Labour & Delivery

LABOR

Late in pregnancy, vaginal bleeding may be a sign of labor. A small amount of mucus and blood is passed from the cervix just before or at the start of labor. This is called “bloody show.” It is common. It is not a problem if it happens within 3 weeks of your due date. If it happens earlier, you may be going into preterm labor. Other signs of preterm labor include the following:

–     Vaginal discharge.

–     Change in type of discharge (watery, mucus, or bloody).

–     Increase in amount of discharge.

–     Pressure in the pelvis or lower abdomen.

–     Low, dull backache.

–     Stomach cramps, with or without diarrhea.

–     Regular contractions or uterine tightening.

As labor begins, the cervix opens (dilates). The uterus, which contains muscle, contracts at regular intervals. When it contracts, the abdomen becomes hard. Between the contractions, the uterus relaxes and becomes soft. Up to the start of labor and during early labor, the baby will continue to move. Certain changes also may signal that labor is beginning. You may or may not notice some of them before labor begins:

–     Feeling as if the baby has dropped lower.

–     Increase in vaginal discharge (clear, pink, or slightly bloody).

False Labor

Lightening – This is known as the “baby dropping”. The baby’s head has settled deep into your pelvis.

Show – A thick mucus plug has accumulated at the cervix during pregnancy. When the cervix begins to dilate, the plug is pushed into the vagina.

Your uterus may contract off and on before “true” labor begins. These irregular contractions are called false labor or Braxton Hicks contractions. They are normal but can be painful at times. You might notice them more at the end of the day.

True or False

Usually, false labor contractions are less regular and not as strong as true labor. Sometimes the only way to tell the difference is by having a vaginal exam to look for changes in your cervix that signal the onset of labor.

One good way to tell the difference is to time the contractions. Note how long it is from the start of one contraction to the start of the next one. Keep a record for an hour. It may be hard to time labor pains accurately if the contractions are slight.

Listed as follows are some differences between true labor and false labor.

Differences Between False Labor and True Labor:

–     Type of change.

–     Timing of contractions.

–     Change with movement.

–     Strength of contractions.

–     Pain of contractions.

False Labor

Often are irregular and do not get closer together (called Braxton Hicks contractions).

Contractions may stop when you walk or rest, or may even stop with a change of position.

Usually weak and do not get much stronger (may be strong and then weak).

Usually felt only in the front.

True Labor

Come at regular intervals and, as time goes on, get closer together. Each lasts about 30–70 seconds.

Contractions continue, despite movement.

Increase in strength steadily.

Usually starts in the back and moves to the front.

Fetal Heart Rate Monitoring

Fetal heart rate monitoring is the process of checking the condition of your baby during labor and delivery by monitoring his or her heart rate with special equipment.

Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. A normal fetal heart rate can reassure both you and your healthcare provider that it is safe to continue labor if no other problems are present.

Electronic fetal monitoring uses special equipment to measure the response of the baby’s heart rate to contractions of the uterus. It provides an ongoing record that can be read by your healthcare provider. Your healthcare provider will review the electronic recording of the baby’s heartbeat (called the fetal heart rate tracing) at set times. The tracing may be reviewed more frequently if problems arise.

Electronic fetal monitoring can be external, internal, or both. You may need to stay in bed during both types of electronic monitoring, but you can move around and find a comfortable position. Some centers provide Wi-Fi monitoring which allows you for better mobility.

Abnormal Patterns

Abnormal fetal heart rate patterns do not always mean there is a problem.

Steps can be taken to help the baby get more oxygen, such as having you change position. If these procedures do not work, your physician may decide to deliver the baby right away. In this case, the delivery of the baby is more likely to be by cesarean birth or with forceps or vacuum extraction.

PRETERM BIRTH

Most pregnancies last about 40 weeks. Babies born between 32 and 37 weeks of pregnancy are considered preterm. Babies born before 32 weeks are called “early preterm.”

If you are at risk of having an early preterm baby, survival depends on many factors. You also need to be aware that early preterm infants who do survive often have serious, long-term health problems. Babies may be physically or developmentally disabled and need special medical care.

Complications

The earlier an infant is born, the more likely he or she will have health problems. These problems can be short-term or long- term disabilities that may include the following:

–     Respiratory Distress Syndrome (RDS).

–     Bleeding in the brain.

–     Infection.

–     Problems with the digestive system.

–     Problems controlling body temperature.

–     Trouble communicating and making sounds.

–     Vision and hearing problems.

–     Cerebral palsy and other neurological problems.

–     Developmental delays.

Treatment

Drugs called tocolytics can be given to many women with symptoms of preterm labor to slow or stop contractions of the uterus. Tocolytics may provide you with extra time to take corticosteroids for the baby’s lung development or to get to a hospital that offers specialized care for preterm babies.

Steroid Injection

Medications sometimes can be given to women at risk of preterm birth to help the baby’s lungs mature (corticosteroids) or help prolong pregnancy (tocolytics or progesterone). If you are between 24 weeks and 34 weeks of pregnancy and your healthcare provider suspects that you may have your baby within the next week, you may receive an injection of a corticosteroid. This drug helps speed the development of your baby’s lungs and some other organs.

Surfactant

Surfactant is a substance that helps the air sacs stay inflated in the lungs. The lungs begin making surfactant at around 23 weeks of pregnancy. Lack of surfactant is the main cause of RDS in preterm infants.

Infants who need surfactant replacement therapy often are very sick and need highly specialized care. For this reason, surfactant therapy is offered only in hospitals where the staff is specially trained in giving this treatment and caring for very sick babies.

Hospital Impact

Preterm infants who are delivered at hospitals with high-level neonatal intensive care units (NICUs) have a better chance of survival. High-level NICUs provide specialized care for infants with serious health problems. These units are better equipped and have doctors and nurses with advanced training and experience in caring for preterm infants. A team of healthcare providers usually will care for you and the baby. The team may include a neonatologist, a doctor who specializes in treating problems in newborns.

Hard Decisions

If your baby is not responding to treatment, there is only a very slim chance of survival. Your team of doctors and nurses will talk to you and your family about your options. It is possible that the baby will not be able to survive without the ventilator. It will be a difficult time for you and your family, but it may be necessary to remove your baby from the breathing machine. Your healthcare team will help you decide what is best for your baby.

PAIN RELIEF

The amount of pain a woman feels during labor may differ from that felt by another woman. Pain depends on many factors, such as the size and position of the baby and the strength of contractions.

Some women take classes to learn breathing and relaxation techniques to help cope with pain during childbirth. Others may find it helpful to use these techniques along with pain medications.

There are two types of pain-relieving drugs—analgesics and anesthetics.

–     Analgesia is the relief of pain without total loss of feeling or muscle movement. Analgesics do not always stop paincompletely, but they do lessen it.

–     Anesthesia is blockage of all feeling including pain. Some forms of anesthesia such as general anesthesia cause you to lose consciousness.

Other forms, such as local anesthesia, remove all feeling of pain from parts of the body while you stay conscious.

Systemic analgesics are often given as injections into a muscle or vein. They lessen pain but will not cause you to lose consciousness. They act on the whole nervous system rather than a specific area. Sometimes other drugs are given with analgesics to relieve the anxiety or nausea that may be caused by these types of pain relief.

Like other types of drugs, this pain medicine can have side effects. Most are minor, such as nausea, feeling drowsy, or having trouble concentrating. Systemic analgesics are not given right before delivery because they may slow the baby’s reflexes and breathing at birth.

Local anesthesia provides numbness or loss of sensation in a small area. It does not, however, lessen the pain of contractions. Your doctor before delivery may do a procedure called an episiotomy. Local anesthesia is helpful when an episiotomy needs to be done or when any vaginal tears that happened during birth are repaired. Local anesthesia rarely affects the baby. There usually are no side effects after the local anesthetic has worn off.

Regional Analgesia

Regional analgesia relieves pain in one region of the body. It tends to be the most effective method of pain relief during labor and causes few side effects.

Epidural analgesia, spinal blocks, and combined spinal–epidural blocks are all types of regional analgesia that are used to decrease labor pain: Epidural analgesia – sometimes called an epidural block, this form of analgesia causes some loss of feeling in the lower areas of your body, yet you remain awake and alert.

An epidural block is given in the lower back into a small area (the epidural space) below the spinal cord. Pain relief will begin within 10-20 minutes after the medication has been injected. After the epidural needle is placed, a small tube (catheter) is usually inserted through it, and the needle is withdrawn. Small doses of the medication can then be given through the tube to reduce the discomfort of labor. The medication also can be given continuously without another injection. You can move after you have an epidural block, but you may not be allowed to walk around.

Spinal block – A spinal block can be given using a much thinner needle. It is injected into the sac of spinal fluid below the level of the spinal cord. The spinal block uses a much smaller dose of the drug. Once the drug is injected, pain relief occurs right away. However, it lasts only for 1-2 hours. A spinal block usually is given only once during labor, so it is best suited for pain relief during delivery.

Risks

Although rare, complications or side effects, such as decreased blood pressure or headaches, can occur. To help prevent a decrease in blood pressure, fluids will be given through a vein by a tube in the arm. 
Some women (less than 1 out of 100) may get a headache after having an epidural block. A woman can help decrease the risk of a headache by holding as still as possible while the needle is placed. If a headache does occur, it often subsides within a few days. If the headache does not stop or if it becomes severe, a simple treatment may be needed to help the headache go away. 
The veins located in the epidural space become swollen during pregnancy. Because of this, there is a risk that the anesthetic medication could be injected into one of them. If this occurs, you may notice dizziness, rapid heartbeat, a funny taste, or numbness around the mouth when the epidural is placed. If this happens, let your healthcare provider know right away.

General anesthetics are medications that put you to sleep (make you lose consciousness). If you have general anesthesia, you are not awake and you feel no pain. General anesthesia often is used when regional analgesia is not possible or is not the best choice for medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. Therefore, it is often used when an urgent cesarean delivery is needed.

For Cesareans

If you already have an epidural catheter in, stronger medications (anesthetics, not analgesics) may be injected if you need a cesarean delivery (or if vaginal birth requires the help of forceps or vacuum extraction). Spinal anesthesia also can be used. Whether you have general anesthesia or regional anesthesia for a cesarean birth will depend on your health and that of your baby. It also depends on why the cesarean delivery is being done. In emergencies or when bleeding occurs, general anesthesia may be needed.

INDUCTION

Labor induction is the use of medications or other methods to bring on (induce) labor.

Labor is induced to stimulate contractions of the uterus in an effort to have a vaginal birth. Labor induction may be recommended if the health of the mother or fetus is at risk. In special situations, labor is induced for non medical reasons, such as living far away from the hospital. This is called elective induction. Elective induction should not occur before 39 weeks of pregnancy.

To prepare for labor and delivery, the cervix begins to soften (ripen), thin out, and open. These changes usually start a few weeks before labor begins. Healthcare providers use the Bishop score to rate the readiness of the cervix for labor. With this scoring system, a number ranging from 0-13 is given to rate the condition of the cervix. A Bishop score of less than 6 means that your cervix may not be ready for labor.

Ripening

Ripening the cervix is a process that helps the cervix soften and thin out in preparation for labor. Medications or devices may be used to soften the cervix so it will stretch (dilate) for labor.

Prostaglandins are drugs that can be used to ripen the cervix. They are forms of chemicals produced naturally by the body. These drugs can be inserted into the vagina or taken by mouth. Some of these drugs are not used in women who have had a previous cesarean delivery or other uterine surgery to avoid increasing the possible risk of uterine rupture (tearing).

Stripping the membranes is a way to induce labor. The healthcare provider sweeps a gloved finger over the thin membranes that connect the amniotic sac to the wall of your uterus. This action may cause your body to release prostaglandins, which soften the cervix and may cause contractions.

Amniotomy

Rupturing the amniotic sac can start contractions. It also can make them stronger if they have already begun. The healthcare provider makes a small hole in the amniotic sac with a special tool. This procedure, called an amniotomy, may cause some discomfort.

Amniotomy is done to start labor when the cervix is dilated and thinned and the baby’s head has moved down into the pelvis. Most women go into labor within hours after the amniotic sac breaks (their “water breaks”).

IV Medications

Oxytocin is a hormone that causes contractions of the uterus. It can be used to start labor or to speed up labor that began on its own. Contractions usually start in about 30 minutes after oxytocin is given.

With some methods, the uterus can be over stimulated, causing it to contract too frequently, which may lead to changes in the fetal heart rate, umbilical cord problems, and other problems.

Other risks of cervical ripening and labor induction include the following:

–     Infection in the mother or baby.

–     Uterine rupture.

–     Increased risk of cesarean birth.

Success Rates

Sometimes labor induction does not work. A failed attempt at induction may mean that you will need to try another induction or have a cesarean delivery. The chance of having a cesarean delivery is greatly increased for first-time mothers who have labor induction, especially if the cervix is not ready for labor.

Reasons to Induce

A medically indicated delivery is done for a medical reason. These reasons may be the woman’s medical condition or a problem with the baby. Labor may be induced (started with the use of certain drugs or other means) or a cesarean delivery may be performed (in which the baby is born through incisions made in the abdomen and uterus).

An elective delivery is performed for a non medical reason. Some non medical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy. Some women request a cesarean delivery because they fear vaginal birth.

Risks of Early Induction

A normal pregnancy lasts about 40 weeks. It was once thought that babies born a few weeks early – between 37 weeks and 39 weeks – were just as healthy as babies born after 39 weeks. Experts now know that babies grow throughout the entire 40 weeks of pregnancy.

The lungs, brain, and liver are among the last organs to fully develop during pregnancy. The brain develops at its fastest rate at the end of pregnancy – it grows by one third just between week 35 and week 39. Also during these last weeks, layers of fat are added underneath the baby’s skin. This fat helps keep the baby warm after birth.

The following health problems are possible in babies who are born too early:

–     Breathing problems, including respiratory distress syndrome.

–     Temperature problems – Babies born early may not be able to stay warm.

–     Feeding difficulties.

–     High levels of bilirubin – Too much bilirubin can cause In severe cases, brain damage.

Can result if this condition is not treated.

–     Hearing and vision problems

–     Learning and behavior problems.

If you are considering an elective delivery before 39 weeks, it is important to discuss the potential risks and benefits with your healthcare provider as well as your reasons for requesting this type of delivery. If discomfort is a reason, it may help to know that it is normal to feel uncomfortable at the end of pregnancy. Your healthcare provider may be able to suggest ways to help you feel better. If you live far away from the hospital, you might want to stay with someone who lives closer. You also may be able to set out for the hospital when you are in early labor. Talk to your healthcare provider to get other suggestions and advice.

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