contractions (Image)*0044301a.tif
Presentation Positions*0044302.tif
Electronic Fetal Monitoring*0044303.tif
Journey to Birth*0044304.tif
Episiotomy*0044305.tif
Forceps Help Delivery*0044306.tif
Anesthesia*0044307.tif
As the baby's head emerges, you'll know the baby is almost here*0054901.tif
Your job won't end with delivery--the placenta will need to be expelled*0055001.tif
While you are admiring your baby, your doctor will focus on your well-being*0055101.tif}

Miracle of Birth


Labor and Delivery


     The changes that have been taking place in your body, in the placenta,
and in your developing baby during pregnancy culminate in the process called
labor.  As the placenta ages and gradually loses its ability to maintain the
pregnancy, the baby grows strong and becomes capable of surviving outside your
body.  Your uterus, which has been growing and stretching for nine months,
will now begin a series of contractions to push your baby out of your body and
into the world.

What is Labor?

     Labor is the work performed by your uterus in expelling the baby and the
placenta out of your body.  Labor is well-named; it may be the hardest work
that you will ever do.  While the uterus is the center of activity during
labor, the process involves your entire body and mind.  During labor, all of
your energy will be devoted toward the one goal of giving birth to your baby.
If you understand what is going on in your body, you will be able to face
labor with confidence.
     The uterus is a large, strong, hollow muscle that, like other muscles,
has the ability to contract and relax.  During pregnancy, the uterus has two
major functions.  The first is to house and protect the growing baby, the
placenta, and the amniotic sac.  The second function is to push the baby and
the placenta out of the mother's body when it is time for the baby to be
delivered.
     Labor consists of rhythmic contractions of the uterus--in other words,
the uterus contracts and relaxes in a regular, flowing pattern.  When it
contracts, it tightens and hardens, putting pressure on the baby.  Each
contraction helps to push the baby downward through your pelvis and vagina
and, finally, out of your body.  Each contraction also serves to dilate (open)
the cervix, which is the portion of the uterus that protrudes into the vagina.
It is through the cervix that your baby will exit your uterus during a vaginal
delivery.  The uterus may contract anywhere from 25 to 300 times during labor.
The process of labor, in turn, may take anywhere from a few hours to more than
a day.
     Before the cervix can dilate enough to allow the baby to pass through, it
must first soften and thin out.  This thinning out of the cervix is called
effacement; it results from the contractions of early labor.  In many women,
some degree of effacement will occur even before labor begins, as a result of
Braxton Hicks contractions.  During the last few weeks of your pregnancy, your
doctor will perform a pelvic examination to determine if your cervix has begun
to soften and efface.
     During labor, the doctor or nurse will determine the degree of effacement
by gently inserting two gloved fingers into your vagina, as in a pelvic exam,
and feeling the thickness of the cervix.  The extent of effacement will be
expressed as a percentage.  For example, if the cervix has thinned out to half
its normal size, it is called 50 percent effaced; if it is completely thinned
out, it is called 100 percent effaced.  If this is your first baby, most
effacement of the cervix will take place before the cervix starts to dilate.
If you have had previous children, the cervix will usually efface and dilate
at the same time.
     As the contractions of the uterus progress during labor, the cervix will
continue to efface, and the opening of the cervix will start to enlarge or
dilate, eventually reaching a size of ten centimeters (about four inches)
across.  It is at this point that the cervix is termed fully dilated and the
baby can be pushed out of the uterus.
     Dilation of the cervix is caused by a combination of your uterine
contractions and the pressure of the baby on the cervix.  In many women, some
dilation of the cervix will occur even before labor begins.  Don't be
surprised if your cervix is dilated to two to three centimeters during the
last few weeks of pregnancy.
     During labor, the degree of dilation is also determined by a pelvic
examination.  Either the doctor or the nurse will gently insert two gloved
fingers into the opening of your cervix; the distance that the fingers can be
spread apart is then judged.  If your doctor says that your cervix is dilated
to four centimeters, this means that you have six centimeters to go until the
cervix is completely open (ten centimeters).  In medical terms, the word
"complete" means that your cervix is completely thinned out (100 percent
effaced), and completely dilated (ten centimeters in diameter).

Factors that Influence Your Labor

     The length and difficulty of labor vary from woman to woman, and even
from pregnancy to pregnancy in the same woman.  Some labors are very fast,
lasting only a few hours.  Some are average in length, lasting about 15 to 16
hours for first-time mothers and about seven to eight hours for women who have
had babies before.  Some are very long, lasting nearly a day.  Some labors
start slowly and then speed up unexpectedly.  Others start rapidly and then
slow down.  The amounts of pain and fatigue vary also.
     Many factors play a part in how long and how difficult your labor will
be.  You can influence some of these factors, but not others.  Factors you
cannot control include:

  -  The size and shape of your pelvic bones
  -  The size and shape of the baby's head and shoulders
  -  The condition of your cervix when labor begins
  -  The strength of your contractions
  -  The position of the baby
  -  Some aspects of your general health and your baby's well-being

     Factors that you can control, to some extent, include:

  -  Your emotional state and attitude toward birth (whether you are anxious
     and tense or relaxed and confident)
  -  The presence of a helpful, caring partner
  -  Knowledge of what to expect
  -  An environment and professional staff that help you feel secure
  -  Good prenatal care (including good nutrition and good health habits)

     The length of your labor and your success in delivering the baby
vaginally will be influenced most by the strength and coordination of your
uterine contractions, the size and position of the baby, and the size and
shape of your pelvic bones.

     Your Contractions

     The strength and coordination of your contractions play major roles in
determining the progress of your labor, because the contractions open your
cervix and push the baby down.  In general, the more powerful, coordinated,
and frequent your contractions, the more quickly and efficiently labor will
progress.  If labor is progressing very slowly, your doctor may ask you to
walk around to help stimulate contractions.  If necessary, a drug may be
administered to speed the process along.

     Size of Your Baby

     In addition to the strength and coordination of your contractions, the
size of your baby will play a major role in determining how quickly your labor
progresses and how successful you are at delivering your baby vaginally.
Since the baby must pass out of your body through the rigid walls of your
pelvis, his size is important if he is to fit through safely.  If he is too
large to pass through, a cesarean section will be necessary. Even with the aid
of techniques such as ultrasound, it is difficult to predict the size of the
baby before labor begins.

     Presentation

     Presentation refers to which end of the baby is closest to your cervix.
In about 97 percent of pregnancies, the baby presents in a head-first or
cephalic position.  That is, his head is in the lower part of the uterus and
his buttocks are at the top of the uterus near the mother's chest.  In about
two-and-a-half percent of pregnancies, the baby is in a breech presentation,
meaning that his buttocks are in the lower part of the uterus and his head is
at the top.  Rarely, the baby may present in a transverse position, meaning
that he is lying sideways and that one of his shoulders is in the lower part
of the uterus.  In general, the baby's head is the part that most effectively
dilates the cervix.  Therefore, labor is likely to progress more smoothly if
the baby is in a head-first position during his final weeks in the uterus.

     Position

     Your baby's position will also affect your labor.  Position refers to the
direction that the baby is facing in relation to your back.  He may be facing
your back, facing away from your back, or facing sideways.  Labor and delivery
are usually least painful and more rapid if the baby is facing your back.

     Size and Shape of Your Pelvis

     The third factor that will influence your labor is your pelvis.  Your
baby must pass through the cavity surrounded by your pelvic bones to reach the
outside world.  During your first prenatal visit, your doctor probably
determined the size and shape of your pelvic opening when she performed a
pelvic examination.  If the opening of the pelvic cavity is too small or if it
has an unusual shape, even an average-sized baby may not be able to pass
through it safely.  If this is the case, a cesarean section will be required.

The Stages of Labor

     Labor is described as having four stages.  The first stage begins with
the onset of true labor contractions and lasts until your cervix is completely
dilated.  The second stage begins when your cervix is completely dilated and
ends when your baby is born.  Delivery of your baby, therefore, occurs during
the second stage of labor.  The third stage begins after your baby is
delivered and ends when the placenta is expelled.  The fourth and final stage
begins once the placenta is expelled and lasts until your medical condition
has stabilized.

     The First Stage

     The first stage is almost always the longest (lasting anywhere from two
to 24 hours or more).  It usually starts slowly and then speeds up when the
dilation of the cervix reaches about four to five centimeters.  Your
contractions may not be clear and strong at first, but they will become
longer, stronger, and closer together with time.
     Much of your time in the first stage of labor may actually be spent
trying to figure out if you are in labor or not.  If you can be distracted
from your contractions, it is unlikely that you are in very advanced labor.

     Determining that labor has begun.
     If you are in the latter half of your pregnancy, you probably have
already felt your abdomen getting hard and then relaxing and getting soft.
Perhaps you have also experienced menstrual-like cramping in the lower part of
your abdomen near your pubic bone.  These are all contractions, but they do
not indicate that you are in labor.  Unlike true labor pains, these so-called
Braxton Hicks contractions are usually more uncomfortable than painful and
they usually occur irregularly and in different areas of the uterus.  They
serve to soften, thin out, and slightly dilate the cervix before you actually
go into labor.  During the third trimester, these contractions will get
stronger.
     Once labor begins, your contractions will start at the top of your uterus
and then spread down toward the cervix in a regular, rhythmic pattern.  In
this way, the baby will be pushed downward in the direction of the vagina with
each contraction.
     Each labor contraction has three parts that you will easily feel:  the
gradual buildup; the peak or apex; and the tapering off.  Between each
contraction, there will be a relaxation period during which the uterus rests
and no contraction occurs.  The next contraction will begin in the same
fashion, by building up, peaking, and then tapering off into relaxation.

     Timing your contractions will help you to know when you are in labor and
how your labor is progressing.  When you think you are in labor and you call
the doctor or hospital, you will be asked to describe your contractions in
terms of duration, frequency, interval, and intensity.

  -  The duration of a contraction is measured from the time that you first
     feel it to the first moment that the uterus is completely relaxed.
  -  The frequency of contractions is measured from the beginning of one
     contraction to the beginning of the next.
  -  The interval is the time between the end of one contraction and the start
     of the next.
  -  The intensity of a contraction is an observation that only you can make.
     You will need to compare the strength of the latest contractions with the
     strength of previous ones.

     Remember that the contractions you will feel in early labor will be just
the beginning, and there is normally no need to rush to the hospital after
your first two strong contractions.  You'll probably have to wait several
hours before it will be time to go to the hospital.  As labor progresses, a
pattern will develop in which your contractions will become stronger, longer,
more painful, and closer together:  there will be little if any doubt that you
are in labor.

     False labor.
     Sometimes women will experience what is often called "false labor."  This
is not really "false," but rather a period when contractions are generally
irregular and the cervix is not dilating.  These contractions may actually
start up and stop over several days.  The chart above shows some differences
between true labor contractions and "false labor" contractions and may help
you to decide if you are in labor.  Remember that you may not always follow a
"textbook" pattern.  If you are unsure if labor has begun, call your doctor,
or go to the hospital, where a nurse can check you.

     When to call the doctor.
     During your prenatal visits, you should ask your doctor when she wants
you to report labor to her and when you should go to the hospital.  Make
certain that you have your doctor's 24-hour phone number and the number of the
maternity department at the hospital.
     In most cases, your doctor will tell you to call her or report to the
hospital when your contractions have been occurring about five minutes apart
for at least one hour.  If you have a history of very rapid labors, or if you
live a long distance from the hospital, your doctor may advise you to come in
earlier.  Also, if your baby is in a breech position, if you are carrying
twins, if you have had a previous cesarean section, or if you have developed
any other pregnancy complications, such as high blood pressure or diabetes,
your doctor will probably instruct you to come to the hospital immediately if
you think you are in labor.
     If you ever experience contractions that you believe are labor and you
are more than two weeks away from your due date, go to the hospital
immediately.  Premature labor can often be stopped with drugs, and this will
avoid the delivery of a premature baby that may have difficulty surviving
outside your body.
     Also, if you feel a gush of fluid or even a slight leak coming from your
vagina, go to the hospital immediately, even if you are not having labor
contractions.  These sensations may indicate that the amniotic sac, which
forms a protective covering around the baby and keeps out harmful bacteria,
may have ruptured.
     Because of the uncertainty and discomfort that tend to occur during the
first stage, it is a good idea to plan your method and route for getting to
the hospital well before you actually go into labor.  Can you reach your
husband during the day if he is at work?  Will road construction or rush-hour
traffic cause you any delay?  What are some alternate routes?  Can a neighbor
or friend take you to the hospital if you are unable to contact your husband?
Make your plans well before labor begins so that you are not caught in a
last-minute panic.

     Arrival at the hospital.
     Upon your arrival at the hospital, your first stop may be the admitting
office, where you will be asked to read and sign forms and indicate how you
will pay for your hospital stay.  Since hospital procedures vary considerably,
it is a good idea to find out in advance about your hospital's admitting
policies--especially the procedures for late-night and weekend admissions.
Many hospitals will allow you to preregister so that you may avoid these
procedures when you are going through the discomfort and the emotional ups and
downs of the first stage of labor.
     From the admitting office, you will go to the labor-and-delivery or
maternity floor, where a doctor or nurse will greet you.  A quick but thorough
physical examination, including a vaginal examination to assess your degree of
dilation and effacement, will be performed.  The baby's heart rate,
presentation, and position will also be checked.  If you feel that you have
ruptured your amniotic sac, a visual examination of the vagina may be
performed to confirm this.
     The type of routine care you will receive from this point on will vary
widely from hospital to hospital.  Feel free to discuss these procedures with
your doctor in advance and express your preferences.  The following are common
hospital procedures that may be performed.

     Enema in early labor.
     An enema, which evacuates your rectum, may be performed to prevent stool
from contaminating the vaginal area during the latter stages of labor and
delivery.  Some hospitals and doctors routinely prescribe an enema for all
women during labor.  Other hospitals and doctors consider it to be optional.

     Administration of intravenous fluids.
     During labor, digestion stops, and any food or liquid in your stomach may
cause you to vomit.  For this reason, food is usually prohibited during labor,
although small amounts of water or juices may be allowed.  To prevent
dehydration, intravenous fluids, commonly called "IVs," are usually given.  To
administer these fluids, the nurse or doctor will insert a small needle into a
vein in your arm.  The needle will then be attached to a length of plastic
tubing, which will be connected to a bottle or a plastic bag filled with a
sterile solution of water, sugar, and sodium (salt).
     Hospitals and doctors also vary considerably on the routine
administration of intravenous fluids, especially if the woman's labor is
normal and no complications are expected.  However, most doctors agree that
intravenous fluids will be needed if the woman develops continuous nausea and
vomiting, experiences a very long labor, or requires pain medication or
anesthesia.

     Shaving of pubic hair.
     In the past, it was customary to shave off all of a woman's pubic hair
when she entered the hospital in labor.  Today, this is no longer standard
practice; many doctors believe that removal of the pubic hair is unnecessary.
In some hospitals, a "mini-prep" is performed, in which only a small area of
hair near the lower part of the vaginal opening is shaved.

     Restriction to bed.
     Most hospitals will allow you to be out of bed--either walking, sitting,
or squatting--during the early phases of labor.  Once your uterine
contractions become quite strong or you have been given pain medication,
however, you should remain in bed for your own safety.  If your blood pressure
is abnormally high or if the baby's heart rate is abnormal, you should remain
in bed for your entire labor.

     Vaginal examinations.
     At regular intervals during your labor, usually every one to two hours,
your doctor or nurse will examine your cervix by placing two gloved fingers
into your vagina.  This examination will be performed to determine the extent
of effacement and dilation of the cervix.  Such checks are usually kept to a
minimum, however, to avoid introducing bacteria into the uterine cavity and
causing infection.

     Electronic fetal monitoring.
     One of the major advances in obstetrical care in the last two decades has
been the ability to monitor the condition of the baby during labor.  An
electronic fetal monitor is an instrument that continuously records the baby's
heart rate and the pattern of your uterine contractions.  By looking at this
recording, your doctor can determine not only the frequency, duration, and
interval of your contractions, but also the well-being of your baby.
     A fetal monitor may be used either externally or internally.  In the
external form of monitoring, two elastic belts are placed around your abdomen.
On one belt is placed an ultrasound device to detect the baby's heartbeat, and
on the other, a device to detect your contractions.  In the internal form of
monitoring, a small wire attached to the top of the baby's head detects the
heartbeat, and a thin plastic tube inserted through your cervix and into the
cavity of the uterus detects uterine contractions.
     The rate and pattern of the baby's heartbeat during labor has been found
to accurately reflect how well he is receiving oxygen from the placenta.
During the ninth month, the baby's heartbeat should remain within the range of
120 to 160 beats per minute.  Any heart rate higher or lower than this may
indicate that the baby is not receiving sufficient oxygen.  An abnormal heart
rate pattern during contractions may also indicate that the baby is not
receiving enough oxygen.
     Hospitals and doctors likewise vary in their views concerning the routine
use of electronic fetal monitoring.  Some believe that all women in labor
should have electronic monitoring at all times.  Others believe that
electronic monitoring is not necessary for a woman experiencing a normal labor
with no medical complications.  However, electronic monitoring will be
necessary if there is any doubt about the baby's condition.

     Mother's activity during the first stage of labor.
     During the first stage of labor, you may become serious and quiet,
focused on only one thing--your labor.  Jokes will not be funny, and world
events will lose their importance.  You will probably experience many
emotional ups and downs in a relatively short period of time.  You may feel
discouraged and may cry from time to time, but if you accept labor as it comes
and understand what is happening and what to expect, you will be able to
recover from these down periods and go on.  Support, encouragement, help, and
comforting gestures from your partner, doctor, and nurse will be especially
helpful at this time.
     Once settled in at the hospital, you will find a routine for handling
contractions, perhaps based on what you learned in childbirth preparation
classes.  Labor contractions should always be thought of as contractions and
not as labor pains.  The following is a routine that many women learn and use
successfully with their contractions.

  1. Greet the contraction with a long sigh.  As you breathe out, try to
     release all of your bodily tension.
  2. At the same time, focus your attention in some way.  For example,
     focus on your partner's face or a picture or object of your choice;
     close your eyes and "see" your cervix opening as your uterus contracts;
     picture yourself in a peaceful, relaxing place; focus on music of your
     choice, or the soothing sound of your husband's voice; or have your
     husband stroke you, and focus on the sensations.
  3. Breathe slowly and easily.
  4. Try to stay relaxed and limp through each contraction.  It may help if
     you focus on one part of your body each time you exhale.  Try to
     release tension in that part as you breathe out.  Then focus on another
     part with the next breath.

     You can follow this routine for each contraction and in any position that
seems to make you more comfortable--lying down, sitting, standing, squatting,
down on hands and knees.  You can do this type of exercise in the car on the
way to the hospital, in bed, in a chair, or in the hospital corridor.
     These techniques and others are often effective in keeping pain within
manageable limits for part or all of labor.  Women who use them generally need
less pain medication than women who don't.  Indeed, some women do not use any
pain medication when using these techniques.  (Do not, however, get
discouraged if you feel that you need pain medication; ask your nurse or
doctor for it.)
     Some women learn several types, or levels, of breathing to use through
different stages of labor.  In addition to the slow method just described,
some women use a lighter, faster, but still relaxing pattern.  There are a
variety of techniques, many of which you may learn in your childbirth
preparation class.
     Besides using a routine for each contraction, you should try to change
your position every 20 or 30 minutes, go to the bathroom every hour or so, and
sip liquids or suck on ice after every contraction.  You will find these
measures quite comforting.
     You may also find that having hot packs placed on the lower portion of
your abdomen, on your groin, and near your vagina and having cold packs placed
on the lower part of your back will be very comforting.  Having a cool, moist
washcloth rubbed over your face and neck may also feel good.  Being touched
and rubbed, especially in tense, sore areas, such as the shoulders and lower
part of the back, may help a great deal at this time.  If you feel a bit out
of control, it may help to have your husband hold you tightly or to have him
hold your head gently but firmly in his hands.
     Many women, especially first-time mothers, become extremely anxious about
how rapidly their cervix is dilating.  You, too, may ask "How can my cervix
not be dilating when I am having such strong contractions?"  Don't be
discouraged if you are examined by your doctor and she tells you that your
cervix is dilating slowly.  More than likely, after your next examination, you
will show a great deal of progress.
     After your cervix has dilated to about seven to eight centimeters, you
will usually find that your contractions become long, very strong, and more
difficult to manage with your breathing and relaxation techniques.  During
this so-called "transition" phase, you may feel almost out of control.  This
part of labor is the most difficult and the most physically and mentally
demanding.  You may actually feel that your body is running away with you, and
that you are being swept along in a tide of intense sensations.  Fortunately,
this is the shortest phase of labor.
     As your cervix dilates even more, you will feet an intense urge to push
the baby out through your vagina.  It will be very important for you to try to
resist this urge if you are told that your cervix is not completely dilated.
Pushing too soon may injure the cervix and vagina and may lead to heavy
bleeding.  Pushing before your cervix is ready may also cause it to swell and
may slow down your progress.
     It is also quite common during this phase to feel extremely nauseated;
you may actually want to vomit.  Hiccups may also occur, adding further to
your discomfort.  Another symptom typical during the transition period is
trembling of your arms and legs:  this can be a bit unnerving for your husband
if he doesn't know what to expect.  You may also feel extremely hot or
extremely cold, and you may either throw off your blanket or feel the need for
additional blankets.
     During transition, it is also common to feel extremely irritable.  You
may not want to be touched at all.  You may even scream at your husband and
tell him to leave you alone.  This is not uncommon, and he should understand
that this disagreeable mood will pass as the transition phase ends.

     The Second Stage

     Once your cervix has dilated to ten centimeters in diameter, the second
stage of labor will begin.  This is also called the "pushing" stage, since you
will be directed to push with each contraction in order to force the baby down
through your pelvis and vagina.
     Your baby will actually be born during the second stage of labor.  This
stage ranges in length from 15 minutes to three hours or more.  On average, if
this is your first baby, the second stage will last about one hour; if you
have had previous babies, it will last about 15 to 30 minutes.
     When your cervix is completely dilated, the intense, out-of-control
feelings will usually subside, and you will be ready to get down to the
business of delivering your baby.  The contractions often space out somewhat,
and you may even get a short break from contractions (this is more likely with
first-time mothers).  It is always wonderful news when you are told that your
cervix is completely dilated and you can begin pushing when you feel like it.
     During the second stage, you may behave differently than in the first
stage.  You may find yourself holding your breath or slowly letting it out as
you bear down (in a way that is similar to, but more intense than, what you do
when you have a bowel movement).  Relaxing the vaginal area as you bear down
is especially important, because by tensing the muscles in this area, you will
actually be fighting against the birth of your baby.  It will also hurt much
more if you tighten these muscles.
     You will probably notice a real change in your contractions at this time.
Most will contain a reflex need to strain or grunt, called an "urge to push,"
which will come and go about three to five times per contraction.  With each
urge to push, you will need to bear down.  Every time you bear down, you will
push the baby closer to the outside world.  It will be hard work and it will
hurt, but it will also be an exciting time, with lots of cheering and praise
for your efforts.  Most women find that they have a new sense of energy and
have the strength to keep pushing.
     The best way to push is to push only when your body makes it happen--only
when the urge to push comes.  That way, you won't exhaust yourself, and you
won't hold your breath so long that you or the baby get too little oxygen.
The following is a routine many women use for pushing during second stage
contractions.

  1. Regardless of your position (reclining, lying on your side, squatting),
     greet the contraction with a long breath, and curl your body forward.
  2. Breathe as you did during first stage contractions.
  3. When you feel the reflex urge to push (it is unmistakable), follow it by
     grunting or holding your breath and bearing down.  Make certain that as
     you are pushing, you are also consciously trying to relax your vaginal
     muscles.  The urge to push will go away after a few seconds.  When it
     does, breathe until the urge to push returns; then repeat this process
     through each urge until the contraction ends.
  4. Relax or change position between contractions.

     Positions for the second stage.
     Unless the baby is coming fast, you will have time to change positions
during the second stage.  Many childbirth educators encourage women to learn
to squat comfortably before labor because this is such a helpful position for
the second stage.  By squatting, you will be giving the baby more room to come
down through your pelvis than he would have if you were in any other position.
You will also be taking advantage of gravity in this position.
     Lying on your side is a good position if the baby is coming fast, if you
have painful hemorrhoids, or if you must lie down for some reason.  Resting on
your hands and knees may help if the baby is large or if his heartbeat has
been slowing down during your contractions.  Semi-sitting allows you to see
your baby as he comes out.  It is also a convenient position for your doctor.

     The birth of your baby.
     Once the top of the baby's head is visible at the opening of your vagina
between contractions, your nurse will ready you for delivery.  In some
hospitals, you will be transferred to a specially equipped delivery room.  If
your hospital has an LDR room (labor-delivery-recovery room) or a birthing
room, you will not be moved; rather, you will deliver your baby in the same
bed in which you went through labor.
     Once you are on the delivery table or labor bed, you will be asked to
move your buttocks to the end of the table as you would during a routine
pelvic examination in your doctor's office.  Your legs will then be raised up
and placed into either stirrups or leg platforms, unless you and your doctor
have previously agreed that you will deliver without them.  Once, all women
gave birth lying on their back with their legs up in stirrups (the lithotomy
position).  Today, many doctors and midwives allow their patients to use other
birth positions.  You may, for example, be able to lie on your side with your
upper leg raised and have your husband hold it up.
     In whatever position you use, your thighs, vagina, and anal area will be
washed with a warm antiseptic solution, and sterile drapes will be placed over
your abdomen and thighs.  Your husband may then be asked to sit on a stool by
the head of your bed.
     While preparations are being made for delivery, you will continue to
have contractions and you will experience the urge to push.  In some cases,
your doctor may tell you to continue pushing.  However, if preparations are
not complete, you may be asked to try not to push and instead to pant rapidly
when you have the pushing urge.
     After preparations for delivery are completed, you will be urged to push.
You may ask if the head of the table or bed can be elevated to about a
35-degree angle so that you can push in a semi-upright position.  This is
usually much more effective than pushing when you are flat on your back.  Some
hospitals may also have a wedge that can be placed under the mattress to
achieve this position.  Your partner can also help by holding up your
shoulders as you push.
     As you continue pushing, your baby will be making his way down through
the pelvis and vagina; he will accommodate himself to their shape by turning
his body and head.  As the baby's head emerges, you will feel a great deal of
stretching and burning in your vagina and pressure on your rectum.  This will
be an intense time.  You'll know the baby is almost there, and you may be
tempted to push as hard as you can to get him out quickly.  That would be a
mistake, however, because a sudden push could make the baby come out too
quickly and tear your vagina and rectum.  Your doctor will usually tell you
when to stop pushing.  Let your contractions do the work alone.  You should
pant rapidly and lightly, so that the baby will emerge gradually.
     To prevent tearing of the vagina and rectum during delivery, your doctor
may perform an episiotomy.  In this procedure, she will make a small incision
through the skin and muscles from the lower portion of your vagina toward your
anus.  This will enlarge the opening of the vagina to allow for delivery of
the baby's head.  (The head is the largest part of the baby to come through
your vagina.)  If this is your first baby, you will probably need an
episiotomy; if you have had previous babies, you will often not need an
episiotomy since your vagina will have been stretched by previous deliveries.
     The length and direction of the episiotomy will depend on the size of the
baby's head and the elasticity of your vaginal tissues.  In most cases, a
midline episiotomy will be performed--straight down from the midpoint of the
vaginal opening directly toward the anus.  If the incision is made at an
angle, it is called a mediolateral episiotomy.  After the baby and placenta
have been delivered, your doctor will sew the skin and muscles back together
using sutures.  The sutures will not have to be removed:  they will dissolve
on their own in about two weeks.  You will, of course, be given a local
anesthetic before the episiotomy is performed (unless the area is already numb
from previous anesthesia), so that you will feel neither the incision nor the
sewing.  Not all doctors routinely perform episiotomies, so during your
prenatal visits, ask your doctor if she thinks you will need to have one.
     As the baby's head is delivered, your doctor may ask you to stop pushing,
so that she may use a suction bulb to remove mucus from the baby's mouth and
nose.  As you again begin pushing, the upper shoulder, the lower shoulder, and
then the rest of your baby will emerge.  And what a sense of relief you will
feel.
     Your baby will usually begin crying on his own.  (The doctor slapping an
upside-down baby happens only in the movies).  The doctor may then place the
baby on a sterile sheet on your abdomen so that you may see and touch him.
Next, the doctor will clamp the umbilical cord in two places and cut between
the clamps.  Since there are no nerves in the umbilical cord, neither you
nor your baby will feel anything.
     Once you have had a chance to hold your baby, he will probably be placed
in a heated bassinet and carefully examined.  His footprints will be taken and
then he will be brought to your side.

     The Third Stage

     Your job will not end with the delivery of your baby.  The placenta will
need to be expelled.  This third stage usually lasts from about five to thirty
minutes.  The nurse or doctor will keep a hand on your abdomen to determine
when the placenta separates from the wall of your uterus.  Then you will be
asked to push it out.  You may feel some cramping, but there is usually only
slight discomfort.  Your doctor will then carefully examine the placenta to
make certain that no parts have been left inside your uterus to cause bleeding
or infection.

     The Fourth Stage

     Immediately after birth, while you are admiring your new baby, your
doctor will focus on your well-being.  The condition of your uterus and vagina
will be of major concern.  It is important that your uterus remain contracted
after birth to keep it from bleeding.  Most women lose about one cup of blood
at the time of birth.  While this may seem like a lot, remember that among the
many other changes of pregnancy, your blood supply greatly increases.  Your
doctor will watch the amount of blood lost immediately after birth and, if
necessary, take measures to reduce the blood loss.  These may include
massaging your uterus vigorously or giving you an injection of a medication
that will cause your uterus to contract.
     Your doctor will also carefully examine your vagina and cervix to make
certain there were no tears made during delivery.  Although the idea of
tearing sounds rather unpleasant, these tears are usually not serious and will
heal rapidly.
     For about the next two hours, you will remain in bed and your nurse will
continue to check your recovery from labor and delivery.  About every 15
minutes, she will check your pulse, blood pressure, and breathing rate.  She
will also check your vagina to make sure that you are not experiencing
excessive bleeding.

Variations of Normal Labor

     The pattern of labor and delivery that has been described to this point
is considered "normal," and chances are that this will be the course of your
labor and delivery.  However, some women may experience a deviation from this
normal pattern.  A woman's delivery may deviate for a variety of reasons,
including the large size or unusual position of her baby, the small or
abnormal size or shape of her pelvis, or the extended duration of her labor.
If a problem should arise, your doctor will know the best course to follow.
However, to be prepared for any deviation from the norm, you should understand
the need for the following procedures.

     Forceps Delivery

     Forceps are spoon-shaped metal instruments (they've been compared to
salad tongs in appearance) used to help in delivering the baby's head.  If the
force of your uterine contractions and your pushing efforts are not enough to
deliver the baby, and if your second stage becomes excessively long (over two
hours), your doctor may deliver the baby with forceps.  Forceps may also be
used if the baby's heartbeat slows rapidly during the second stage and an
immediate delivery is necessary for the baby's health.
     The doctor will insert the two separate blades of the forceps into your
vagina on the sides of the baby's head.  As you push, the doctor will pull
gently on the handles of the forceps to deliver the baby's head.  Sometimes
forceps will leave small bruises on the baby's face.  These marks are
temporary and usually fade completely in about one week.

     Artificial Rupture of the Membranes

     Normally, during labor, or sometimes before labor, the membranes of the
amniotic sac will rupture, releasing the amniotic fluid into your vagina.  In
some cases, your doctor may wish to artificially rupture the membranes by
inserting a small plastic hook through your cervix and making a small hole in
the membranes.  This procedure often speeds up a slow labor.  There will be no
pain for you or your baby during this procedure, only the minor discomfort of
a vaginal examination.

     Induction or Stimulation of Labor

     In some cases, your doctor may decide that it is time for the baby to be
born, even though your labor contractions have not yet started.  Your doctor
may then induce labor.  This is usually performed by giving you a hormone,
called oxytocin, intravenously in the hospital.  The labor contractions that
are produced are usually similar to those that you would have during a normal
labor, but they may be stronger in the beginning.
     There are various reasons for inducing labor, including:

  -  The baby is overdue--that is, two weeks or more past the due date
  -  Health problems in the baby require immediate delivery
  -  The mother has certain medical problems, such as high blood pressure or
     diabetes, that can best be treated if the baby is delivered

     Labor is never induced just because the parents think that a certain day
would be convenient.
     There are also certain circumstances when your doctor may need to
stimulate or speed up contractions that have already begun.  If you are having
an unusually slow labor and the doctor has determined that the baby can safely
pass through your pelvis, oxytocin can also be administered intravenously to
make your contractions more intense and closer together.

     Cesarean Section

     Nearly 20 percent of deliveries in the United States today occur by
cesarean section.  Recent medical advances have made this procedure much safer
than it was a few decades ago.  Cesarean section is performed in cases where a
vaginal delivery would be hazardous for the baby, the mother, or both.  A
complete discussion of cesarean section can be found in The Ninth Month:  Ask
the Doctor.
     The preparation for a cesarean section will involve shaving the hair from
your abdomen and then scrubbing the skin with an antiseptic solution.  A thin,
hollow rubber tube, called a catheter, will then be inserted into your bladder
to drain off the urine.  There will be many more people in the operating room
than for a normal delivery, and each will have an important job to perform.
These will include your doctor and an assistant, who will perform the surgery;
at least two nurses, who will prepare surgical instruments for the doctor; the
doctor who will administer the anesthesia; and the pediatrician, who will take
care of the baby once it is delivered.
     Depending upon your doctor's preferences and the condition of you and
your baby, you will either be rendered unconscious by inhaling a gas (general
anesthesia) or you will remain awake and will be given either a spinal or an
epidural anesthetic (see The Eighth Month:  Ask the Doctor) to numb the area
from your navel to your toes.  The spinal and epidural are both administered
by injecting an anesthetic into an area in the lower spine.  The entire
operation will take about 30 to 90 minutes.  After it is over, you will be
moved to a recovery room where you will stay for about two to three hours,
while a nurse carefully monitors your recovery.  Since you will have had a
major surgical procedure, you should expect to spend about four to seven days
recovering in the hospital (this is only a few days longer than if you had a
vaginal delivery).
     Most couples have in their minds a clear expectation of how labor and
delivery will occur for them.  But it is important to remember that each labor
and delivery experience is unique, and there may be times when this process
does not go as smoothly as you may wish.  Some couples feel guilty and blame
themselves if cesarean section or a forceps delivery is required, thinking "If
we had only done something different."  For the most part, this is not so,
since no one can know ahead of time exactly what will happen.
     As your labor begins, accept it as uniquely yours, and understand that
whatever procedures are performed are done for your health and the health of
your baby.  Remember, too, that no matter how smooth or how difficult your
pregnancy, labor, and delivery are, they will fade to memories the moment you
hold your beautiful new baby in your arms.