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What to Expect in a Normal Delivery

Stages of Labor
You'll find that the medical community uses a lot of jargon while you're in labor. We'll try to clear up some of what you're likely to hear and what it means throughout this chapter. There are three stages of labor, and you have to go through all three stages to get to the final outcome, aka the baby. The length and duration of these three stages may vary slightly for each woman.

The first stage of labor is when you are actively having contractions and officially diagnosed as being in labor. This can last a few hours or from to 8-14 hours. The first stage of labor is divided into two phases. The latent phase is the first portion of the first stage. This is the slow, drawn out portion that everybody hates (and they're told, "no, you're not in labor, go home.") Active phase is the second portion of the first stage of labor, and this is when the delivery process occurs at a faster rate. Because labor is more predictable at this point and the progress is steady, patients are typically admitted to the hospital once they reach this point.

The second stage of labor occurs when the cervix is maximally dilated (10 centimeters). This is usually when the mother is told she can push. For a first-time mother if she doesn't have an epidural, this second stage of labor can last one to two hours; with an epidural two to three hours (an epidural can slow labor down).

The third stage of labor begins after the baby is delivered until the placenta comes out. This stage can last up to 30 minutes. We'll break down these stages more completely in the sections that follow.

When You're First Admitted to the Hospital: The Preliminary Exam
After you are evaluated in the labor and delivery area and a determination is made that you are indeed in labor, you will be admitted to the hospital. Forms will need to be signed and papers filled out, but the hospital staff is conscious of the fact that you may be otherwise preoccupied (insert primal scream: I'M IN LABOR – LEAVE ME ALONE!). Your partner can help with this part of the administrative process. In fact, he or she is expected to do so, except for any signatures that you may need to provide.

From the time that you are admitted, doctors and nurses will be discussing your examination findings, based on the fetal heart rate tracings and contraction patterns. But first things first – you'll be given a preliminary exam, either by a doctor or a nurse.

Your first exam at the hospital will include a cervical exam, where three areas are measured: your dilation, effacement, and the station.

Dilation of the Cervix
The dilation of the cervix is measured in centimeters. During the exam, the doctor basically is trying to decide how dilated (or open) the cervix is. The doctor will place his hand gently (we hope) inside your vagina all the way up to the cervix to feel the presentation of the baby's body part. He should feel the head if all is well. Occasionally, the baby will be breech – that is, the doctor will feel the baby's butt or feet. If this condition is diagnosed, the patient will probably be advised to have a c-section, or the doctor may try to turn the baby to the head-down position.

Dilation can be measured anywhere from 1-10 centimeters, one being the beginning of the dilation process and 10 being fully dilated (i.e., the baby is almost out). If the cervical dilation is approximately 3-4 centimeters or greater and the mother is contracting regularly, then she will usually be diagnosed as being in active labor and will be admitted to labor and delivery (in first stage labor).

Effacement of the Cervix
In most cases, the baby's head is down, so the doctor continues with his exam and measures the effacement of the cervix (or the thinness of the cervix). Effacement is measured in percentages. In a normal, nonlaboring woman the cervix is 3-4 centimeters long, which is 0% effacement. If a woman is in labor, then the cervix thins. As it thins, it starts to stretch and becomes incorporated into the lower part of the uterus. For example, if the doctor determines the cervix is about 2 cm. thick, then the effacement is approximately 50%.

Station of the Cervix
The station of the baby is based on the relative distance of the baby's presenting body part (the head) to the level of the patient's ischial spines. These ischial spines are part of the bony portions of the mother's pelvis that the doctor or nurse can feel during the exam. A station is described as being anywhere on a scale from -5 to +5 with 0 being at the level of the ischial spine. If the baby is at 0 station, then the top of his head is at the level of the ischial spine. If the baby's station is a positive number, that means that the baby has moved farther down the birth canal past the ischial spine (ergo, closer to delivery).

Putting It All Together
Typical doctor lingo for a woman in labor might be something like this: 4 cm. dilated/50% effaced/-1 station. Translation: The cervix is 4 centimeters open. An effacement of 50% means that half of the cervix is thinned out (or the thickness has decreased by half). And -1 refers to the baby's presenting part or head being -1 cm. above the ischial spines.

If you are having regular contractions with the above diagnosis, then you have passed from the latent phase of labor (or the slow portion of the first stage) into the active phase of labor (or the faster portion of the first stage). For a first-time mother, once she has entered the active phase of labor, then the baby usually will be delivered within 8-12 hours, if not sooner. Patients at the active phase of labor are admitted to the hospital because the chance that the baby will deliver within several hours is fairly high, and the doctors and nurses will want to monitor the patient very closely during this time. This is the phase where the mother and baby are at higher risk for potential complications.

Admission
Once you are officially admitted and taken to a labor and delivery room, the nursing staff will go over certain items with you. They will ask you questions, some of which you may have answered already at your doctor's visits. For example, they will review your medication history and potential allergies. Your doctor (or a nurse) will explain what happens during labor and delivery, if he has not already done so, and go over potential procedures that may or may not need to be performed. Once you have an understanding of what will happen, you will sign a patient consent form, which implies that you understand what will occur in labor and delivery. This time is also your opportunity to ask questions.

The question and answer period serves as a protective mechanism for both the hospital and the patient. Some topics that might be discussed with you are the possibility of using forceps, having an episiotomy, what conditions might warrant a c-section, and so on. The patient is protected by virtue of the fact that she knows what is going to happen before it happens (in the best of all possible cases). The hospital and medical staff are protected because they have proof that they told the patient what they were going to do in order to take care of her.

A Chance For Partners to Earn Their Keep
During this process of admission, you are going to be distracted by contractions and not at your best or sharpest mentally. Your entire focus is on your body and the impending birth of your baby. It's important that your husband, partner, significant other, or coach be alert and attuned to what the nursing staff is explaining. If you don't fully understand what is going on or what the staff is saying, that's OK. Perhaps your partner can explain it to you later. Rely on your partner to go back to the doctor or nurse and get a more satisfactory or fuller explanation, if necessary.

Another tip: You might want to have your partner take a notebook so that he or she can jot down your questions. Or you could prepare some questions in advance. The important thing to remember is that your partner is your advocate. Make sure that person realizes his or her role in your delivery process and just how valuable that role is. (On the other hand, don't let them be too obnoxious, constantly pestering the medical staff and diverting attention from you – it does happen occasionally.)

Labor Is Truly Labor-Intensive
Once all the paperwork is done, you'll be admitted to a labor and delivery room, which is usually a private room in most hospitals (although there are exceptions).

An IV (intravenous) line will be placed in one of your arms. This IV line serves multiple purposes:

The baby will be placed on an external fetal monitor where the baby's heart rate and the mother's contraction pattern will be evaluated. The mother will also have her blood pressure checked regularly throughout labor. The mother's heart rate can also be monitored with a pulse oximeter, which measures the maternal heart rate, in addition to how well she is oxygenating.

During this time, the doctors and nursing staff will be monitoring the progression or lack of progression of the labor. The doctor will probably check your cervix every two hours, as needed, to determine whether or not you are making progress with cervical dilation, effacement, and station.

The Nurse's Role during Labor
The nurse who is handling your case quickly becomes your best friend in crime, so to speak, because he/she is probably going to be the person whom you see the majority of the time. Usually, the nurse has one-on-one care of a patient, or at most, she might be taking care of two patients at the same time.

The nurse will be your most visible health care provider during the laboring stage. She (or he) attends to your every need, monitors your condition constantly, answers questions, takes care of unwanted visitors, coordinates with the doctor, administers medicines as necessary, listens to your fears, and generally serves as your point man/woman for any problems during your labor. She will check your vital signs, help you go to the bathroom, maintain close observation of the baby's heart rate, and do the necessary charting. She will maintain your IVs. The nurse is there to look out for your best interests. She's also making sure that your spouse and other family members are comfortable as well; but her primary care rests with you, her patient.

Treat this person like gold – they are certifiable saints.

The Doctor's Role during Labor
If you have an outside doctor (meaning he doesn't work at the hospital), he will be notified the moment you arrive and he may ask a nurse to do the initial evaluation. He will immediately make plans to be there for the delivery, but he might not be there for the duration of the labor. Instead, he may ask the nurse to do the cervical check if you're not close to delivery, and then he might ask the nurse to give him a call once the patient reaches 8-10 centimeters. That way, he can complete his schedule with his patients in his office or finish surgery if he's in the middle of surgery. However, if there is a problem, he will drop everything to get there immediately. If the doctor's schedule is free, he will probably go into the hospital to monitor your progress once you're admitted.

When the doctor arrives at the hospital, he will be meeting with you to evaluate your progress and answer any questions. He'll continue to be in touch with your nurse and give orders to the nurse about procedures that need to be given. Even though your doctor may not be in the room as much as your nurse (he may have other patients in the hospital that he's responsible for), he will be accessible and usually waits in the boardroom, which is a place where electronic monitors are centralized. He will be monitoring your heart rate, your contractions, and your baby's heart rate from that remote location within the hospital. If everything is going smoothly with your labor, you will see the doctor every two hours until you are about to deliver. However, if there are any concerns or any problems arise, then the doctor will be coming in more frequently.

Pain Medications during Labor
Labor hurts – no ifs, ands, or buts about it. Once you are in active labor, the pain can be quite significant. But not all women experience the same reaction or level of discomfort with their contractions. If you request pain relief (and don't hesitate to do so if you need it), your doctor will review several options for you, including IV pain medications or regional anesthesia, which can include an epidural or an intrathecal (slightly different location than an epidural). The doctor will determine which one of these regional anesthetics will work best for you. This is not a choice made by the patient. Usually, the doctor will make the choice in consultation with an anesthesiologist.

The IV pain meds are given by the attending physician or nurse. An anesthesiologist usually administers epidurals or regional anesthesia, although your obstetrician may also administer anesthesia, depending on the hospital.

If Your Labor Slows Down, or The Three P's
Occasionally, the mother's labor pattern may slow down or stall altogether. This could be due to several reasons. First, the contraction pattern may have stopped for an unknown reason also known as a dysfunctional labor pattern. Second, the mother may have an infection of the uterus. Third, the mother may not have a pelvis that is the optimal size for a vaginal delivery. In this case, even if the baby is a normal size, it might get hung up on the bony structures within the birth canal. Doctors will check you carefully if your labor slows or stops to try to determine what is going on (or not).

Typically, doctors check for the three "P's" when trying to determine why labor has slowed or stopped. The first P refers to power – that is, the frequency, strength, and duration of the contractions. The next P refers to the pelvis. Doctors check to see if the pelvis is large enough for the baby to traverse through it or if there are any obstructions preventing the baby from going through. The third P refers to the passenger (or the baby). Is the baby's size or the way the baby is orienting itself in the pelvis the problem? For example, the head could be down, but turned in an improper way.

In truth, it's usually varying combinations of the three P's that contribute to protracted or slow labor. The doctor will make the determination as to why the labor has slowed and how best to correct the situation.

Internal Monitors on the Baby
For most patients, external monitors are adequate; however, if the baby's heart rate becomes worrisome or if it's difficult to tell how well a patient is contracting, internal monitors may be recommended. A fetal scalp electrode is placed on the baby's head to measure the baby's heart rate and any abnormalities. There might also be an IUPC (intrauterine pressure catheter) inserted that is not attached to the baby, but is a flexible probe inserted between the baby and the uterine wall through the vagina. This device detects the strength of the contractions and offers a more accurate interpretation of labor. The IUPC also serves as a means to increase the amount of fluid surrounding the baby, called an amnio infusion. This occurs when saline or water is transfused into the space around the baby and provides additional cushioning for the umbilical cord in times of stress. When the patient gets internal monitors, the external monitors are removed. There is a slightly increased chance of infection, which is why these monitors aren't routinely placed on all patients.

Using Pitocin to Speed Up Labor
If your labor has slowed or stopped and the doctor has made the assessment of the three P's and it is still possible to deliver vaginally, then the doctor might administer pitocin through an IV. Pitocin is a medicine that stimulates the uterus to contract. It mimics the body's own natural hormone called oxytocin, which is supposed to do the same thing – that is, speed up labor. Pitocin is generally a safe medicine; however, there are some precautions that need to be taken – for example, its dosage needs to be carefully regulated.

In rare circumstances, the uterus may become overstimulated, in which case the uterus contracts so frequently that the baby receives less oxygen. This may lead to a decrease in the baby's heart rate as the uterus doesn't have any downtime from the contractions. When the uterus is contracting, oxygen is at its worst for the baby. During the relaxation phase between contractions, the baby's optimal oxygen status is usually restored.

If, by some chance, the contractions become too frequent, the doctors will recommend turning down or turning off the pitocin temporarily in order to give the baby a break and a chance to recover sufficiently. In extreme circumstances, when this does not work, the doctor may recommend that the patient receive a different medication to relax the uterus and counteract the effects of pitocin temporarily.

One other potential complication from pitocin is that the uterus could rupture, due to hyperstimulation (overstimulation) or extreme contraction strength generated by the drug. For these reasons, the drug is carefully monitored at all times.

Repositioning the Baby
If the doctor determines that your lack of progress is due to the baby's position or malpresentation, then the doctor may attempt to reposition the baby's head during a vaginal exam, if at all possible. To do this, the doctor will gently feel the landmarks on the baby's skull to imagine which way the baby's head is pointed. Then he will attempt to turn the baby and correct any malpresentation that exists.

Many times, labor will resume in a normal fashion after repositioning without any further intervention, and the mother will eventually reach maximal dilation of 10 centimeters. When the mother is maximally dilated and effacement is 100%, then she is ready to push.

Pushing and Delivery
Usually, the patient's nurse or doctor will have coached her ahead of time so that she knows what to expect when they ask her to push. Pushing is timed to coincide with each contraction for maximum effect. When the uterus is contracting, this is the best time for the mother to exert her pushing efforts in order to deliver the baby. A contraction lasts approximately one minute. She will be asked to push three times during each contraction, with each effort lasting approximately 10 seconds.

Pushing
In-between contractions, the patient is asked to rest and not push, but to take slow deep breaths of oxygen in order to give the baby as much oxygen as possible. Remember, this is one of the most stressful times for the baby. Not only is the uterus contracting, but most of the amniotic fluid has leaked out so there is less cushioning to counteract the pressure that is being generated by the contracting uterus. Also, the space is tighter for the baby as it works its way down the birth canal.

In the early stages of pushing, the doctor or nurse may be examining you simultaneously with your pushing. For the doctor, this is a good opportunity to see how effective the patient is able to push.

From the Doctor's Perspective...
I always ask my patient to pay close attention to my assessment of how well she is pushing while I'm examining her. I want her to focus on those pushing efforts that I've found to be effective and that are allowing her to progress, and for her to continue focusing on that particular pushing effort that she has made with each successive contraction. I'm providing her with feedback as to how well she is doing so that she can minimize any wasted effort and deliver the baby successfully.

There is the potential for the mother to tire out very quickly, so I don't want her to push in an ineffective way if at all possible. In between contractions, I advise patients to remember what they did right so they won't start the next contraction without knowing how to push effectively. I'm examining the baby's head while the mother is pushing so that I can tell if the baby is rotating or coming down the birth canal properly. Unfortunately, there is the potential for the mother to become distracted by her family with oohs and aahs of excitement. I want her to stay on track and not lose focus.

From the Mother's Perspective...
Hey, I delivered five times, and each time I was clueless about what an effective push was and what wasn't. They all felt the same. First of all, it's difficult to tell if you're pushing or not, since what constitutes "pushing" doesn't make a lot of sense. Second, when you're at that phase, it's all a blur. Your only thought is "GET THIS BABY OUT OF ME!" and do whatever it takes. Sorry, Dr. John. Maybe if you'd been my doctor I would have known what an effective push was.

What Everyone Else Is Doing While You're Pushing (aside from Taking Bets)
The doctor will usually have the spouse of the patient get involved in the labor and delivery process. The spouse will stand on the opposite side of where the nurse is, supporting the patient both emotionally and physically while she's pushing (her chin will be pressed against her chest). The patient is asked to open her legs as wide as possible, so the spouse can support her neck and legs on one side, while the nurse supports the other side (picture Twister on a Saturday night). In between contractions the spouse will encourage the patient with words, wipe her forehead with a cool towel, and feed her ice chips if necessary, providing basic support to help the mother deliver the baby.

The nurse is continually monitoring the baby's heart rate and checking the mother's blood pressure. She is also ensuring that IV fluids are running and not stopped for any reason and that drugs or medicines are being administered. The nurse has a huge responsibility during this time, as she is also charting everything that occurs and assisting the doctor as necessary. If requested by the patient, the nurse will bring in a mirror to position between the mother's legs so that she can watch her baby's head as it appears. Some mothers close their eyes through the whole pushing effort, while others may choose to see everything. According to Dr. John, to doctors it is a beautiful experience, but the mother may or may not share that sentiment.

The Delivery
When it's time for the baby's head to deliver, the doctor will do his best to protect the delivery of the head and the mother's perineum to reduce or minimize any tears that might occur. Once the baby's head is delivered, the doctor will ask the mother to stop pushing temporarily. He will suction the mouth and nose of the baby, removing mucous secretion and amniotic fluid that may be present. He will check around the baby's neck to make sure the umbilical cord isn't wrapped around it. If it is, depending on how loose it is, he may unwrap the cord around the baby's neck. Sometimes, the cord may be tightly wrapped around the baby's neck; in that event, the doctor will clamp the cord in two places, cut the cord in-between the two clamps, unwrap the cord manually, and deliver the rest of the baby.

It's a wonderful time for the mother to watch as her entire baby is delivered. Many times a large amount of amniotic fluid that was behind the baby will now flow out. The doctor will also maintain support of the perineum so that there is a minimal chance of tearing. After the baby is delivered, the umbilical cord will be clamped and cut. If the father is interested, he can be given the opportunity to cut the cord. Again, this is a great way of making the extra person feel included in the process.

The baby will be gently stimulated by the delivering doctor and may be placed on the mother's chest or belly and covered with a blanket to provide warmth. The mother is asked to gently stimulate the baby during this time by rubbing the baby's back. Alternatively, the baby may be transferred to the baby warmer station where the medical staff will clean him, warm him, and check his heart rate. If the baby is not doing well, then there may not be time for him to go to his mother. Out of medical necessity, in this case, the baby will go immediately to the warmer or the nursery.

After the baby is born, the doctor and nurse return their attention to their primary patient, the mother. The doctor will reassess the mother's physical status, vital signs will be checked, and the amount of bleeding from the vagina will be determined. The doctor will assess his patient for tears or lacerations that might have occurred in the perineum or vagina or vulva. If any repairs are necessary, the doctor may proceed to do the repairs or opt to do them after the placenta is delivered. The doctor will also see if the cervix has any tears or lacerations, as well as examining the rectum for tears.

If there are any tears from a natural occurrence or from an episiotomy, the doctor will stitch the tears with absorbable sutures, meaning that the suture material will degrade on its own based on the body's ability to break down the suture.

The placenta will be delivered within half an hour after the baby's birth. After the delivery, there is a tendency for the uterus to squeeze down upon itself and return to a contracted state. The placenta will begin to sheer off with the contractions. As it sheers off, there is usually a visible sign of this by a large amount of blood coming out of the vagina and the umbilical cord will lengthen and advance out.

The doctor may aid this process by gentle traction (pulling), but he must be careful not to exert any unnecessary traction, as it could tear the cord off. After the placenta is delivered, the doctor will check to make sure that all of it is intact and no pieces remain in the uterus (which could cause bleeding and infection). The doctor will advise the nurse that the placenta has been delivered, so that she can note the time.

He will ask for pitocin to be administered intravenously, which aids in the contraction of the uterus and stops bleeding. To aid this process, the doctor will massage the uterus and stimulate it physically. The doctor will then check for any remaining clots before the placenta was delivered and evacuate those as necessary. Once the bleeding is under control and all lacerations have been repaired, the patient can be cleaned and her bed will be put back together. She can begin to rest. This is still a potentially dangerous time for the mother as bleeding may resume, so the nurse will continue to check her vital signs (including blood pressure) for the next several hours. The nurse will also check the uterus by pushing down on the abdomen, to make sure that the uterus is contracted and firm to touch. A soft, boggy or enlarged uterus could indicate that bleeding has occurred and the uterus is expanding with blood. That condition may necessitate additional measures, such as checking for clots remaining inside the vagina and uterus, recommendation for additional medications, and a possible blood transfusion. And if bleeding is extreme, surgical measures may be recommended, such as a D & C or a full hysterectomy.

Episiotomy
Often the baby may not be delivered because the vaginal opening is too small or constricted. At other times, the vaginal opening may be appropriate in size, but it has not had enough time to stretch for the baby. Or the baby's heart rate may be of concern to the doctor, so an attempt to expedite delivery may occur. These are all good examples of why an episiotomy might need to be performed.

An episiotomy is a process by which a doctor will make an incision or cut in the space between the vagina and rectum in order to expand the opening for the baby's head. Most doctors do not do this routinely, but rather only when a medical indication arises. When the doctor makes the cut, the vaginal space is enlarged. Of course, after the baby is delivered, the incision or episiotomy must be repaired to restore it to its original anatomy. Occasionally, the episiotomy may be so extensive that it extends to the rectal area. Obviously, this will necessitate more extensive repair afterwards.

Forceps or a Vacuum
In rare circumstances, your baby may need to be delivered with the aid of forceps or a vacuum device. The concept of doing an instrumented vaginal delivery is not new. Forceps have been utilized over the centuries, and they can provide a means to assist in the delivery of a baby when certain conditions arise. For example, if a mother is too tired to push or if the fetal heart rate becomes worrisome, then conditions may warrant the use of forceps or a vacuum. Very strict criteria need to be met before the use of these instruments can be offered to the patient.

If the doctor thinks the conditions are ideal for an instrumented vaginal delivery, then he should discuss his thoughts with the patient so the patient understands the indications, risks, and benefits. Unfortunately, sometimes there isn't time to have a lengthy discussion when the baby's life is at stake, so it's good to go over these procedures with your doctor in advance of the delivery.

The benefit to these two procedures is obvious: They may assist in getting the baby out quickly when there is a fetal heartrate problem.

The risks of using either vacuum or forceps are also obvious. They include the potential to injure the baby and create vaginal tears in the mother. You may see slight bruising of the side of the head on a baby where forceps were used. This bruising usually goes away in a few days.

The choice between using a vacuum or forceps is up to the doctor, depending on the patient's condition. The clinical situation will dictate which instrument is chosen. Safety for both the patient and the baby is of utmost importance.

The Absolute Minimum
A normal delivery is never really normal, simply because it's yours, and that makes it special. However, many of the procedures that you will encounter are easily decipherable and predictable if you simply do your homework in advance.

Reproduced from Absolute Beginner's Guide to Pregnancy, by John Adams and Marta Justak, by permission of Pearson Education. Copyright © 2005 by Que Publishing. Please visit Amazon to order your own copy.


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