Common Variations in Labor and Birth
Pre-term Labor
What is it? Onset of rhythmic
contractions that produce cervical dilation before 37 full weeks of gestation.
How common is it? 6-10% of births are
premature.
Why is it a problem? Although modern medicine
has greatly improved the survival rates of premature babies, they do have more
health complications than term babies.
What increases my risk of
pre-term labor? Lack of prenatal care, multiple fetuses, age under 16 or over 40,
obesity or very low weight, cigarette smoking, alcohol or drug abuse, maternal
medical illness, high blood pressure, strenuous physical work, unusual
emotional stress or anxiety, current infection of vagina or urinary tract.
What can you do about it? Consult with caregiver.
Drink several glasses of water, bed rest on your left side, avoid nipple
stimulation and sexual activity.
What can your caregiver do?
Prior to
37 weeks, they might suture cervix closed, recommend bedrest, or give
medication to stop or slow labor. After 37 weeks, usually labor will be allowed
to progress; caregiver may recommend amniocentesis to determine lung maturity,
or may recommend birthing in a hospital with a newborn intensive care unit.
What is it? A pregnancy lasting 42 or
more weeks from the start of the last menstrual period.
How common is it? 4-14% of pregnancies.
Why is it a problem? Going past the due date can
carry these risks: the placenta may become less able to provide baby with
enough oxygen and nutrients, chance of a pinched umbilical cord increases as
amount of amniotic fluid decreases, higher possibility of fetal distress,
higher chance of baby inhaling meconium from a bowel movement in utero, and
chance that the baby will grow too large.
However, only a small
percentage of “late” babies display postmaturity syndrome. According to ACOG,
95% of babies born between 42 and 44 weeks are born safely.
Post-date pregnancy can
also be frustrating and discouraging for women who are “sick of being pregnant”
and who are impatient to see their babies.
What can you do about it? Stay calm, having faith
in your body’s wisdom, rather than focusing on dates on the calendar. Take good
care of yourself; be active for part of the day, but also rest. Indulge in your
last few days of having only yourself to take care of.
What can caregivers do for
it? Labor induction. (see the details)
The
benefits of induction are that it starts a labor which has not begun on its
own. The risks of induction are that all of the forms of induction can lead to stronger, more painful,
and more frequent contractions for mom. These powerful contractions may also
limit oxygen supply to the baby, so increase the risk of fetal distress and
related interventions, including cesarean.
It’s important to clearly discuss these issues with your caregiver. If
the induction is being done for convenience, or for unclear medical issues,
then the benefits of induction may not outweigh the risks.
A
few caregivers
recommend labor induction shortly after the 40 week mark to avoid post-date
babies; however, research indicates that typically the risks would outweigh the
benefits at that point. Most caregivers recommend routine induction at 42
weeks.
Studies cited in Simkin
(1993) indicate that an appropriate response might be to monitor “post-date”
for fetal well-being twice a week, and inducing only if problems arise.
Ø Tests for fetal well-being:
Fetal movement counting, ultrasound, non-stress test, and contraction stress
test. (For more
information). There is a risk of false positives with these tests, so
consult with your caregiver about whether multiple tests should be used before
intervening.
A note on due dates. A diagnosis of post-date
pregnancy is based on the assumption that a normal “Term” pregnancy is 280 days
(40 weeks) from last menstrual period, or 266 days from ovulation (based on a
formula from the 1800’s). A recent study (Mittendorf, 1990) indicates that term
for uncomplicated pregnancies in first-time, Caucasian mothers, averages 274
days from ovulation. Based on this, you might want to add 8 days to your “due
date” before thinking of yourself as overdue.
What is it? A labor that is less than
3 hours from start of contractions through birth.
How Common is it? Probably less than 5% of
births (I do not have exact statistics). The rates for first time moms are much
lower than the rates for women who have given birth before.
Why is it a problem? Emotionally stressful for
the family: panic, fear, sense of being out of control. Intense contractions
can be very painful, and there’s often no time for medication. Some risk of
damage to the baby’s head and to the mother’s perineum.
What can you do to help
prevent it?
Cocaine use is clearly associated with precipitous labor. Poor nutrition might
be associated. Beyond those, it appears to be a combination of anatomical
issues: small babies, large bony pelvises, or soft, pliable genital tissue.
What can you do about it? If your labor begins with
very rapid, intense contractions that cannot be managed with comfort
techniques, call your caregiver. Go to the hospital immediately. Whenever
possible, lie on your side, rather than standing or sitting.
If you feel your body
pushing and you cannot stop it, or if you or your partner can see the baby’s
head at the vaginal opening, call 911 and request assistance and advice.
For more information on handling
an emergency birth, read the section in Simkin, Whalley, and Keppler. Or read this.
How common is it? More common than
precipitous labor.
If labor is moving slowly,
it is probably the result of:
Powers: Insufficient strength
and/or frequency of contractions.
Passages: The shape and flexibility
of the mother’s pelvis and soft tissues.
Passenger: Baby is in a non-optimal
position.
Pain: If mother is very tense
because of pain, muscular tension can slow labor.
Psyche: Maternal stress and
anxiety.
Keep these in mind as you
consider solutions; look for ideas that work on each of these areas.
Prodromal Labor: Prolonged
Early Labor
What is it? Early labor that last 24
hours or longer, before reaching 4 cm dilation.
What can you do to help
with it?
Stay well-nourished, drink plenty of fluids, and stay as rested as possible.
Encourage your partner to do the same. Try not to worry, and get anxious; this
is a normal pattern of labor for some women. Alternate quiet relaxation, with
distracting activities, shifting position frequently. Walking can be helpful,
but don’t exhaust yourself. Any of the non-medical induction methods (e.g. nipple
stimulation, orgasm) can also help augment labor, but check with your caregiver
before attempting to stimulate labor.
If you have slow progress,
back pain, and/or irregular contractions (maybe “coupled” contractions), assume
that your baby is occiput posterior, and look below at back labor for ideas to
help your baby rotate.
What can your caregiver do
for it?
Caregiver may just recommend relaxing and self-care until your body goes into
more active labor. Or, if you are exhausted, caregiver may recommend trying to
stop contractions and help you rest, by using sedatives, tranquilizers,
morphine, or alcohol. Or, caregiver may augment
labor by rupturing your membranes, and/or using Pitocin.
What is it? Labor that slows or stops
after you have reached 4 cm dilation. Some caregivers diagnose dysfunctional
labor if dilation averages less than 1 cm/hr; others say less than .5 cm/hour
over a four hour period. One recent study says abnormal progress should not be
declared unless a mother has taken more than 19.5 hours to go from 4 cm to 10
cm.
Basically, it’s a labor
that’s taking longer than the people involved think it should take.
Possible causes? Exhaustion, lack of
nourishment, dehydration, full bladder, anxiety, fear, cervix not effaced,
baby’s position.
What can you do to help
with it?
Rest, eat, drink, go to the bathroom, relaxation and comfort measures, plenty
of reassurance and encouragement from partner, use positions and movements where gravity can help
move the baby down. Voicing your fears. Also see information under back labor
below.
What can your caregiver do
for it?
Your caregivers will regularly monitor baby’s well-being, and may do more
frequent vaginal exams. May recommend I.V. fluids for hydration, and pain
medications for relaxation. May rupture membranes, or recommend Pitocin
augmentation.
What is it? Labor progress that slows
or stops after the cervix is fully dilated. Pushing for more than 3 hours; some
caregivers say 2 hours.
What can you do to help
prevent it?
Use a variety of positions and movement in early labor to help the baby descend
into position for birth.
What can you do to help
with it?
Try positions that open the pelvic outlet,
and use gravity to help baby descend. Squatting, lap squatting, supported squats,
and sitting on the toilet can all help. You can also try standing,
semi-sitting, and hands-and-knees. If you have had an epidural, you might ask
to try exaggerated Lithotomy: flat on your back with your knees drawn up toward
your shoulders. This position is not normally recommended, but may be an option
in this case to help the baby move beneath the pubic bone.
What can your caregiver do
for it?
They will carefully monitor heart rate. If baby seems to be handling the
contractions well, they may not intervene. They may use pitocin to augment your
contractions or use vacuum extraction, episiotomy,
forceps, or cesarean section to deliver the
baby.
Back Labor with an Occiput Posterior
Baby (For
lots of info, see www.spinningbabies.com)
What is it? Labor contractions that
are felt mostly in the mother’s back. May be very painful. Contractions may be
irregular, sometimes “coupling” (two contractions come close together, then
there’s break, then a cluster of two or three more). Also can cause a very long
labor.
Back labor is usually due
to a posterior baby. Baby’s head is pressing on the mother’s sacrum or
tailbone. Once the baby rotates, labor usually returns to normal. A baby can be
delivered in the posterior position, but sometimes posterior babies require
forceps or c-section delivery.
How Common is it? 25% of babies begin labor
occiput posterior. 70-90% of those will rotate on their own during labor.
What can you do to help
prevent it?
Simkin recommends 10 daily repetitions of the pelvic
tilt in late pregnancy. Also, hip circles, like in belly dancing or hula
dancing. How can you tell if a baby is O.P.? Sometimes you can tell by
looking at the mother’s belly. If the baby is anterior, the belly is round. If
the baby is posterior, its feet may make a bulge above the navel, and its head
makes another bulge below the navel. A caregiver may be able to palpate (feel)
where the baby lies. Another symptom is difficulty finding the fetal heart
tones, because the limbs are near the mother’s belly, rather than the back.
Basically, the easiest
answer is: if you have back pain, assume the baby is posterior. Any of the
techniques below will help relieve the pain, and will help the baby to rotate,
if he is posterior, and won’t cause any problems if he’s anterior.
What can you do to help
with it?
ü Massage on her lower back
and buttocks. Use firm, smooth strokes. Some women even like having a tennis
ball or a rolling pin rolled on their back.
ü Hot pads or ice packs on
her back, warm shower spray on her back
ü Counterpressure: partner
uses the palm of his hands to press on the mother’s lower back and sacrum
during contractions
ü Double hip squeeze: partner
stands behind mom, places one hand on each of her hips, with the palms resting
toward the center of her back; firmly squeeze hands together and push up toward
her shoulders during contractions
ü Knee press: mother sits
upright in a chair. Partner kneels on the floor in front of her, placing one
hand on each knee; lean toward her so that he is pressing straight back toward
her hip joints.
ü Any position that helps
take the weight of the baby off of your back will relieve some of the pain:
hands and knees, leaning forward while bracing yourself on a table or on the
wall; straddling a chair, and resting your head on the back of it, raising the
head of the hospital bed and kneeling on the bed while resting your head.
Change positions frequently.
ü Positions that help the
baby rotate: Walking, stair climbing, pelvic tilt (on hands and knees: arch
back like an angry cat, while also ‘tucking your tail’ like a scared dog. Then
relax, letting your back straighten); pelvic rock (on hands and knees, rock
back and forth and side to side during contractions); squatting; lunge (mom
stands with her side next to a chair, then puts one foot up on the chair,
facing to the side; mom faces front. During a contraction, mom “lunges” or
sways toward the raised leg.)
ü Open knee-chest position:
Rumored to be one of the best positions for helping a baby rotate. Start by
kneeling, then place chest on floor, with head resting on folded arms. Hips
should be slightly forward from knees, knees should be slightly spread. Stay in
this position for up to 30 minutes. If this is tiring for the mom, or she finds
her upper body is sliding forward, her partner can support her by sitting in a
chair with his feet on the ground. Mother rests her shoulders against his
shins, with her head between his feet.
Compiled by Janelle Durham.
Sources: Birth Education Northwest’s handout on “Coping with Common
Variations in Labor” by Sheri Feld. Pregnancy, Childbirth, and the Newborn
by Simkin, Whalley, and Keppler (2001 edition). “How long is too long? The
Dilemma of Post-dates Pregnancy” by Penny Simkin, Childbirth Forum,
Spring 1993. Abstract for “The Length of Uncomplicated Human Gestation” by
Mittendorf et al, Obstetrics & Gynecology, V.75, N.6, June
1990. “Pregnancy past your due date” by Terri Isidro-Cloudas on
americanbaby.com. “The Occiput Posterior Baby” by Henci Goer, Childbirth
Instructor Magazine, Summer 1994.