BIRTH

Labor

Labor is the beginning of the active birth process. Many expectant mothers ask themselves the important question "Is this it?" more than once in the late weeks of pregnancy. Sometimes they feel a slight contraction and then nothing more. Such contractions, known as Braxton-Hicks contractions, are relatively painless and begin as early as the sixth month and may continue throughout the pregnancy. Real labor contractions cause more discomfort, occur with greater regularity, and are intensified by walking.

Other signs may or may not indicate that labor is beginning, such as an ache in the small of the back, abdominal cramps, diarrhea, indigestion, "show" (a small amount of blood-tinged mucus emerging from the vagina), and the "water breaking" (a discharge of fluid from the vagina). The discharge of fluid, which is caused by the rupture of membranes, can occur some time before actual labor begins. The only certain signs of labor are the appearance of the show and the onset of regular, rhythmic contractions that increase in frequency and strength. When the fluid from the amniotic sac is discharged, the first line of defense against infection is broken. Often, if labor does not begin after the water breaks, the physician may induce labor.

Stages of Labor

Labor progresses through three stages: dilation, or "the opening," expulsion, and placental. The first stage, dilation, can last anywhere from two hours to sixteen hours or more. At first, each contraction is thirty to forty-five seconds in duration and occurs about every fifteen to twenty minutes. The contractions are involuntary and the woman cannot start them or stop them at will or make them come faster or slower. Their function is to dilate the cervix until it is wide enough to let the baby through—usually about four inches (ten centimeters). In the course of the first stage of labor the contractions increase in frequency until they are only a minute or two apart. Each contraction itself also becomes longer and, toward the end of the first stage, may last ninety seconds.

At the end of the first stage there may be a series of very intense contractions; during this time the cervix has been stretched around the baby's head. The woman may feel ready to give up, but this phase, known as transition, is soon over. It rarely lasts more than half an hour and is often much shorter. In expulsion, the second stage of labor, the involuntary contractions continue to be long in duration and closely spaced, but now the woman has a strong urge to bear down with her abdominal muscles. At each new contraction she pushes down with all her strength as the baby's scalp comes into view, only to disappear again when the contraction ends. This is known as crowning. With each contraction more and more of the baby's head can be seen. At this point in labor, some obstetricians may perform an episiotomy (making a small slit in the skin outside the vagina toward the anus) to prevent this tissue from tearing. When the baby's head comes out as far as its widest diameter, it stays out, and in a short time it is free. The head may be molded (elongated in shape as a result of its passage through the cervix), but the soft skull bones that have been squeezed together soon recover their normal shape.

Some babies will give their first cry at this point. With the next contractions the shoulders emerge, and the rest of the body slips out easily. The feelings of both parents at this time are almost impossible to put into words: elation, exhaustion, and great feelings of tenderness and caring.

It was once the practice for the doctor to hold the baby up by the feet immediately following delivery to allow fluid and mucus to escape from the baby's mouth and nose, so that the infant could start breathing, usually with a gasp and a cry. Today it is more usual to aspirate the mucus from the baby's mouth and nose by suction as soon as the head is delivered. This gives the baby a slight head start on independent breathing.

As soon as delivery is complete, the umbilical cord is clamped and cut. The baby is then wrapped in a receiving blanket, and someone performs a variety of procedures that vary from hospital to hospital. Typically, drops of silver nitrate are placed in the baby's eyes to prevent infection, both mother and baby are given plastic identification bracelets, and fingerprints of the mother and sometimes footprints of the baby are taken.

At this time the neonate's general state of health is evaluated using the APGAR scoring system. At one, five, and ten minutes after birth the baby is given a score of 0, 1, or 2 on Activity (muscle), Pulse (or heart rate), Grimace (or reflex action), Appearance (color), and Respiration (breathing). This test provides very general information on whether the baby's life-sustaining functions appear normal and what kinds of potentially dangerous problems may be present. The majority of children score between 5 and 10, and 90 percent have a score of 7 or better; there is no reason for concern unless the score is below 5.

During the third or placental stage, the afterbirth (the placenta and cord) is expelled from the uterus. Labor is now completed.

The length of the entire process varies greatly, as does the actual experience of labor. Fifteen hours is an average figure for the duration of birth from the first contraction to the expulsion of the afterbirth for a first birth. But this average covers a spectrum of labor as long as twenty-four hours and as short as three hours or less. Labor is usually longer for first babies than for later ones, and longer for boys than girls. Two reasons for a longer first labor might be the easier adaptation of the woman's body to the process and the reduced amount of anxiety present in subsequent births.

"Gentle Birth" Techniques

One way that the process of labor can be made easier for the expectant mother is the use of certain techniques often referred to as gentle births, such as the Lamaze and Dick-Read methods of childbirth. Both of these became very popular in the early 1970s. Grantly Dick-Read believed that pain during childbirth is not inevitable but is the result of fear passed on from mother to daughter over the generations. Dick-Read stressed that by educating the woman about the birth experience, the fear of the unknown can be removed. In its place a more positive view about delivery can be substituted. In 1967 a French obstetrician, Fernand Lamaze, developed a method for childbirth he called "childbirth without pain." This popular technique usually begins in the third trimester of pregnancy when the woman practices breathing and other exercises with her "coach" (usually the father). These exercises are used during labor to help a woman control her anxiety and be able to relax and push at the appropriate time. By practicing the exercises in advance, the command or suggestion of the coach is quick in coming and easy to maintain at the time of childbirth.

There are a substantial number of studies showing that prepared childbirth enhances feelings of self-esteem, increases the husband's degree of participation, and even strengthens the marital relationship. Whereas in the 1970s fathers were still marginally included in the birth of their children, it is almost the exception in the early twenty-first century when they are not.

What are the baby's first impressions of the world he or she is being thrust into? One French obstetrician, Frederick Leboyer, believes that the very act of being born can be a terrifying experience. In Leboyer's view, the violence of modern delivery techniques contributes a good deal to this "hell and white hot" experience.

The Leboyer technique involves a number of radical changes in the delivery procedure. As soon as the infant begins to emerge, the physicians and nurses attending the birth lower their voices, and the lights in the delivery room are turned down. Everyone handles the baby with the greatest possible tenderness. Immediately after delivery the baby is placed on the mother's abdomen, where the baby can start breathing before the umbilical cord is cut. After a few minutes the obstetrician places the baby in a lukewarm bath, an environment very much like the amniotic fluid. In this way the difference between the fetal environment and the world is minimized.

Is Leboyer's method better? Safe? Of the few studies that have been done, the results seem to indicate that babies delivered this way are similar to others delivered in a more conventional fashion. Whether or not there are any long-lasting effects will have to be judged after sufficient information is available about these "gentle birth" babies as they grow.

Alternate Birth Centers

Hospitals operate as bustling, crisis-oriented places. Such institutions are for sick people, and pregnancy is not considered an illness by supporters of a new kind of environment for giving birth—the alternate birth center. Alternate birth centers were developed because many parents objected to what they felt to be the impersonal, needlessly technological, and increasingly expensive childbirth procedures available in the conventional hospital setting. As a growing number of women chose to give birth at home, the risks involved became a concern. Alternate birth centers, then, are a response to both the dissatisfaction with hospitals and the hazards of home births.

These centers were all but unheard of in 1969. Within a few decades, at least 1,000 had been established, and the trend continued into the early twentyfirst century. In 1978 the medical establishment officially endorsed many elements of this alternate care, recommending that it be included in conventional maternity services. Out-of-hospital facilities for the management of low-risk deliveries were also established.

Alternate birth centers provide a relaxed, homelike atmosphere for the pregnant woman, her family, and the newborn. The most dramatic aspect of an alternate birth center compared with a conventional hospital is the room where the deliveries take place. Unlike the operating-room atmosphere to which laboring women are generally sent at the most uncomfortable, critical moment, the birthing room—the location of the woman's predelivery hours—is a cheerfully decorated suite resembling a bedroom. Women in labor move about freely. They rest as they choose and may be accompanied by their husbands, families, and friends. An attending nurse, midwife, or doctor delivers the baby into this low-key, family-oriented environment. It is dimly lit, quiet, and peaceful.

The new mothers, and those with them, report a sense of control and contentment in contrast to the anxiety and isolation experienced by many in the traditional delivery room. Many of these centers also encourage the participation of other siblings in various stages of the pregnancy and birth.

Following the birth, the new family remains in the birthing room, in close physical contact. The newborn is placed on the mother's bare skin (which can act almost like a "natural incubator") and has the first opportunity to suckle and enjoy eye contact. A soothing warm bath may be administered. In these first hours, bonding between the parents and child has a unique quality. In some birthing rooms, siblings may also share these special experiences. The entire family leaves the alternate birth center together, usually earlier than from the traditional setting.

For safety, birthing-room facilities keep a significant amount of emergency equipment hidden within the suite itself and deliver only low-risk births. Nonetheless, of these births, approximately 10 percent develop problems best handled in a more conventional setting. When located in a hospital, birthing rooms are usually adjacent to traditional delivery and operating rooms.

Midwives

At one time the use of a midwife conjured up visions of birth-attending barbarians in a dimly lit, unsanitary room. Today, nothing could be further from the truth. Midwifery as a profession has the status it deserves as an integral and indispensable component of prenatal care and childbirth. Popular in Europe for many years, it is becoming more so in the United States.

Midwives are increasingly associated with physicians, where they can handle the majority of the prenatal care that needs to be done and up to 90 percent of the actual births. The remaining births that are of high risk are usually under the physician's care.

A woman might choose to have a child delivered by a midwife for several reasons. One of the most important is that the traditional medical community continues to treat pregnancy as an illness and the pregnant woman as a sick person. This kind of thinking is slowly being rejected, in part as the result of a U.S. Supreme Court action ruling that pregnancy is a disability and not a disease. There are several other reasons why midwives are becoming more popular:

• New changes in the law allow the licensing of midwives.
• There is, as a result of the women's movement, a sharp increase in the demand for women practitioners to assist in deliveries.
• Midwives are better trained today than ever and often go through intensive university-based classes in physiology and obstetrics.
• The role of technology in childbirth has been questioned in that it tends to be dehumanizing. Midwives are less likely to resort to such techniques, which in some cases may present more dangers to the woman and the infant than not.
• The federal government endorses the use of midwives and encourages institutions to employ them.

Perhaps the best combination is a midwife working directly with a physician so there is adequate technical backup if necessary.

Complications

Most "complications" can usually be dealt with successfully by the obstetrician and the hospital staff. The baby may, for example, come out bottom first in what is called a breech presentation. Sometimes one foot is first to appear, and sometimes the umbilical cord comes out alongside the head. The doctor must manage these variations and often actually turn the baby before birth with great skill to avoid any further complications.

Babies, for the most part, deliver themselves. It is when complications develop that the training and expertise of the health-care provider are needed. The fetal heartbeat is monitored during labor, and when there is cause for concern, a cesarean delivery may need to be performed.

A cesarean birth is one in which the baby is delivered through a surgical incision made into the woman's abdomen and uterus. Although it is generally considered a safe operation for both mother and baby, it is still major surgery. Babies delivered by cesarean do not have molded heads and look better in general than babies born vaginally. A cesarean delivery might be performed for reasons such as difficult and perhaps dangerous labor, fetal distress, breech presentation, and previous cesareans. These reasons explain some 50 percent of all cesareans being performed. As a rule, a cesarean delivery is planned ahead of time and performed before labor has a chance to begin. Today it can be performed even after the uterine contractions have started if the child cannot be delivered otherwise.

Another means of helping nature during birth is through a tonglike instrument, known as forceps. These concave, elongated tools are inserted as two separate units into the vagina. Each is placed on the baby's head. When the handles are joined, the baby be rotated and pulled.

A forceps delivery may be required if the mother's contractions slow down or stop. Today, hormones are usually given to make the contractions continue. But danger signs from either fetus or expectant mother could call for delivery with forceps.

The use of forceps either in the first stage of delivery or early second stage can cause brain damage to the child. At these stages it is important to place the forceps accurately on the child's head. It is also necessary to use considerable force to pull the baby's head out. This is called high forceps delivery and is almost never used today because of the danger involved. Low forceps delivery, that is, the use of forceps in the actual delivery stage, is rarely damaging to the child and is still commonly used in many hospitals.

See also: CESAREAN DELIVERY; PREGNANCY; PRENATAL DEVELOPMENT

Bibliography

Goer, Henci. The Thinking Woman's Guide to a Better Birth. New York: Berkley, 1999.

Leiter, Gila, and Rachel Kranz. Everything You Need to Know to Have a Healthy Twin Pregnancy. New York: Dell, 2000.

Mahler, Margaret S., Fred Pine, and Anni Bergman. The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York: Basic Books, 2000.

Simkin, Penny. The Birth Partner Cambridge, MA: Harvard Common Press, 2001.

Stoppard, Miriam. Conception, Pregnancy, and Birth. New York: Dorling Kindersley, 2000.

Neil J. Salkind