LABOR AND DELIVERY

This link to a tutorial gives a nice overview of the whole birth process. For some, this will be overly simplistic. But there is some value with a broad view.

Birth Tutorial

Group B Strep (GBS) is a bacteria that lives with about 1/4 of us normally. It does not cause a problem in a normal healthy adult. The trick is that during a vaginal birth it has the potential to infect a newborn and can make them sick. For this reason, we started culturing pregnant women between 35 and 37 weeks. If you have a positive culture for GBS, we treat you with iv antibiotics during labor. Why don’t we treat you as soon as we find out? Because it will come back. We generally recommend at least 4 hours of iv antibiotics prior to the delivery. In most labors this is not a problem. In some lucky people, delivery goes faster than that. The truth is that any amount of treatment with antibiotics significantly decreases the risk of the baby getting sick. So even if you have a faster labor and get fewer hours of antibiotics or even none, the most important thing is to know about the risk factor so we can observe for illness. If you haven’t been treated for 4 hours, the pediatrician will maintain a high suspicion to observe for illness. For those that want even more info, check out the CDC.

The test for GBS is very simple and painless. 

Cesarean sections are delivery of the infant(s) through an abdominal incision rather than the vagina. There are many reasons people have cesarean sections (c/s) rather than a vaginal birth. Sometimes it is safer to delivery by c/s as is the case of a breech (butt down) baby. Sometimes people choose this route either because they don’t want to have a vaginal delivery or because they had a vaginal delivery before and it was very traumatic. People who have a c/s with their last delivery may choose to have a repeat c/s rather than try to delivery vaginally. C/S may occur because of things that happen during labor. If surveillance of the baby suggests that they are in trouble, we will suggest a c/s because we know we can get the baby out faster than continuing labor. During labor, we monitor the dilation of the cervix and expect that the cervix will continue to dilate towards complete (10cm). When then doesn’t happen, we try many tricks to get labor to progress. In some cases, it appears that the baby is not fitting through the pelvis, no matter how many tricks we try, and in that case a c/s is the best option.

C/S rate is a hot topic in medicine today. There are people who feel that our c/section rate is too high and we need to try to decrease it. There are people on the other side who feel that we should offer c/s as an elective option. There are valid arguments on both sides. On the side of decreasing our c/s rate is the argument that it is more expensive. This is true, between surgery and stay in the hospital. There is also the point that c/s increase the risks in the next pregnancy. This is also true due to increased risk of the placenta adhering too deeply in the uterus because of the previous scar and the risk of the scar rupturing. On the other side of the argument, c/s is a very efficient way to deliver a baby (caveat that a fast vaginal delivery is the most efficient). It means less trauma to the pelvis and less risks of the stress that baby and mother go through during labor and delivery.

We have found that people have very strong opinions on both sides. All of the above arguments are great on a public health level. But as a doctor and patient, we have to decide what is best for you and your baby in each instance. That means that we will come to the table with some risks and benefits that are derived from public numbers. But in the end, you and your provider will figure out what is best for you and your baby. It may be a c/s it may be vaginal delivery and we will have to be flexible along the way to get the best outcome. We think that every body deserves either an easy vaginal delivery or an easy c/s. Unfortunately, we don’t get that for everybody, but that is the goal.

If you ask me which your provider prefer, your provider’ll tell you it is a vaginal delivery. Usually, it means that people recover more quickly (though not always the case). Babies also do best with an uncomplicated vaginal delivery. Patients will occasionally ask about an elective primary c/s. This means choosing to schedule and deliver by c/section without a history of previous c/s.This decision is important and should be extensively discussed with your provider.

Briefly, the procedure of c/s (these are NOT at home instructions, but for edification):

1. Make sure you are numb from the waist down.

2. Place a catheter in your bladder (you won’t be getting up for a few hours)

3. Cleanse your abdomen (by the way if you have a deep belly button, clean it out)

4. Put up surgical drapes.

5. Make a skin incision (this incision is about 5 inches wide across the abdomen above thepubic bone, so you can still wear a bikini)

6. Cut through the layers of tissue to get to the abdominal muscles

7. Separate the abdominal muscles (we don’t cut them)

8. Move the bladder away from the uterus

9. Incise the uterus and open this incision enough to allow for baby

10. Reach into the uterus and raise the presenting part to the incision

11. Push on the upper part of the abdomen to guide the baby through the incision

12. Clamp and cut the cord, after a 1 minute delay, and hand the baby to a nearby nurse

13. Deliver the placenta through the incision

14. Close the uterine incision

15. Explore briefly the the uterus, fallopian tubes and ovaries to assure normal

16. Close the fascia (this is the solid layer of tissue that holds the abdominal contents in)

17. Close the skin

The risks of the surgery are bleeding, infection and damaging nearby organs in the abdomen. All of these risks are uncommon.

(These instructions apply to gestations over 34 weeks, if you are less than that, go to the pre-term labor section)

Contractions are the coordinated tightening of the uterine muscle. They can range from mild to strong. Having contractions does not mean that you are in labor. Labor is defined as regular contractions along with cervical change. And active labor is not until you have regular contractions and are at least 4-6cm dilated. We admit to Labor and delivery with active labor. So even if you are having regular, painful contractions but your cervix is less than 4cm, it is not time to admit you yet. Why do we do this? When we admit a normal healthy woman to Labor and delivery prior to active labor we increase the risk of interventions and cesarean section and that is not the goal.

You will hear many rules about when you should come in to get evaluated with contractions. 5-1-1, 5-1-2, etc. These refer to how ofter the contractions are coming (i.e. 5 minutes from beginning of one contraction to the beginning of the next), lasting 1 minute, and this going on for 1 or 2 hours. These are great rules but you aren’t a telephone number. 5-1-2 is a nice starting point. But most people will still not be in active labor at that point. By the way, the contractions we are talking about are not, “Oh, I think I’m having a contraction”, they are not even quotable because you can’t talk through them. They strong and painful. When you reach at least the 5-1-2 rule and if you still feel like you are handling things well, able to ambulate or take a bath then wait longer. We tell people that they should call when they are going to TELL us they are coming in. If you need to ask if it is time, it isn’t. Even when you do come in to be evaluated, you will not necessarily be admitted because you may still not be in active labor. We hate sending people home, we would rather admit with active labor. So we are trying to time it so you don’t make a wasted trip. This is not a science this is an art. We will all guess wrong sometimes. We will have you come in but then send you back home. Or, you move along a little faster than expected and you come in and delivery quickly. Delivering very soon after you get to the hospital is a great outcome, not a bad one. Many people are fearful that they will deliver in the car on the road. It is not that common, and is in fact rare. So please don’t view this as a likely scenario.

Doulas are birth assistants specially trained to help guide you through delivery and sometimes the post partum period. They are an absolutely wonder asset during what is a very trying and confusing journey. They are one of the interventions that have been studied that increase vaginal delivery. Finding the right doula is important. Make sure your doula is Dona certified to know that they have been appropriately trained.

DONA

When you come in to Labor and delivery, either to to be evaluated or when you get admitted for labor, we will monitor your contractions and the heart rate of your baby. We do this with two small monitor discs that sit on your belly and are held on by bands. By watching the pattern of the fetal heart rate, we can assess if your baby is doing well or might be getting into trouble. During labor we have two options for monitoring. We can monitor continuously, keeping the monitors on and watching the heart rate and contraction pattern with little interruption. Or we can monitor intermittently. Intermittent monitoring is reasonable if everything about your labor is reassuring and the baby has looked good with a small amount of continuous monitoring. Intermittent monitoring allows for more mobility. Though, even with continuous monitoring you can move around quite a bit. We have remote monitors that allow your provider to do this.

On occasion, babies can be a bit stubborn on the final entrance and need a little last help out. This occurs if the baby appears in trouble as they are about to come out. It can also happen if you have pushed your heart out and are pooped. Forceps or vacuums are very effective ways to help the baby out. Forceps and vacuums have received an unfair bad reputation by some because of very rare complications and frankly they look a bit intimidating. The fact is that forceps and vacuums, in trained hands, are very safe and thank goodness we have them. For those of you who really want to know the history and use of forceps, Wikipedia does a pretty good job. For discussion of the vacuum (ventouse) Wikipedia also does a pretty good job.

For a second discussion of assisted delivery, visit our friends at the Royal College (United Kingdoms OB/Gyn organization)

Bottom line, nobody goes into delivery saying, “I plan on having my OB help pull the baby out at the end”. But it is important to know that we have these safe alternatives because they can avoid an unnecessary c/sections.

On occasion, we will decide that we want to over ride nature and induce labor. This means that we start the labor process rather than letting the natural labor process occur. By the way, we don’t know what the natural labor process is anyway, we wait for it. Inducing labor rather than letting natural labor occur increases the c/section risk by most studies. For some this is a small risk for others a large risk.There are many reasons for induction of labor. Inductions are considered elective if there is no medical indication. For the record, being tired of pregnancy is not a medical indication. Neither is discomfort. Medical indications include 1 week or greater past the due date, high blood pressure, diabetes requiring medicine, rupture of membranes (breaking of water bag) with no labor to name a few. The most common reason for induction is post dates (1 week or greater past due date).

Elective inductions are when there is no medical reason for the induction.  These can never be scheduled prior to 1 week before the due date because the baby could still be maturing up until 39 weeks.

Either medical or elective the process is the same, your provider will be in charge of scheduling this. If your cervix is not dilated, your provider may place a catheter through your cervix before your induction. The catheter has a water balloon on the end that we fill up above your cervix so it presses down on the cervix overnight which softens and often dilates the cervix. This procedure involves placing a speculum and then the catheter through your cervix. It is usually not painful, though not particularly comfortable. Sometimes the placement of the catheter will start some contractions, this is a good thing since labor is the goal. On occasion they are even pretty painful. Again, this is a good thing. Most people can go about their normal daily business after we place the catheter. When you come in to Labor and delivery, they will put you in a room, have you change into a hospital gown, give a urine sample and then place the uterine and fetal monitors. They will then start an iv. If you are GBS positive, antibiotics will be started. Then pitocin  or cytotec ( a substance to soften the cervix) will be started. We start slow and go up according to how your body reacts to the pitocin or cytotec to get you into labor. You are welcome and encouraged to walk around in your early labor to avoid boredom and in theory to help things along. We will monitor continuously because you are on pitocin but we have remote monitors that let you be mobile.

During labor, an infection can occur in the membranes surrounding the fetus. This is called chorioamnionitis. We call it chorio. It occurs in about 1-13% of term births. The risk of this is increased with prolonged labor, especially after the membranes are ruptured. We diagnose this if you get a fever in labor and the baby’s heart rate goes above 160 beats per minutes and stays there. We treat this with iv antibiotics. You will receive antibiotics until delivery and like for one dose after delivery. Your baby will also get treated with iv antibiotics after birth because chorio has a high risk of making a baby very sick if we don’t treat them. Mothers and babies do very well overall when this is recognized and treated.

Having an IV placed (a small catheter into your vein) is very important for safe labor management.  It does not need to be connected to a bag of fluid.  It does allow us to help quickly if anything happens that is unexpected.  Think of it as a seatbelt, you probably won’t use it but you still put it on every time you get in the care.

In up to 25% of births (range 2-25%) babies may have their first bowel movement before being delivered. We call this meconium. Most of time this does not severely effect the infant. But sometimes, the baby can inhale this meconium and it can make it hard to breath. When your bag of waters is ruptured, we can tell if the baby has had this first poo by the color of the liquid. If it is green or thick green, we know the meconium is present and we will take the precaution of having the newborn docs and nurses present at the delivery in case your baby needs a little help. If your baby is vigorous and yelling at us, we can usually observe. If your baby looks a bit less vigorous, we will have the newborn team evaluate and maybe try to clear the meconium from the baby’s mouth and throat. For a really complete description, see here.

Your OB is not a pediatrician. So we are providing some general knowledge and links here but please know that if you have more detailed questions, you should ask your pediatrician. Before your baby leaves the hospital, there are some screening tests that will be offered. More information is available at this link https://dph.georgia.gov/NBS You will also be offered a hearing screening, this may or may not be covered by insurance.

Labor and delivery hurts. We have options to help manage this pain. But you should not have the expectation that we can take all of the pain away. The options vary depending on your desires and ability to cope with the pain. We usually recommend things like walking, changing position. If that is not cutting the mustard and you know you need more help, the next choices are iv narcotic pain medication (fentanyl) or an epidural. The iv narcotic works well if you are still in earlier labor and desire to continue to be mobile and need something to take the edge off. Truthfully, narcotics usually aren’t enough if you are having severe pain. Narcotics do pass the placenta and effect the baby. This is only a concern if you are near delivery and it suppresses the infant’s desire to breath, so we don’t give narcotics close to delivery. Epidurals are the next step. This involves calling an anesthesiologist (one is available on Labor and delivery 24/7). They will administer some numbing medicine in your back and then place a catheter near your spine that will drip a medication that mostly numbs you from the rib cage down. Remember, it may or may not take all of the pain away. As a rule, it works pretty well to make the process tolerable.
Getting or not getting an epidural is a choice that many people get hung up about prior to labor.We encourage you to be educated but not make a decision until you are in labor. You simply don’t have all of the facts until you are there. Maybe you thought you wanted an epidural but you cope really well with the pain and so really don’t need one. Or maybe you decided you don’t want an epidural, but in labor it turns out to be overwhelming for you. The decision to get or not get an epidural is rarely medical but is rather personal depending on your experience. The medication does not get to the baby, it only effects your pain. It does not increase your risk for c/section. It may make it slightly harder to push when the time comes but we can coach you. Anyway, when the times comes you will need one or not and you have to respect that you  won’t know until you get there. Anesthesiology would like people to know some information before hand. We encourage you to read the following even if you aren’t planning an epidural because if you do need one, you are in pain and don’t absorb the information as well.
Informed consent for epidurals:
-spinal headaches (severe headache after epidurals or spinals) occur in <1%
-the perfect block doesn’t always happen, about 70% are great, but 30% can be patchy
-remember their goal is to leave you with the feeling of pressure in your pelvis so you can effectively push
-it takes 10-20 minutes to take full effect, so it is not immediate but pretty quick
-if the anesthesiologist is busy, it may take as long as 1 hour to get your epidural after you request it, more often it is closer to 15 minutes
-you will have a blood pressure cuff on your arm going off annoyingly frequently. Your blood pressure can drop after an epidural and we want to stay on top of that.
-the nurse will do periodic checks to see if the epidural is working
-you may experience a backache after the epidural that is variable in how long it lasts

-there is a very nice flyer from our anesthesia colleagues here

Every woman has a unique labor and delivery story. But there are certainly themes that run through typical experiences. We want to walk through the generalities go give you an idea of expectations. This applies to a term, uncomplicated situation.

So you start having some contractions. At first you might notice that you are having a few more than usual. You may experience some back pain or some vaginal bleeding. This is normal. If this is going to be real labor, your contractions will increase in frequency and intensity and pain. You will hear multiple “rules” about when to call. My recommendation is to call when you have been having very painful contractions at lest every 5 minutes, lasting 1 minutes a piece and this has been going on for 2-3 hours. When you can tell that the pattern is strong and not going away you can call your provider for advice. The nurse or provider on the other end of the line will advise you to either wait a bit longer or come in to get checked. If you are less than 4cm, will likely advise you to either go home for a bit more or walk around. If you go into Labor and delivery triage to be evaluated, the nurse will put you on the monitor and check your cervix. She will then call the doctor on call to develop a plan. Again, if you are less than 4cm, we will likely advise you to walk around and then get rechecked or go home. Admitting people in latent labor (labor with cervix less than 4cm) increases the risk of c/section, so we avoid that.
So, say you are greater than 4cm, so we admit you to Labor and delivery. You will be put in a room and assigned a nurse. She will place an iv (see iv discussion). From there it depends on your plans and circumstances. If you want an epidural, you will let the nurse know and she will arrange that. If you are coping well you can consider walking, changing position in the room. The overall plan is to let things progress. There is not a time table for rechecking the cervix, we usually look a clinical change in how you are acting or the baby is acting. If we check and the cervix isn’t changing, we may work hard on changing positions or we may consider using pitocin which can augment the labor and strengthen the contractions. As long as you are making progress (the cervix is opening) we continue labor. If you are not making progress, we will discuss how long we want to monitor depending on how the baby is tolerating things. Staying pregnant forever is not an option so if no matter what we do, we don’t get some progress, we will discuss c/section (see the section on C/section). When you get to complete dilation, the nurse will help you in starting to push. Pushing can take anywhere from 1 push to 4 hours. We consider it prolonged if it takes greater than 3 hours to push the baby out. During this time the nurse is assessing your progress and connecting with the doctor on the continued plan. When you are about ready to deliver, the nurse will call the doctor to the room for delivery. When the baby is born, we usually place the baby directly on your chest. We wait for 1 minute. We then cut the cord. While you are getting to know your newborn, we get the placenta delivered and repair any tears that have occurred. You will be annoyed by our pushing and massaging your uterus in this phase as this is not comfortable but it is very important to decrease bleeding. We also administer pitocin (whether you were on it or not) after delivery of the baby because it saves an average of 300cc of blood loss.
You will stay in the hospital for about 24-48 hours after delivery depending on timing of delivery and if there are complications. A doctor will visit you once per day to check in and discharge you home. After the delivery there is a bunch of things that need to get done before you are discharged. For pain management after delivery, your provider primarily advise ibuprofen and tylenol.

Sometimes, the bag of waters around the baby decides to break before labor. Usually the bag breaks or is broken during labor. When the water breaks, it is not a subtle finding. When this occurs, a large amount of water gushes out and continues to gush, ruining clothing floor or furniture. Sometimes it is a smaller amount but you can tell the difference between the water breaking and normal discharge because it will continue to gush with every step and move you make. When the water breaks, it is time to have a baby. This is not an emergency, rather you give a call (the office if during office hours or Labor and delivery outside of that). We will tell you to make your way on in. In Labor and delivery or our office, we will do a confirmatory exam or test to make sure the water is broken. If you are still not in labor by they time you get to the hospital, your provider will recommend that we start pitocin and get labor going. The longer your water is broken without delivery, the higher the risk of infection. So it is best to get the ball rolling. If you object to induction of labor with pitocin, of course we will respect your wishes. Your provider can only advise and give you reasons.