Even a “normal” vaginal delivery can bring trauma and physical injury to a newborn. Birth injuries happen as a result of mechanical forces (forceps and vacuum), compression (pressure from labor), and traction (the baby gets stuck requiring pulling) during delivery. Problems at birth related to lack of oxygen are not discussed in this article. Birth trauma can happen either from the pressure of a prolonged labor, the small or irregular size of the mother’s pelvis, or certain delivery procedures like forceps or a vacuum to deliver the baby. Injuries can also happen if the fetus is in a breech or transverse position inside the mother’s uterus or with a premature birth. In general, large babies (over 4500g or 9lbs 14.73oz) are more likely to sustain birth injuries. Most injuries and trauma are temporary and reversible while others are permanent and there is no treatment to correct them.

Risk Factors for Birth Injuries

Factors that increase the risk for an injury to the baby during birth include:

• it’s the mother’s first birth
• the baby’s head is too large to fit through the mother’s pelvis
• labor that lasts longer than 24 hours
• pregnancy that goes longer than 42 weeks
• a quick (rapid) labor
• the baby stops moving down into the pelvis
• too little amniotic fluid
• abnormal presentation of the baby — feet first, shoulder first
• forceps or vacuum delivery
• baby needing to be turned or extracted
• very low birth weight or the baby is very premature (preterm birth)
• a very large birth weight baby
• large fetal head
• the fetus has a developmental disorder

Types of Birth Injuries

Assisted delivery—using vacuum extraction or forceps—can cause minor injuries to the baby. There may be bruising, swelling, tissue damage, and/or, very rarely, fractures. These minor injuries usually heal within a few weeks. The number of assisted deliveries has gone down due to the increase in the number of cesareans in recent years.

Injuries caused during delivery are categorized based on the type and location of the injury and include:

• head and face injuries
• neck injuries
• peripheral nerve injuries
• spinal cord injuries
• bone injuries

Head and Face Injuries

Checking out your newborn is normal. This article explains normal findings on a newborn’s head.

Caput Succedaneum

Caput Succedaneum is a swelling of the soft tissues and forms on the surface of the newborn’s head during a head-first delivery. This condition is caused from pressure created by the uterus pushing the baby’s head against the dilating cervix. It is more likely to occur during a prolonged delivery. It is also associated with head molding and too little amniotic fluid to cushion the baby’s head. During a delivery using a vacuum device, this condition is known as vacuum caput.

There may or may not be bruising or redness. It is most often seen on the part of the head that presents first. The swelling usually resolves on its own within a few days and does not cause complications or permanent injury.

Subgaleal Hematoma

Similar to caput succedaneum, subgaleal hematoma is also caused by pressure from the uterus, especially during a birth using vacuum extraction. The vacuum assist breaks the veins and blood accumulates under the skin in the space between the skull bones and the scalp. The swelling usually develops between 12-72 hours after birth. The bleeding may extend from around the eyes towards the ears or even cover the entire calvaria (skullcap or top o the head). This injury may be associated with anemia, low blood pressure, persistent metabolic acidosis, or hyperbilirubinemia. Because this condition is not easily identified, careful monitoring is required after the birth of the baby. On diagnosis, the baby should be constantly watched and monitored. In there is significant blood loss, fluids or blood transfusion may be needed. Phototherapy may also be considered in severe cases.

Cephalhematoma

Cephalhematoma is a when the hemorrhage occurs between the skull and the periosteum. In this condition, the hemorrhage is limited as it occurs only over a single bone. In a very few cases, there may be an underlying bone fracture. The newborn may need testing for anemia or hyperbilirubinemia as a result of the hematoma being absorbed. Cephalhematoma usually requires no special treatment and resolves on its own over a few weeks.

Intracranial Hemorrhage

This hemorrhage occurs in and around the brain mainly due to pressure during delivery or variation in blood pressure. Intracranial hemorrhage usually happens in deliveries of a premature baby. Presence of hematologic disorders, like hemophilia or a vitamin K deficiency, also increases the risk of intracranial hemorrhage. Hemorrhage at the subarachnoid space is the most common intracranial hemorrhage. Symptoms include breathing problems, seizures, and sluggishness. Intracranial hemorrhage is also associated with meningeal inflammation which results in non-obstructive hydrocephalus as the baby grows.

Subdural hemorrhage is caused by tears in the blood vessels. Subdural hemorrhage happens mainly in a difficult delivery, first time delivery, or when the baby is very large. Symptoms include an enlarging head, seizures, poor startle reflex and/or bleeding of the blood vessels in the retina. The most serious kind of intracranial hemorrhage is intraventricular and/or intraparenchymal hemorrhage. Hemorrhage generally occurs within three days of birth. In most cases, there are no symptoms, but in larger hemorrhages, symptoms include a bluish color to the skin, apnea (breathing problems) or even sudden collapse.

Subaponeurotic Hemorrhage

Though very rare, this condition can be caused by pressure in the blood vessels from using forceps or vacuum during delivery. In this condition, blood accumulates beneath the aponeurosis (that is the sheet-like fibrous tissue that connects muscles) of the skull. This is an emergency condition and requires an immediate blood transfusion to replace lost blood.

Other Head Injuries

Other head injuries include cuts and bruises that can happen during cesarean delivery or instrumental delivery with a vacuum or forceps. Infection can be a risk in these type injuries but most heal without problems. Steri-Strips may be used or sometimes cuts require stitches.

Neck Injuries

A plexus is a network of nerves that supplies a specific area of the body.

Brachial Plexus Injuries

The brachial plexus is the nerve network that originates in the neck and shoulder controls the movement and sensation of the shoulder, arm and hand. Brachial plexus injuries range from a simple tear to hemorrhage within a nerve to severing of the nerve root from the spinal cord. These injuries happen most often in large babies. Dislocations or fractures of clavicle or humerus may also be present with this injury. Brachial Plexus injuries are usually caused due to breech (legs first) delivery, shoulder dystocia (where the shoulder gets stuck in the birth canal) or stretching of the neck in a cephalic (head-first) presentation. Brachial plexus injuries can be categorized into two types depending on the location of the injury. An upper brachial plexus injury, that is C5-C6, affects the shoulder and elbow. A lower brachial plexus injury is rare, that is C7-C8, T1, and affects the muscles of the forearm and hand.

One example of an upper brachial nerve injury is Erb’s palsy or Duchenne-Erb paralysis. This is the most common form of brachial plexus injury. In this condition damaged tissue in the upper brachial nerve causes palsy of the muscles of the upper arm and shoulder girdle. Treatment includes immobilization of the arm and passive range-of-motion exercises from the time the baby is a week old to prevent contractures.

Klumpke’s palsy or Dejerine-Klumpke palsy is caused from a lesion in the lower brachial nerve. In this condition there is paralysis of the lower forearm and hand. Treatment is passive range-of-motion exercises for all joints in the affected arm.

In both of Erb’s palsy and Klumpke’s palsy no major treatment is required and both usually resolve on their own by the time the baby is 3 months old. However, if problems continue, an MRI can be done to identify the extent of the injury and determine if surgical correction can be done to correct the problem. If the entire brachial plexus is injured, neurosurgical corrections may be needed but the outcome is poor and the chances are that the affected arm will have impaired growth.

Sternocleidomastoid Hematoma (congenital torticollis)

In this condition, the head of the baby is twisted to one side. This is generally caused due to the tightness of the sternocleidomastoid muscles (that is the muscle between the breastbone and collarbone that connects them to the skull behind the ear). The muscles can tighten during delivery or can be in that position in the mother’s womb. Congenital torticollis can also be caused by an abnormality of the vertebrae in the neck, such as fused bones or abnormal bone formation. Torticollis caused by an abnormality of the bones is called Klippel-Feil syndrome. If torticollis is diagnosed, the baby should be thoroughly tested to find out the cause since the treatment procedures and stretching exercises for congenital torticollis can cause serious problems if used to treat Klippel-Feil syndrome.

Nerve Injury

Cranial and spinal cord injuries can result from hyperextension, traction, and overstretching while rotating. Injury can range from localized paralysis to complete nerve or spinal cord damage.

Cranial Nerve Injuries

Among the 12 cranial nerves, the facial nerve is most prone to trauma during a vaginal delivery. Injury can be caused by the position of the fetus, the presence of uterine fibroids or pressure of forceps used during delivery. In most cases, the compression happens when the head passes by the sacrum. This condition often results in facial asymmetry because the facial muscles controlled by the injured nerve cannot move. It is visible when the baby cries — one side of the face smooth while the other side wrinkles up. Another form of this injury is mandibular asymmetry where both sides of the face can move but the maxillary and mandibular surfaces are not parallel. These conditions do not need treatment and usually resolve on their own in a week or so, but can take up to several months. Palsy that does not get better is often due to the nerve being absent. If an eye is involved, an eye patch and eye drops may be needed to protect the eye.

Peripheral Nerve Injuries

Peripheral nerves such as the radial, sciatic or obturator can be injured indirectly but associated with delivery. For example, an injection near the sciatic nerve may cause peripheral nerve injury. This causes paralysis of the affected nerve and surrounding connective tissues. Treatment consists of resting the affected area (nerves and muscles) until recovery. In most cases, there is complete recovery; however in rare cases neurosurgery may be needed.

Spinal Cord Injuries

Though this is very rare, spinal cord injuries generally happen in a breech delivery which involves excess traction to the spine or hyperextension of the baby’s neck while in the uterus. The most affected region is C5 to C7. The degree of injury can vary considerably. In a serious injury, the injuries are fatal as breathing is obstructed. Initially, there is spinal shock along with flaccidity around the injured area. There is slight sensation and movement which slowly develops into spasticity. With a complete spinal cord damage, the abdominal and surrounding muscles are paralyzed and the bladder and rectal sphincters lose control. Sweating and feeling is lost, which in turn causes fluctuation in body temperature. An MRI can show whether the damage is surgically treatable. Most babies can live for many years with proper treatment and care, which includes skin care to prevent ulcers, treatment of urinary or respiratory infections right away, and regular check ups to find associated problems such as problems passing urine.

Bone Injuries

Fractures are most often seen following a breech delivery, shoulder dystocia, or both in large babies. The clavicle is the most often fractured bone during birth. There is a relationship to this fracture and birth weight, midforceps delivery and shoulder dystocia. Associated injuries include spine, brachial plexus, and humerus injuries. Risk factors for shoulder dystocia include diabetes, large birth weight, and obesity in the mother.

Fractures of the long bones (thigh and humerus) can happen during delivery. These fractures are treated with splinting and watched for associated nerve injury. Separation of the shoulder and hip can also occur.

Resource Web Sites

BirthInjury.org

HealthPages.org | Health Information You Can Use

As you get close to your due date, you’ll start thinking about labor and giving birth. It’s normal to start looking for signs that labor is near or has started. There are several signs you can watch for. These signs may or may not happen and when they do, they can happen in any order and over weeks or hours.

Some women have very distinct signs. Their first “labor” contraction feels different that any other contraction they felt during pregnancy. Also, the contractions continue at predictable intervals. For other women, it’s hard to identify labor contractions when they start and stop over a period of time. Uterine contractions aren’t the only sign your labor is about to begin. There are other changes that can happen before contractions start.

Lightening

Baby has not entered pelvis yet

If this is your first birth, the presenting part of your baby may move down into your pelvis about 2-3 weeks before the first stage of labor begins. Lightening is the baby’s descent down into the pelvis. If this is not your first birth, lightening may not happen until you’re in labor. Before you baby moves down into the pelvis, you may feel like you can’t get a deep breath because your baby pushes up your diaphragm and lungs. You may have felt pressure on your stomach.

Lightening – after the baby moves down into the pelvis

Your baby moving further down into your pelvis takes pressure off your lungs, giving you more room to breathe. If you’ve had heartburn, you’ll probably get some relief as pressure on your stomach is also reduced. However, when your baby moves further down, the uterus and baby press on your bladder. The added pressure on your bladder makes you feel like you have to pee more often.

Baby Stations

Baby Stations During Labor – For illustration only.

The location of your baby’s leading part—usually the head—within your pelvis is judged in relation to two bony projections in the middle of your pelvis called ischial spines. This level of the pelvis is called ”zero station.” On vaginal examination, when the leading part reaches zero station it is  ”engaged” in the pelvis. The location of the leading part is estimated in centimeters above and below zero station and described as ”station plus 1” or ”station minus 2,” etc. Locations above zero station are -1, -2, -3, etc., and mean your baby’s head is above the spines or floating. Locations at +1, +2, +3, etc mean your baby is below zero station. Numbers +3 to +5 mean you baby is crowing and it’s time for delivery.  Zero station is at the ischial spines of the pelvis. During labor, your baby’s movement (descent) through your pelvis is an important sign of how your labor is progressing. (In our illustration, the leading part is the baby’s head, and is shown at zero station. Each increment is 1 cm.) Ideally, you should not push until your baby is engaged even if you are fully dilated.

Several major nerves and blood vessels run through your pelvis and branch down into your legs. When your baby’s head is down in your pelvis there is pressure on these nerves and blood vessels that may cause leg cramps and swelling in your feet and ankles. It’s important to reduce swelling and pain of your feet and legs by getting off your feet several times a day. Prop up your feet and legs when you can.

Rupture of the Amniotic Sac

Fetus in the uterus

In about 12 percent of women, the amniotic sac, or “bag of waters,” breaks on its own before labor begins. In most women, the sac does not break on its own until late in labor. When your due date gets near, protect your furniture and bedding from amniotic fluid by covering them with a plastic sheet or a layer of towels if your amniotic sac ruptures.

The sac may break near the opening of the uterus and you’ll have a gush of amniotic fluid. Although it may seem like a lot of fluid comes out, there’s still more fluid behind the baby’s shoulders, which will leak out each time you have a contraction.

The sac can also break higher up in the uterus and you’ll have a “slow leak” of fluid. Since many pregnant women leak a bit of urine with pressure on their bladder when they sneeze or cough, you may not realize it’s the amniotic fluid that’s leaking. You can tell the difference because urine is usually yellow and amniotic fluid is usually clear and smells like weak bleach.

In about 80 percent of women, near the end of pregnancy, labor will begin on its own within 24 hours of the amniotic sac breaking. When your “bag of waters” breaks write down the time, how much fluid came out, did the fluid leak or gush out, and the general color and smell of the fluid. Call your doctor’s office and give them this information. Some doctors may want to induce labor while other doctors are content to wait and see if labor starts on its own.

Once your sac ruptures, don’t try to control the leaking fluid by putting a tampon in your vagina or try to check yourself with your finger. This will reduce the chance of infection. Use menstrual pads to soak up the fluid, and change the pads often to keep the area dry. Don’t have sex. Take showers instead of tub baths.

Sudden Burst of Energy

Some women notice a sudden burst of energy about 24 to 48 hours before labor begins. After feeling tired for the last few weeks, you may find that you suddenly want to rearrange your home or clean everything in sight. If you find yourself cleaning and moving furniture—stop. You can pack your suitcase for the hospital, then rest and save your energy for labor and birth.

Weight Loss

You may notice that you’ve lost 1-3 pounds. This can result from your hormone levels changing just before labor begins.

Other Signs

Some women have indigestion, diarrhea, or nausea and vomiting right before labor begins. The cause for the flu-like symptoms are unknown but may be your body’s way of getting ready for the birthing process.

Still other women say they just felt “different” the day they went into labor. They may have felt like they didn’t want to do their normal daily routine.

Onset of Labor

The actual onset of labor is often uncertain. But there are two main ways that true labor is recognized.

• Progressive opening and thinning of the cervix
• Palpable uterine contractions; palpable contractions are ones you can feel with your hands.

Labor is divided into 3 stages. the first stage—the progressive dilation and effacement of the cervix—is completed with the cervix has fully dilated, usually 10 cm. The first stage of labor is further divided into the latent phase and the active phase. The first stage averages 12 hours for first-time mothers and 8 hours for later births. The active phase is regular contractions (every 2-5 minutes, lasting 45-90 seconds) that result in increasing cervical dilation and descent of the baby’s presenting part. Active labor lasts about 1-4 hours. During active labor is usually when the bag of waters breaks.

Changes in the Cervix

The cervix is a firm muscle that makes a strong base at the bottom of the uterus.

Throughout pregnancy the cervix—the opening to the uterus—forms a protective barrier and stays long, firm, and closed. In late pregnancy, hormones cause the cervix to soften and thin out allowing your baby to be born.

Bloody Show

During pregnancy a mucous plug seals the opening of the cervix. This plug may come out of the cervical canal, sometimes as a “blob” but more often as streaks of blood-tinged mucus. The blood is from tiny blood vessels that tear as the membranes separate and the blood mixes with the mucus.

You may notice this “bloody show” over a several hours or even days. It is a sign that your newborn is almost here. If you had a vaginal exam within the last day, you may notice a trace of bright red blood, which is not bloody show; show is also different from the fresh flow of blood for which you should normally call your doctor right away.

Ripening of the Cervix

The cervix must soften so your baby can pass from the uterus into the birth canal (vagina). The softening usually starts in late pregnancy and is a sign of readiness for labor and not a sign of labor starting.

Effacement of the Cervix

Before your cervix can stretch around your baby’s head, it must get shorter and thin out. By the time the cervix has fully opened it will be almost paper-thin. The process of shortening and thinning, called effacement, is measured in percentages from 0 to 100 percent.

Dilation of the Cervix

A vaginal exam is done to check for progressive changes in your cervix. The actual stretching and opening of your cervix around your baby’s head is called dilatation. It is gauged by vaginal exam and the diameter of the opening is measured in centimeters from 1 to 10 cm.

• 1 finger is 2 cm
• 2 fingers is 1/3 dilated
• 3 fingers is 1/2 dilated
• 4 fingers is 3/4 dilated

The cervix can thin out and dilate some during late pregnancy, or it may not change any until true, active labor starts. During true labor, effacement (thinning) and dilatation (opening) usually happen at the same time. It takes a lot of thinning and shortening of the cervix before it can open completely. At 2 cm dilation, the cervix has shortened and is beginning to open; your contractions may still be irregular. At 6 cm dilation, you are in active labor. Your contractions will be more frequent, regular and stronger. At 10 cm you are fully dilated; contractions may be almost continuous and you’re ready to start pushing your baby out.

Uterine Contractions

The uterus is the largest muscle in the human body, male or female. When the pituitary gland releases the hormone oxytocin, it causes the uterus to tighten or contract. The upper part of your uterus, the fundus, tightens and thickens while the lower part of your uterus and cervix relax and stretch. The contractions eventually push your baby through the birth canal and out the vagina. What triggers the release of oxytocin is unknown. Otherwise, it would be far easier to predict the actual onset of labor contractions.

What does a contraction feel like?

Contractions usually begin at the top of the uterus and feel like a tightening or hardening of a muscle. Your uterus will feel harder as the tightness increases to a peak. Then the uterus relaxes or softens as the contraction ends. If you feel your abdomen tighten (contract) and get hard and then soften (relax), you’re having a contraction. You may be able to see your abdomen move as it tightens—when the uterus becomes firm it alters the contour of the abdomen because it rises and moves in the direction of the birth canal as it contracts. This movement is easier if you’re upright and walking may make labor easier. The discomfort with contractions is usually felt in the lower back and lower abdomen.

When the uterus contracts, it will feel firm to your fingertips—like your biceps feel when you “make a muscle.” During a contraction, your whole uterus should feel firm. So spread out your fingers so you can feel a large area. If you feel a hard “spot,” it may be your baby’s buttocks or a foot—not a contraction.

Monitoring Contractions

Self Monitoring Contractions Worksheet

Click on the image to the left to download our contractions worksheet to record your contractions. Self-monitoring contractions means feeling your abdomen to see if you are having uterine contractions and then timing the contractions if you do. Your doctor will tell you how often to watch your contractions. Monitoring contractions includes measuring how long they last, how far apart they are, and how many you have in an hour. Do not trust your memory or guess. If you get upset during the process, you may not be able to remember. So, have pen and paper nearby and a clock or watch with a second hand.

Timing Contractions

Count how many seconds each contraction lasts. When it’s over, write down the time and how many seconds the contraction lasted. If you have more than four contractions in one hour, empty your bladder again, drink at least two 8-ounce glasses of water, and monitor for a second hour. If the contractions start coming closer together or become painful, call your doctor.

How long do contractions last?

The length of a contraction is usually measured in seconds. Begin counting the seconds when the contraction begins (the uterus starts getting hard) and stop counting when the contraction stops (the uterus is soft and has completely relaxed). If you don’t have a watch with a second hand, count “one-thousand-one, one-thousand-two, one-thousand-three”. If you count to one-thousand-ten, and the contraction stops, the contraction lasted about ten seconds.

How far apart are contractions?

The time between contractions is measured in minutes. The time between the beginning of one contraction to the beginning of the next is “how far apart” your contractions are. For example, if your first contraction begins at 9:00 and the next begins at 9:15, your contractions are 15 minutes apart. If a contraction began at 9:00, 9:15, 9:30, 9:45, and 10:00, you had four contractions in one hour. The contractions are “regular” because they happened every 15 minutes.

False Labor

False labor can be very frustrating when you’re ready but your body is not. Braxton-Hicks contractions, which you may have had before may now be noticeable and you can time them, the sometimes last for hours. You might have contractions for 2 hours on Sunday, 6 hours on Monday, and 3 hours on Tuesday. They may be so strong they keep you up at night; then they are gone by the next morning.

False Labor Contractions

• Usually irregular and short
• Don’t get stronger or closer together
• Longer intervals between contractions
• Discomfort in lower abdomen and groin
• Lying down may make them go away
• Walking does not make them stronger
• Contractions decrease with sleep.
• Bloody show is usually not present.
• Cervix does not dilate (thin and open)
• There is no effacement in the cervix

While these contractions are not real painful and you can cope with them, they can still drain your energy and leave you tired and exhausted by the time your true labor pains begin. If you’re having false labor for several days, it is important to take naps and rest when you can; put your feet up. Take a warm shower and drink something warm, without caffeine. Ask someone to rub your back or feet, get in bed and stay there. You need plenty of rest to be ready for the work of labor.

If you keep having false labor, how can you tell when true labor begins? Over a period of hours, true labor produces measurable progress as your cervix thins out and begins to open. You may have to go to the hospital or birth center to have a vaginal exam to see if your cervix is changing and getting ready for childbirth.

If no changes are taking place in your cervix and you’re sent home after being mentally ready for labor, you may feel very discouraged, embarrassed, and even afraid that something is wrong. Your body is just easing into labor and not jumping into it. If you have had a baby before, you may think that you should be able to know when you’re having true labor. It is not always easy, even for health care workers who see women in labor all the time.

When To Call Your Doctor

Since there is so many ways labor can start, how will you know when to call your doctor? Keep notes about what is happening in early labor along with your doctor’s specific instructions and phone numbers. The instructions will vary according to your pregnancy; how far you live from the hospital or birth center; whether this is your first pregnancy or if you have a history of rapid labor; whether you have had any signs of labor in the last weeks etc.

If you’re not sure what the signs you’re having mean or you feel confused, don’t hesitate to call your doctor and talk about what is happening and what you should do. Call your doctor immediately if you have warning signs such as severe or persistent headache, dizziness or light-headedness, blurred vision, fever, or other unusual sign.

What your doctor will want to know

When you call your doctor, he will want to know as much as he can about your current condition and pregnancy. He may ask many questions, especially if it’s after office hours and your medical records are not available. Be sure to have your pharmacy phone number and be able to answer the following questions.

• Are you having contractions? How far apart are they? How long do they last? How long have you timed them? Are they mild or strong? Are they regular? Do they hurt?
• How long will it take you to get to the doctor’s office? The hospital?
• How many babies are you expecting?
• How many weeks pregnant are you?
• Has the bag of waters broken? (a gush of water or leaking)
• Are you having any bleeding? If so, how many pads have you used?
• Are you having diarrhea, vomiting, chills, or pain?
• Have you ever had a cesarean birth?

Depending on several factors—such as how long it will take you to get to the doctor’s office or the hospital and how many weeks pregnant you are—your doctor may have you monitor your contractions for a while longer, come into the office, or meet him at the hospital.

No Signs of Labor Yet?

As your due date gets close and you haven’t had a single sign that labor is near, you may start feeling frustrated and even have doubts about the birth process. You may think you’ll be pregnant forever. Have faith. Some women go into true labor without any signs of lightening, “bloody show,” cervical effacement or dilatation. Your due date may still be a few days off; spend your time resting and having special time with your partner.

Going Past Your Due Date

Due dates are just a target; the time of actual conception is hard to pinpoint; don’t depend on your baby arriving on your due date. This maybe hard to do since you’ve been looking forward to that day for so long. A day that means we won’t always have a backache, that we will get to see our toes again along with that special little face of the baby we are carrying inside. Without meaning to, we get so focused on that date that we invest a lot of our emotions in it. If our due date comes and goes without a baby, our spirits can take a beating—especially since your hormones are changing. Try to stay calm and as upbeat as you can and keep in mind you’re another day closer to your baby arriving.

For most women, labor begins by week 40. However, doctors may wait until the 42nd week (2 weeks after the estimated due date) to declare the mother overdue and recommends induced labor.

While you’re waiting, here are some things you can do. Pack your pregnancy suitcase to take to the hospital. You can also learn about what can happen during birth, such as a cesarean, episiotomy, epidural anesthesia, how to care for your self after your baby is born and go through your layette and see if you have enough diapers, sleepers, etc. Caring for Your Newborn.

HealthPages.org | Health Information You Can Use

Every expectant mother wants to have normal delivery of a healthy baby near her due date. In a normal pregnancy, labor starts on its own any time between weeks 37-42. Sometimes it is safer to have the baby than to continue the pregnancy. In these pregnancies labor is started artificially to deliver the baby before natural labor begins to reduce the health risks of the mother or baby. Or, labor may have started on its own, but problems arise that put you or your baby at risk. Labor that is started early or stimulated to speed up labor is called induced labor.

There are three stages of labor:
• First stage: active labor; this stage is the longest. It begins with the onset of regular contractions of the uterus and ends when the cervix has completely dilated to 10 cm.
• Second stage: pushing phase which begins at the end of the first stand and ends with the birth of the baby
• Third stage: delivery of the placenta; this stage is the shortest. It begins after the baby is born and ends when the placenta and membranes are expelled.

You may also want to read our article on How will I know when I’m in labor?

Reasons for Inducing Labor

Since 1999, induction rates have shown that 1 in 5 births has been induced.

The two most common reasons for inducing labor are high blood pressure (gestational hypertension) and prolonged pregnancy (going past your due date). In addition to health reasons, labor may be induced because the mother asks to be induced, called elective induction. Prior to elective induction, the gestational age and maturity of the fetus has to be determined. The following are reasons where induced labor is recommended.

• Going past your due date: For most women, labor begins by week 40. However, doctors may wait until the 42nd week (2 weeks after the estimated due date) to declare the mother overdue and recommends induced labor.

• Nonfunctioning placenta: The placenta carries food and oxygen from the mother’s blood stream to the fetus. After 42 weeks, the placenta may stop functioning and pose a danger to the health of the fetus.

• Broken bag of waters: In a normal pregnancy, when the amniotic sac breaks it is a sign that labor is starting. Sometimes, the bag of waters breaks, but labor contractions do not begin.

• Restart or stimulate labor: If initial normal labor slow downs after several hours, artificial stimulation may be used to restart contractions.

• Health issues of the mother: If the mother has diabetes, hypertension, heart disease, pulmonary disease, abruptio placentae, an infection or other health issues that might put the mother or baby at risk, inducing labor can prevent complications of birth.

• Fetal growth: If the fetus is not growing at is should.

• Fetal death.

Problems With Being Overdue

There are health problems that can occur after the due date for both mother and baby. The major problem that arises is after 42 weeks gestation is death of the fetus.

When a pregnancy goes past the due date, the physician may order test to check the health of the baby. These test include a non-stress test or an ultrasound. The mother may also be asked to monitor all movements the baby makes, called “kick counts.” Learn more about kick counts and how to do them.

Criteria for Induction

The following situations are suitable to induce labor:
• The presenting part of the fetus is engaged in the pelvis
• There was no previous cesarean birth using a classic uterine incision
• There is enough room for the baby to get through the mother’s pelvis
• No problems with the baby’s heart rate and baby is not in distress
• If the placenta has started separating from the wall of the uterus, but there is no major bleeding
• Placenta previa or vasa previa are not present
• No active genital herpes infection
• Definite signs that normal labor is slowing down

In addition to the above requirements of the mother and baby, the hospital staff should be competent and available to administer and monitor mother and baby during the induction process and have all necessary equipment for monitoring. There should also be a doctor available that can perform a cesarean section.

The following are reasons why labor should not be induced and are similar to those for mothers who should be prevented from having normal (spontaneous) labor.
• The baby is in a transverse position (lying sideways instead of head or feet down)
• The umbilical cord has dropped down into the vagina instead of the baby
• The mother had a previous cesarean with a classic incision in the uterus
• The mother has a transfundal incision in the uterus from prior surgery (such as fibroid removal)
• The blood vessels of the placenta present before the fetus (vasa previa)
• The placenta has grown over the opening of the cervix (complete placenta previa)
• The mother has an active genital herpes infection

Labor is seldom induced on when the mother is having twins, has had more than 5 pregnancies, or there is excess fluid in the amniotic sac (polyhydramnios).

Medical Ways to Induce Labor

There are many medical ways to induce labor, but we will address the ones most commonly used. These methods may be used alone or together.

Cervical Ripening Agents

As labor approaches there are changes in the cervix which cause to thin and open so the baby can pass through. The cervix also becomes soft, called “ripening” so that it is able to stretch during labor. The condition of the cervix is the most important factor in successfully inducing labor. A cervix is considered ripe when it is soft, anterior, effaced more than 50%, and dilated 2 cm or more. When ripening has not occurred there is an increased chance of a long labor, a reduced oxygen supply to the baby and ultimately a cesarean birth.

A Bishop Score is one way of determining whether induced labor will be successful. A Bishop Score takes into account these factors:
• dilation (opening) of the cervix – greater than 5 cm is best with a score of 3
• consistency of the cervix – soft is best with a score of 2
• effacement (thinning) of the cervix – greater than 80% is best with a score of 3
• position of the cervix – anterior is best with a score of 2
• station of the fetus – +1 or +2 is best with a score of 3

Each factor can receive a score of 0-2 or 0-3, with a maximum total score of 13. The higher the score, the more likely labor induction will be successful. A Bishop Score of 8 or more is similar to that for spontaneous labor and is favorable for induction. A Bishop Score of less than 6 usually means cervical ripening agents are needed before using other methods of inducing labor.

Recent studies have shown that other factors can affect a successful induction including the mother’s age, weight, height, body mass index and previous pregnancy history.

The first step in labor induction is ripening the cervix with substances like prostaglandin. Dinoprostone a synthetic prostaglandin that is inserted in the vagina to “ripen the cervix.” After the dose has been given you should remain lying down for up to 2 hours. A second dose may be given after 6 hours if the first dose does’nt produce the desired response. This induces gentle labor. Dinoprostone may also be used along with Pitocin and/or an amniotomy). The ripening of the cervix helps the other induction methods to be more effective. Depending on the type of Dinoprostone used, oxytocin can be started within 1/2 to 12 hours later.

Side effects of Dinoprostone include:
• Upset stomach
• Vomiting
• Diarrhea
• Dizziness
• Flushing of the skin
• Headache
• Fever

Amniotomy

During normal active labor, the amniotic sac may break and contractions will start or become more intense. An effective way of inducing or speeding up labor is by breaking amniotic sac (bag of waters) called artificial rupture of membrane. The amniotic sac is ruptured using a hook-like instrument causing the amniotic fluid to run out and putting pressure on the cervix. This increased pressure on the cervix makes contractions start or get. Amniotomy is a pain-free process and is effective in most cases in starting labor. If labor doesn’t start after breaking the amniotic sac or labor starts but does not progress as it should, IV oxytocin may be given.

Synthetic Hormones

Oxytocin is a natural hormone that stimulates the uterus to contract. During labor, contractions help push the baby through the birth canal and deliver the placenta (called after birth). After delivery of the placenta, oxytocin helps contract the uterus and stops the bleeding. Synthetic versions of oxytocin (Pitocin, Syntocinon or a generic version) are used to induce labor, contract the uterus, and control postpartum hemorrhage. Pitocin is given through an intravenous (IV) tube (placed in the arm or hand) to start or strengthen labor contractions. Pitocin cannot be given by mouth because digestive juices keep Pitocin from working. Pitocin can be used or in combination with breaking of the amniotic sac to induce labor. The amount of Pitocin administered depends on the mother’s ability to accept it. Pitocin is monitored and increased at regular intervals until a good contraction is attained. With an IV, Pitocin can be stopped at any time and it’s effects on the body usually stop quickly after stopping the Pitocin.

Pitocin can be given in a low-dose or high-dose. The higher dose of Pitocin makes labor and delivery go more quickly. Pitocin is used along with amniotomy and the amniotic fluid is checked to see if the baby is having problems. A fetal heart rate monitor is also used during labor to monitor the length and strength of the contractions and the heart rate of the fetus. A baseline for the fetal heart rate (FHR), the mother’s vital signs, and uterine activity is measured and recorded before Pitocin is given. An initial vaginal exam will be done to determine cervical effacement and dilation, and the presentation and station (how far down in the pelvis the fetus has moved) of the fetus. The mother is either in a sitting position or lying on her left side. Pitocin will be started through an IV at a low dose and gradually increased until the contractions are in the desired pattern of 3 contractions every 10 minutes lasting 40-60 seconds each and 1 minute between each contraction. (A normal contraction pattern in active labor is contractions about every 2-3 minutes and lasting about 60 seconds.) This dosage should dilate the cervix at the rate of 1 cm per hour during active labor. When labor progresses to 5-6 cm dilation, the amount of Pitocin can be reduced. Pitocin is often stopped after the cervix dilates to 7-8 cm.

Over stimulation of the uterus may harm the baby or mother. If the contractions are too strong, the uterus can rupture. If the contractions occur more often than 4 every 10 minutes and last 90 seconds or more without a period of rest between them, then Pitocin is decreased or stopped. Too many contractions in a short time for an extended period can keep the fetus from getting a good exchange of oxygen and waste through the placenta. During a contraction, blood flow through the uterus slows down; as the contraction eases up, blood flow resumes and by the end of the contraction, blood flow is back to normal. But, if the contractions are strong enough, all blood flow through the uterus will stop. Pitocin can be stopped if the fetus shows distress on the heart rate monitor. The baseline fetal heart rate is normally between 120 and 160 beats per minute (110 to 160 at full term).

If labor does not start or progress is not made within 2 to 3 hours your doctor may stop the induction. In which case, a cesarean may be done to deliver your baby.

Side Effects of Pitocin
For the mother:
• Over reaction to the medicine
• Heart arrhythmia
• Nausea, vomiting
• Rupture of the uterus
• Too much water in the body (water intoxication)

For the fetus:
• Slow heart rate (below 120 beats per minute)
• Heart arrhythmia
• Significant, prolonged overstimulation may cause brain damage or death

Risks and Complications of Inducing Labor

Problems don’t always happen, but some of the complications include:
• Change in the fetal heart rate, fetal distress
• Increased risk of infection in the mother or baby
• Problems with the umbilical cord
• The uterus is overstimulated and the contractions become too strong or too close together
• The uterus can rupture

Inducing labor brings also has added risk because of the need for other interventions such as:
• An IV tube limits activity
• The mother’s activity is limited which can cause phlebitis
• More frequent monitoring of mother and baby is needed
• More pain relief may be needed due to the more painful contractions related to induced labor
• Increase in cesarean birth or instruments (vacuum or forceps) to help with vaginal birth

To reduce pain, most doctors give pain medication, which in turn has it’s own side effects including slowing down labor and limiting the mother’s activity.

When labor is induced, the fetus tends to go into an unfavorable position and forceps or vacuum extraction then becomes a necessity. Failed induction requires a cesarean section to be done right away to prevent problems for baby and mother.

When Labor Induction Doesn’t Work

Although most women do go into labor with one or more of the above methods, there is the chance that the induction will fail. If so, you may need another induction procedure to start labor. Depending on your situation, you may need to stay in the hospital. In some cases you can go home after the induction procedure. If you stay in the hospital, you and your unborn baby will be monitored to see if labor starts or there are problems. If you go home after the procedure, be sure to ask your doctor if there are activities you should avoid and if there is anything special you should do or watch for if your labor begins at home.

Glossary

Amniotic Sac: Fluid-filled sac in the mother’s uterus where the fetus develops.

Cervix: The lower, narrow end of the uterus at the top of the vagina.

Cesarean Birth: Delivery of a baby through an incision made in the mother’s abdomen and uterus.

Placenta: Tissue that provides nourishment to and takes away waste from the fetus through the umbilical cord.

Prostaglandins: Chemicals that are made by the body that have many effects, including causing the muscle of the uterus to contract, usually causing cramps.

Uterus: A muscular organ in the female pelvis that contains and nourishes the developing fetus during pregnancy.

Vagina: A passageway surrounded by muscles leading from the uterus to the outside of the body, also known as the birth canal.

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As the time for you baby’s birth gets near, your friends and family may give you a baby shower or baby gifts. We’ve put together a list of very basic supplies you need for your baby for the first weeks or months. If you can afford it, you may want to add extra items. Get things ahead of time so you will feel ready to care for the baby. You can buy additional items as you need them. Keep in mind everything does not have to be new—just safe and clean. Go to garage sales, second-hand stores, special sales, or swap items with family or friends. There are plenty of baby clothes that never get worn because babies grow so fast or the outfits we bought for the wrong season.

Make a list of the things you would like to have—then take that list with you to a local baby store and register your list of items. There are also websites that will allow you to register online so your friends don’t even have to leave home to shop. When someone asks what you need, tell them where you have registered. They can buy what they can afford and you will be getting items you really need. If you know ahead of time whether you are having a girl or boy, then be sure to register that, too. It’s more fun to buy baby outfits made for a boy or girl than one that will work for either a boy or girl.

Baby Care Supplies

See Bathing Your Newborn
• Rubbing alcohol/cotton balls for cord care—1 bottle/1 package.
• Petroleum jelly (Vaseline) for lubricating rectal thermometer and circumcision care—1
• Sterile gauze pads (if baby is a boy and will be circumcised)—1 package.
• Ointment for diaper rash (such as A&D Ointment or Desitin)—1 tube.
• Diaper wipes—1 box (nice to have but not necessary) Use soft, cotton wash cloths and water, or cotton balls and water, for diaper changes for the first couple of weeks—commercial wipes can cause rashes. You can use soft, paper towels to clean up after poopy diapers—then just wrap them up inside the diaper and throw it all away.
• Rectal thermometer
• Bulb syringe for cleaning stuffy noses

Clothing

See Dressing Your Newborn
Don’t buy too many newborn sizes—babies outgrow them so quickly.
• Shirts (tie front or snap)—6-8.
• Sleepers, kimonos, nightgowns—4-6.
• One-piece rompers (above the knees; snap at the crotch; for spring or summer baby)—4-6.
• One-piece stretchies (long pants; with or without feet)—4-6 (fall or winter baby); 2-3 (spring or summer baby).
• Pairs of booties or boot-like socks—4-6.
• Sweaters—2.
• Caps (knitted for winter; brimmed for summer)—1.
• Bunting or hooded jacket (winter)—1.
• Blanket sleepers (winter)—2-3.

Diapers

See Changing Your Newborn’s Diaper
• Diapers, washable—3-4 dozen. If you use disposable diapers, cloth diapers make good burp cloths, at least a dozen are helpful to have.
• Diaper pins for cloth diapers—8-12
• Diapers, disposable—12 per day.
• Waterproof pants (if using cloth diapers)—3-4.
• Diaper bag for supplies—1.

Bedding

See Shhh! We’re Sleeping
• Receiving blankets—4-5.
• Flannel waterproof pads—3-4.
• Fitted sheets—3-4.
• Bumper pad—1.
• Lightweight blanket—1-2.
• Quilted mattress pad (nice but not necessary)—2.

Bath Time

See Bathing Your Newborn
• Hooded towels—2-3.
• Wash cloths—8-12.
• Mild soap—1 bar or bottle.
• Oil or lotion—1 bottle.
• Baby bathtub (optional)—1.
• No-tears baby shampoo—1 bottle.

Feeding Supplies

See Feeding Your Newborn
• Bibs, washable (protect baby’s clothes from spit-up)—4-6

Breastfeeding

• Support/nursing bra—3-6.
• Bra pads—5-6 washable; 2-3 dozen disposable.
• Breast pump if you’re going back to work or you’re away from home a lot—1.

Formula

• 4 oz bottles, nipples and caps even if you’re breastfeeding—4.
• 8 oz bottles, nipples and caps—4-8.
• Extra nipples and caps—2-4.
• Disposable bottle inserts (if you’re using this type bottle)—1 box of each size (4 oz. and 8 oz.).
• Formula (as prescribed by your pediatrician)—1 week supply to start with.
• Boiled sterile water for mixing with powdered formula or liquid formula concentrate—1 gallon.

Nursery Furniture and Supplies

See Keeping Your Baby Safe
• Crib/bassinette/cradle with mattress: be sure to get one that meets the current federal safety standards.
• Changing table (nice to have but not a must)
• Diaper pail with cover
• Fever thermometer
• Infant carrier/car seat: be sure to get one that meets the current federal safety standards, you can’t take your baby home from the hospital without one.
• Bunting or hooded jacket (winter)
• Stroller (optional and is a great item to register at the baby store)
• Baby swing (optional and is a great item to register at the baby store)
• Rocking chair (optional and is a great item to register at the baby store)
• Portable crib or playpen (optional and is a great item to register at the baby store)
• Baby monitor
• Soft carrier or backpack (optional and is a great item to register at the baby store)

Finishes on new clothing and soap residue on used clothing can cause rashes. To help prevent rashes, wash and rinse well all of his clothes, crib sheets, and towels before your baby uses them for the first time.

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It’s often recommended that mothers at risk for preterm birth self-monitor contractions for at least one full hour each morning and again in the evening. Self-monitoring contractions means feeling your abdomen to see if you are having uterine contractions and then timing the contractions if you feel them. (For more about preventing preterm birth and preterm labor.)

Your doctor will tell you when and how often to monitor your contractions. Monitoring contractions includes measuring how long they last, how far apart they are, and how many you have in an hour. Do not trust your memory or guess. If you get upset or worried during the monitoring process, you may not be able to remember. Therefore, have pen and paper handy and a clock or watch with a second hand. To make things easier, you can download our contractions worksheet. Here’s how to monitor contractions.

Place your fingertips wide apart.

Steps for Self-monitoring Contractions:
1) Empty your bladder to relieve any pressure on your uterus.
2) Drink one to two 8-ounce glasses of water; dehydration increases the level of the hormones that can lead to contractions.
3) Lie down on your left side with a pillow at your back. Don’t lay on your back. It can cause contractions to happen more often.
4) Place your fingertips wide apart on the top of your uterus, up near your breast bone. Press in lightly and feel for a tightening inside your abdomen.

What will I feel with my hands and fingers?

Contractions usually begin at the top of the uterus (above your belly button) and feel like a tightening or hardening of a muscle. Your uterus will get harder as the tightness increases to a peak. Then the uterus relaxes or softens as the contraction ends. If, with your fingertips, you feel your abdomen tighten (contract) and get hard and then relax and soften, you’re having a contraction. Also, you may be able to see your abdomen move as it tightens.

The uterus is a muscle. When the uterus contracts, it will feel hard to your fingertips — like your biceps feel when you “make a muscle” in your arm. With a contraction, your whole uterus should feel hard. So spread your fingers out so you can feel a large area. If you feel a hard “spot” it may be your baby’s buttocks or a foot — not a contraction in the uterus.

Click image to download our worksheet.

Timing Contractions

Each time you have a contraction, count how many seconds it lasts. When it’s over, write down the time and how many seconds the contraction lasted. If you have more than four contractions in one hour, empty your bladder again, drink at least two 8-ounce glasses of water, and monitor for a second hour. If the contractions start coming closer together or become painful, call your doctor.

How long do contractions last?

The length of a contraction is usually measured in seconds. Begin counting the seconds when the contraction begins (the uterus starts getting hard) and stop counting when the contraction stops (the uterus is soft and has completely relaxed). If you don’t have a watch with a second hand, count “one-thousand-one, one-thousand-two, one-thousand-three”. If you count to one-thousand-ten, and the contraction stops, the contraction lasted about ten seconds.

How far apart are my contractions?

The time between contractions is measured in minutes. The time between the beginning of one contraction to the beginning of the next is “how far apart” your contractions are. For example, if your first contraction begins at 9:00 and the next begins at 9:15, your contractions are 15 minutes apart. If contractions begin at 9:00, 9:15, 9:30, 9:45, and 10:00, you have had four contractions in one hour. The contractions are also “regular” because they happened every 15 minutes.

What to Do

It is common to have false labor—Braxton Hicks contractions—during the final weeks of pregnancy. These contractions are called false labor because they do not cause the cervix to expand (dilation) or thin out (effacement). These contractions may be regular and painful. They usually go away within an hour or so with rest. Count how many contractions you have in 20 minutes and how many you have in an hour. If you have regular contractions 4 times every 20 minutes or 8 times an hour that last for more than an hour, call your doctor’s office right away.

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The birth of your child is one of the most significant events you will experience. It deserves careful thought and advance preparation. There are many things you can do as a responsible parent to have and prepare for a healthy pregnancy and childbirth. These include eating well, getting good prenatal care, strengthening and protecting your body as it progresses through pregnancy, and learning all you can about pregnancy, birth, and parenting.

Learning all you can includes taking prenatal classes. Prenatal classes can increase your enjoyment of pregnancy and giving birth by helping you become a more active participant. Attending classes gives you a chance to share knowledge and experiences with other mothers also having a baby. The knowledge you gain about pregnancy and birth can reduce the stress than comes from the fear of not knowing what to expect. Attending classes with your partner can help you strengthen your relationship with each other and your families, and begin building a support system. Your increased knowledge will help you communicate better with your doctor, certified nurse midwife, and other members of your health care team.

Also, the more you know the more flexible you will be if your pregnancy doesn’t go exactly as “you planned”. Your knowledge will allow you to make the choices that are best for you, your baby, and your family. As you go through pregnancy and begin making choices, either about lifestyle or breastfeeding, it is important to keep in mind the real goal ~ a healthy mother and healthy baby!

Our Healthy Mother~Healthy Baby Pregnancy Guide is a collection of topics and information put together by maternal/child health educators, lactation consultants, birth coaches, and labor-and-delivery nurses based on what they have heard mothers want to know most about pregnancy, labor, delivery, cesarean and VBAC. Most of this information has been used in childbirth classes. Refer to the guide as you go through your pregnancy and use it to help you have better talks with your doctor and nurses as you go through this wonderful experience.

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What Gestational Hypertension & How It’s Treated

If you get PIH, it is very likely that you will have a healthy baby and fully-recover from the disease.

This article is for women who may get or already have gestational hypertension (pregnancy-induced hypertension (PIH)), sometimes called Preeclampsia or Toxemia. This disease affects about 5 to 10% of all pregnant women. If you are one of them, you should learn as much as you can about it so you can help your health care provider keep you and your baby healthy. Pregnancy-Induced Hypertension (PIH) can remain under control with treatment long enough for you to deliver a healthy, mature baby or it can become a serious problem for you and your baby almost without warning. The most important things you can do are:

• know if you are at risk so you can tell your health care provider,
• continue regular pre-natal care,
• follow your health care provider’s instructions for controlling PIH and
• tell your doctor or PIH specialist right away of any symptoms during pregnancy.

If you get PIH, it is very likely that you will have a healthy baby and fully-recover from the disease. But it will take alertness and skill on the part of your health care provider and full cooperation from you. The rewards for you and your baby are well worth it!

What is pregnancy-induced hypertension (PIH) (also called gestational hypertension)?

If you are pregnant and your systolic pressure is 140+ or the diastolic pressure is 90+ on several readings, it is too high.

Pregnancy-induced hypertension (PIH) is a type of hypertension (high blood pressure) that happens only during pregnancy. It can be mild or become very serious. The chart under the heading “How will I know if I have PIH?” shows the different stages and symptoms of PIH.

PIH may develop slowly or come on suddenly without warning anytime during your pregnancy, during labor and even just after you have your baby.

There is no cure for PIH while you are pregnant; the only cure is to deliver your baby. But there are treatments and medicines to (1) help you from becoming more ill, (2) to prolong the pregnancy so your baby becomes more mature and (3) to help you and your baby get through delivery safely. After delivery, the disease eventually goes away. You may have to continue taking medicines and seeing your doctor or specialist but you shouldn’t have any lasting effects of the disease.

How common is gestational hypertension (PIH)?

The more serious stage of Pregnancy-Induced Hypertension, called preeclampsia, occurs in 5-10% of all pregnant women. Of women with preeclampsia, only about 5% will get the most serious stage of the disease, called eclampsia.

What happens when you have PIH?

Hypertension means the pressure that your blood exerts against your artery walls as your heart pumps blood through the body is higher than it should be. Higher-than-normal blood pressure is one of many conditions that happens when women get pregnancy-induced hypertension, but is not what causes the disease. PIH starts with vasospasms—like muscle spasms—in the arteries.

At the most serious stage of PIH, these vasospasms can cause:

• damage to artery walls
• a build up of blood platelets and other blood products that form blood clots; this build-up causes a narrowing of the space in your arteries, which cuts down the amount of blood and oxygen flowing to organs like the brain, kidneys and liver
• a drop in the amount of platelets, which can cause spontaneous bleeding
• torn cells that break open and dump toxins, which causes more damage to organs and high blood pressure, and which, if left untreated, can cause stroke
• leaky blood vessels that can cause severe swelling of face, eyelids, hands, legs, feet and sometimes the brain (cerebral edema); swelling in the brain can cause seizure, which, in turn, can cause early birth, a lack of oxygen to the baby or a loss of blood supply to the placenta
• serious damage to or even failure of kidneys and liver

Remember – only a small percentage of women with PIH experience the most serious stage of the disease. Telling your health care providers of any risk factors that you have, getting regular pre-natal care and alerting your doctors to any symptoms are critical to the continued good health of you and your baby.

What causes PIH?

The simple answer is doctors and scientists don’t know what causes PIH. Some studies suggest that PIH may be caused by the mother’s poor diet, an “allergy” to the placenta and fetus or even family history. But after many years of research, there is no clear answer to what triggers PIH. There are, however, risk factors for who is more likely to get PIH, as follows:

Risk Factors for Pregnancy Inducted Hypertension

• if this is your first pregnancy
• if you had PIH with an earlier pregnancy
• if you have a family history of PIH
• if you had high blood pressure before you became pregnant
• if you are younger than 20 or older than 34
• if you have lupus, diabetes or kidney disease
• if you were obese before pregnancy
• if you are pregnant with more than one baby
• if you did not have regular pre-natal care and/or a poor diet
• if you have a hydatiform mole
• if you are African-American
• if there is something wrong with your baby (e.g., chromosomal abnormality) or with your placenta (e.g., maternal serum alpha feto protein – MSAFP)

How will I know if I have PIH?

Diagnosing PIH starts with your first pre-natal visit. If you have one or more of the risk factors shown above, then your pre-natal health care team should be on the alert for (1) high blood pressure, which is the first sign, followed by
(2) protein in your urine. This may happen early in your pregnancy or not until the end. Most often, it occurs after the 20th week or so of your pregnancy and lasts until a week after childbirth.

On each pre-natal visit, your health care provider should (1) weigh you, (2) take your blood pressure, and (3) get an early-morning urine sample to check protein levels.

The chart below shows the stages of PIH, the medical problem your health care provider will look for and the symptoms you may have.

How will I be treated for PIH?

If you are considered high risk for PIH

If you are considered high risk for PIH (for example, you have diabetes or a family history of preeclampsia), your health care provider may:

• Recommend more frequent office visits after 24 weeks of pregnancy. If you develop any warning signs of preeclampsia (weight gain or swelling), tell your doctor right away.
• Have you check your weight and blood pressure at home.
• Prescribe one baby aspirin per day throughout your pregnancy, which may protect you from developing preeclampsia.
• Send you to a perinatologist, an obstetrician who specializes in high-risk pregnancies.
• Remind you that a good diet should include:

Daily Food Guide During Pregnancy

Be sure to follow all dietary advice your doctor gives you. You may be put on a low sodium diet to reduce the amount of salt your eat or the DASH Diet which has been shown to lower blood pressure. You should avoid foods and drinks that contain caffeine like sodas, coffee and chocolate.  You may need to restrict your salt intake by eliminating table salt from your meals and avoiding foods high in salt. To find out if a food is high in salt, read the label of any foods before you eat them and look for sodium content. Be sure to take your prenatal vitamins.

If you get mild preeclampsia and your baby is not in danger

There are several things your health care provider may recommend if you get mild pregnancy-induced hypertension (preeclampsia) and your baby is not in danger.

• Bed Rest – Rest often. Many women can reduce their high blood pressure by resting in bed for a few days. Lying on your left side helps to improve blood flow.
• Add Protein to Your Diet – If the disease is causing you to lose protein in your urine, you may be helped by a high-protein diet to replace the lost protein.
• Check you and your baby - A visiting nurse can check your weight, your blood pressure, your urine for protein and listen to the baby’s heart rate in your own home. You can even be trained to do these things for yourself with a scale, blood pressure monitor, urine test strips and an external fetal heart rate monitor.
• Test your blood – If your health care provider becomes concerned, you may need to have a blood test in the office to check for poor kidney function, abnormal liver function and/or a drop in the amount of platelets in your blood.
• Test you further in the hospital – If your symptoms and test results show that you are developing severe preeclampsia, your health care provider may want to put you in the hospital for more tests for you and the baby, as well as around-the-clock monitoring.

If you get severe preeclampsia

If your mild preeclampsia becomes more serious preeclampsia, you will be hospitalized and prepared to deliver your baby. The goal of your doctors, nurses and other specialists at this time is to stop your condition from getting worse, while making sure your baby is not in distress before it’s time to deliver. Here’s what you can expect in the hospital:

• A doctor or specialist will take your medical history and perform a physical exam.
• Blood tests will be done for the latest findings.
• A fetal monitor will check your baby’s heart rate and you may have an ultrasound for further evaluation of your baby.
• If you are delivering your baby before the due date, you may have an amniocentesis; this is a test that uses a needle to draw amniotic fluid from around the baby to measure if your baby’s lungs are mature.
• You will probably be given medicines to help you and your baby come through labor and delivery in the safest way possible.

Medicines to help you and your baby

Your doctor or other specialists may give you one or more medications during your pregnancy, labor and delivery. If you are given drugs, which type and how much will depend upon (1) the overall health of you and your baby, (2) how far along your disease is and (3) the maturity of your baby just before delivery.

Generally medications are used to:

• Lower blood pressure
• Treat cell damage caused by spasms
• Prevent seizures and convulsions
• Decrease breathing problems in premature babies
• Decrease the risk of brain hemorrhage and intestinal problems in premature babies

Labor and Delivery

The moment of birth by cesarean.

Your doctor, the anesthesiologist and any other specialists who will help with your baby’s birth will decide whether you can deliver your baby vaginally or by cesarean section (c-section) and what kind of pain medicine will work best for you. Normal labor and vaginal delivery are preferred if your cervix is dilated and you and your baby are healthy and strong enough. You should also learn about induced labor. If you or your baby are under any stress because of your disease, your doctor will probably perform a cesarean.

If you develop complications of preeclampsia during labor or delivery (e.g., you are in danger of having a stroke, or show signs of kidney failure), one of your health care team specialists will explain any other treatments that might become necessary. Be assured your health and the health of your baby are their utmost concern.

What will happen after I have my baby?

For the first few days after you deliver your baby, the hospital staff will keep a close watch on you. In all likelihood, your PIH will go away and you will be on your way to a full recovery. However, if your PIH became very serious, your health care providers will closely monitor you. They will check for excess blood loss, any effects of the drugs used during delivery or any damage to your kidneys or liver. If any problems are found, treatment will begin immediately and may continue for a while. If your baby was born prematurely, your baby may have to remain in the hospital for further care.

Don’t Panic!

Don’t panic if you have been diagnosed with pregnancy-inducted hypertension. It is a condition that is treatable. Most mothers and babies come through it fine. But don’t ignore it either.

For the healthiest pregnancy and delivery, remember these things:

• Know if you are at risk and tell your health care provider
• Have regular pre-natal care
• Eat a healthy diet, get plenty of rest (lay on your left side to help circulation) and avoid stress
• Follow all your doctor’s instructions
• Don’t worry or guess about symptoms, tell your health care team
• If you take good care of you, you will be taking good care of your baby

Glossary

• Cesarean Birth: Delivery of a baby and the placenta through an incision made in a woman’s abdomen and uterus.
• Eclampsia: The end stage of pre-eclampsia. Seizures occurring in pregnancy and linked to high blood pressure.
• Placenta: Tissue that provides nourishment to and takes away waste from the fetus.
• Preeclampsia: A condition of pregnancy in which there is high blood pressure, and protein is present in the urine and ranges from mild to severe.
• Prenatal Care: A program of care for a pregnant woman before the birth of her baby.

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A cesarean birth (cesarean or c-section) is major surgery where a baby is delivered by an incision that is first made on the skin, then the underlying abdominal muscle wall and finally the uterus itself. Cesareans may be done as planned surgery or as an emergency procedure when vaginal birth isn’t possible. The American College of Obstetricians and Gynecologists recommends that non-emergency cesareans be performed no sooner than 39 full weeks of gestation. Although cesarean births are considered very safe, there are risks, including death. The reasons for and the outcome of any surgical procedure depend on age, how severe the problem is, and your overall general health.

Types of Uterine Wall Incisions

There are three types of incisions made in the uterine wall for the delivery of the baby. The type of incision chosen depends on the presentation of the baby and the speed at which the procedure can be done.

• the low vertical incision—an up-and-down incision is made in the lower, thinner part of the uterus. This incision is usually made when the baby is presenting breech—rump first or feet first.
• the high vertical (classical) incision—an up-and-down incision is made in the upper part of the uterus. This incision is made when the baby is presenting sideways or the placenta is abnormally placed.
• the low transverse incision—also called a bikini cut, is a side-to-side incision is made in the lower, thinner part of the uterus that contracts minimally during labor. This incision is made when the baby is presenting head first.

Cesareans can be done with either an up-and-down or side-to-side incision in the skin of the abdomen. Therefore, it’s not possible to know whether the uterine wall had a transverse or up-and-down incision based solely on the scar on the abdomen.

Apart from the major difference in the pattern of incision as mentioned above, there are other advantages between a low transverse, low vertical and classical cesareans:

• The chances of hemorrhage or rupture during future pregnancies in a low transverse delivery are much less compared to that of the classical delivery.
• There is less blood loss.
• The incision is easier to close up.
• There is less risk of uterine infection.
• There is a lower risk of gastrointestinal complications.

The major disadvantage to this incision is that it takes longer to do so in case of an emergency, this incision isn’t used. Today, the low transverse cesarean is preferred and performed by most OB/GYNs. The way your uterus is cut may not seem important, but it can play an important part in the decision on later births whether you can try a vaginal birth after cesarean (VBAC).

Love at first sight as the doctor shows mom the moment of birth by cesarean.

Reasons for Cesarean Birth

At one time, most babies were born by vaginal birth, which in some cases caused complications both for the mother and the newborn, which led to a high mortality rate. Cesarean births were only performed in emergency situations and most of those were the classical cesarean that had more complications. As surgical techniques and anesthesia have developed, cesarean birth has become a more common method of birth and the chances are much higher of delivering a healthy baby and reducing risks for mother.

Cesarean births are most often performed for two main reasons:

• the danger to the mother or baby would be greater with a vaginal birth
• things go unexpectedly wrong during a vaginal delivery

The following reasons fall under these two main reasons:

• Dystocia. The number one reason for cesarean birth is ‘dystocia.’ Dystocia refers to any difficulty in labor. The difficulty can be caused by:
  • The fetus is not be able to progress down the birth canal. Failure of labor to progress can be caused by contractions that aren’t vigorous enough to open the cervix (dilate) enough for the baby to move through the vagina or the baby presents other than crown first that prevents progress through the birth canal. Failure to progress accounts for about 1/3 of all cesarean births.
  • The size of the baby compared to the size of the mother’s pelvis—if the baby’s head is too big to pass through the mothers pelvis it can cause a very difficult vaginal delivery and even stop the cervix from completely dilating. In some cases, the pelvis may be misshapen or the baby presents the largest part of the head instead of the crown and it’s too large for the pelvis. Some babies are just too big to be born vaginally; large babies are common with gestational diabetes.
  • Weak contractions in the mother’s uterus; strong contractions are needed to push the baby out from mother’s womb. Extended labor can be a risk to both the mother and the baby, more so to the baby.
  • Your baby’s head is in the wrong position or presentation—the normal position at birth would be head down with the back (crown) of the head leading the way—called the cephalic presentation. This presentation makes your baby the “smallest.” If your baby presents face first or forehead first, your pelvis may not be large enough for your baby to get through.
• Obstruction or severe distortion of the birth canal (caused by pelvic tumor or fibroid tumors)
• Previous cesarean birth. There is a common saying “once a cesarean, always a cesarean.” This thinking led to an large increase in cesarean birth rates. This used to be true since most surgeons used the classical cesarean incision that had more blood loss and left weak incision sites. Weak incision sites made ruptures more common in later pregnancies. Recently, the low transverse uterine incision has become more common reducing the risk of rupture and enables a mother to try a vaginal delivery after cesarean (VBAC).
• Position of the fetus within the uterus. The normal position just before the delivery is a head-down (cephalic) position. If the baby presents in one of the positions listed below, vaginal delivery could lead to the trauma or death of the fetus. Sometimes the baby can be turned to allow vaginal delivery. Problems can also arise when the umbilical cord is “born” before the baby, cutting off the baby’s blood supply.
  • Breech presentation. When the fetus is in a head-up, feet-first or rump-first position it’s called a breech presentation. The breech position can be further classified as frank (hips are bent and knees are straight), complete (knees and hips are bent), footling (knees and hips of one or both legs straight) or incomplete (one or both hips bent and one or both feet or knees lying below the breech).
  • Shoulder. There are many shoulder presentations, however, all transverse positions (sideways) are called shoulder presentations.
  • Compound. When two body parts appear at the pelvis at the same time, such as a hand beside the head, it’s called a compound presentation.
• Fetal distress is used to describe any complications with the fetus—such as abnormal heart rate from poor oxygen supply—and usually does not allow vaginal delivery. In most cases, fetal distress is lack of oxygen to the brain of the fetus (oxygen deprivation). Lack of oxygen can be caused by the umbilical cord is compressed or there are problems with the placenta, cutting off the blood supply to the fetus. Lack of oxygen can be diagnosed by monitoring the fetal heart rate. Lack of oxygen can cause very serious complications if the fetus is not delivered right away. Cesareans can also be necessary in cases of congenital (at birth) abnormalities of the fetus.
• Multiple births. When there is more than one fetus most surgeons deliver by cesarean births. Cesarean birth is a much safer method to deliver multiple babies. About half of all mothers who have twins, have a c-section, while 90% of triplets are born by c-section.
• Very premature fetus.
• Problems with the Umbilical When the umbilical cord is delivered ahead of the fetus, called cord prolapse, it causes the cord to get compressed by the baby and oxygen and the blood supply to the baby is cut off. This is an emergency that requires cesarean birth. Sometimes, the cord can be completely delivered and if the baby is coming right behind it, you may be able to have a vaginal birth. If the cord is around the baby’s neck, contractions can compress the cord causing the blood flow—and therefore oxygen—to your baby to slow down.
• Problems with the Placenta. The placenta can detach from the uterine wall (abruptio placentae) before labor begins and be life threatening for both you and your baby. Placenta previa is when the placenta partially or completely blocks the opening of the cervix. In this case, the placenta would have to be born first, leaving the fetus without oxygen. In addition, blood loss for the mother could be fatal.
• Health of the Mother. Certain health conditions of the mother can require a cesarean birth:
  • History of previous problems during childbirth
  • Active herpes sores
  • Narrow cervix (vaginal atresia)
  • Gestational diabetes
  • Pregnancy-induced hypertension
  • Vaginal infections or tumors
  • HIV
  • Cervical cancer
  • Heart disease or risk of stroke
  • Severe obesity
  • Repeat Miscarriages: Mothers who have had repeat miscarriages in the past usually have weak uterus may need a medical procedure to stitch the cervix closed. If the stitches are in at the time of labor, the only way of delivering the baby is by cesarean.
  • Rh Factor: In erythroblastosis fetalis (difference in the Rh factor of the mother and the fetus), there is a risk of fetal anemia.
• Health of the Baby. If your baby has been diagnosed with health problems, it may be better for your baby to be born by cesarean birth. Also, monitoring during labor will tell how well your baby is handling labor and how well the placenta and umbilical cord are working

Many of these complications happen in a very small number of births. And the decision for cesarean birth is decided by balancing the risks and benefits to mother and baby.

Risks to Mothers During Cesarean

Any kind of surgery involves risks, and a cesarean will, too. Risks are usually measured by the rate of deaths, complications, and disorders during or after the surgery.

Maternal deaths during cesarean birth are very rare—about 2 in 10,000. However, research shows that the death after cesarean birth is twice that of vaginal birth. This is mostly not related to the surgery, but rather illnesses or complications taking into account cesarean births are usually done for complicated pregnancies.

Like any major surgery, cesarean births have risks and possible complications:

• Endometritis. The most common complication is endometritis—the inflammation or infection of the lining of the uterus.

• Infections. Other complications include respiratory tract infection, urinary tract (bladder and kidney) infection (the second most common complications) and infection at the incision site. The risk of infection of your incision site is higher if you have type 2 diabetes, are obese or abuse alcohol. If the incision becomes infected, it increases the risk of the incision opening up.

• Reduced bowel function. Sometimes the medicines used for pain relief or anesthesia can slow down bowel functions causing gas, bloating and abdominal discomfort for a few days after surgery.

• Reaction to anesthesia. Sometimes breathing problems are associated with general anesthesia. General anesthesia is used in less than 20% of cesarean births. Also, follow your health care teams advice about ways to prevent pneumonia.

• Blood loss is higher in cesarean birth than vaginal birth, although transfusions are rarely needed.

• Accidental injury to bladder or bowel from surgery. These are rare, but can happen.

• Placenta accreta is when the placenta is too firmly or deeply attached to the uterus and can lead to hysterectomy.

Risk to Baby During Cesarean

In an elective cesarean birth performed before the mother goes into labor at full term, the infant is at risk of respiratory distress syndrome and a low birth weight if the baby’s due date is not accurate. Respiratory distress is with premature birth caused by the baby’s lungs not fully developing as they would at full term.

• Fetal injury can occur if the baby is accidentally cut or nicked during cesarean birth.
• Low Apgar scores can result from anesthesia.

Anesthesia for Cesarean

All surgery requires anesthesia since it numbs the pain. In cesarean birth, anesthesia is very important since the fetus can by affected by the anesthesia.

Three types of anesthesia used in a cesarean section:
• Spinal anesthesia – numbs your body from the chest down so you can be awake during surgery. You feel very little or no pain and very little if any medicine reaches your baby.
• Epidural anesthesia – numbs your body from the chest down so you can be awake during surgery. You feel very little or no pain and very little if any medicine reaches your baby.
• General anesthesia – makes you unconscious or “asleep.” General anesthesia is usually used in very serious or emergency cesarean births. It’s also used for mothers who don’t want spinal or epidural anesthesia

There is very little difference between spinal and epidural anesthesia. Both are administered locally—to a specific area—that numbs part of the body without putting you to sleep. Spinal anesthesia was prevalent before the popularity of lumbar epidural anesthesia that is now used for most cesareans.

The mother usually decides on the type of anesthesia after talking with her OB/GYN and anesthesiologist. Most doctors recommend local anesthesia—spinal or lumbar epidural—for an uncomplicated cesarean birth.

Cesarean Surgery

Delivery through low transverse incision

The nurses will get you ready for surgery by placing an IV in your hand or arm to give you fluids and medicines. You may also have blood drawn for blood tests. You’ll have monitors attached for watching your blood pressure, heart beat, and how much oxygen you’re getting during surgery. You’ll also have a urinary catheter inserted to drain urine from your bladder so your bladder is not in the way. Once you get to the operating room, you may have added oxygen through a mask. If you haven’t already had the epidural or spinal block, that will be done, too. If you are having an emergency cesarean you will likely have general anesthesia. If you have general anesthesia, all preparations will be done before you are given anesthesia to keep your baby from getting too much anesthetic, making it harder for him to wake up at birth. Your arms will likely be secured onto padded boards. Your abdomen will be scrubbed and drape put up below your chin to help keep the surgical area sterile. If you’re awake, you won’t be able to see what is happening. Your doctor, the anesthesiologist or a nurse will let you what is happening and answer your questions.

Once everything is ready, about a 6 inch  incision will be made in the skin of your abdomen. Whether the incision is up-and-down (vertical) or side-to-side (transverse), will depend on several things—if you had a previous cesarean birth, if this cesarean is an emergency, the position of your baby or the placenta, and the size of your baby. A bikini incision is used most often for cosmetic reasons as well as it heals well and presents fewer problems in later births. If your baby needs to be born quickly, an incision just below your belly button to just above your public bone is made. This allows your doctor to get to your baby more quickly.

Once inside your abdomen, your bladder is moved to one side and a smaller incision is made in the uterus. Again, the incision in the uterus can be transverse or vertical—the type of incision made on your skin does not affect the type of incision made in the uterus. The low transverse it the most common and used in about 90% of cesareans—see illustration above. The low transverse causes fewer problems in later pregnancies because it makes a stronger scar reducing the chances of uterine rupture. In fact, you may be able to try a vaginal birth in later pregnancies.

Your doctor presses on the top of your uterus and pulls your baby out through the incision. You won’t feel any pain but may feel some pressure or pulling because the incision is kept as small as possible. Once your baby is out, the umbilical cord will be cut—if your partner is there, they may allowed to cut the cord. Your baby will be given to the nurses to clean the airways and body. The placenta will be removed, the uterus closed with absorbable stitches, you will be closed up layer by layer. The incision on your abdomen will be closed with staples or clips. The doctor will press on your uterus to force blood and blood clots out through the vagina. You’ll be given medicine to shrink  your uterus and reduce bleeding. You may also be given antibiotics to help prevent infection.

If your baby is OK you may be able to hold her and even nurse her, depending on the rules at your hospital. If your baby is not OK, then she will be taken to the nursery quickly for special care. The nurses with you will talk with the nursery and let you know how your baby is doing.

After surgery you’ll be taken to the recovery room and monitored for a an hour or two. If you feel up to it,  you may be able to try breastfeeding while in the recovery room. If everything is fine in the recovery room, you will be taken to your room and monitored to make sure you are OK and your uterus is shrinking. A typical stay after cesarean birth is 3 days. Most patients are encouraged to get up and move  around the day after surgery. You should be able to return to normal activities in about 4-6 weeks.

Learn more about Self Care After Cesarean Birth.

Psychological Effects of Having a Cesarean Birth

When having a cesarean birth, one must consider the psychological effects. Afterward, a cesarean can be much more painful than a vaginal birth. This most often causes psychological effects on the mother and sometimes the father. Research shows that there is no effect on the newborn.

Some hospitals offer Family Centered Cesarean Births and allow the father to be present in the operating room during the cesarean birth. They also offer closer contact between the mother and her newborn after surgery and you may be able to hold your baby right after birth. If you’re having a planned cesarean, talk with your hospital about having the options they offer such as allowing your partner to cut the cord and carrying the baby to the warmer, breastfeeding in the recovery room, and allowing you to touch or hold your baby in the operating room. All of these can help you begin bonding with your newborn. If you are have an emergency cesarean, your family won’t be able to be with you.

Glossary

• Anesthesia: Relief of pain by loss of sensation.
• Breech Presentation: A situation in which a fetus would be born buttocks or feet first.
• Cervix: The lower, narrow end of the uterus, which protrudes into the vagina.
• Fetal Monitoring: A procedure in which instruments are used to check the heartbeat of the fetus and contractions of the mother’s uterus during labor.
• Placenta: Organ that provides nourishment to and takes away waste from the fetus.
• Umbilical Cord: A cord-like structure containing blood vessels that connects the fetus to the placenta.
• Uterus: A muscular organ in the female pelvis that contains and nourishes the developing fetus during pregnancy.

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Epidural anesthesia is one way of taking away the pain of labor and birth. Like most medical treatments it has risks and benefits. It is important that you learn about those risks and benefits before deciding if an epidural is right for you.

What is epidural anesthesia?

Epidural anesthesia uses repeated doses of a local anesthetic in the epidural space of the spinal area. It numbs the nerves from the uterus and birth passage without stopping labor. A successful epidural once administered gives you an almost pain-free awake state throughout the entire labor and birth of your baby.

An epidural is administered by an anesthesiologist, a physician who is a specialist in anesthesia. Your labor is watched carefully before the medication is given. A specially trained nurse or the physician will be near you until the baby is born.

You and your support person should discuss risks and benefits and sign a written consent before the epidural anesthetic is given.

How is it done?

An epidural is not administered until you are in active labor. Before the procedure begins, intravenous (IV) fluids are started and 1-2 liters of fluids are given. The IVs will continue throughout labor and birth. Then you will be asked to position yourself on your left side or in a sitting position with your chin on your chest and you knees close to your abdomen. This position is uncomfortable for most women. The waistline area of your mid back is wiped with an antiseptic solution to reduce the skin bacteria and thus lessen the chance of an infection.

A coin-sized area of skin on your back is numbed with an injectable local anesthetic. Then a larger needle is placed through the numbed area and into the epidural space of your spine. A small tube (catheter is threaded into that needle until the tip reaches the epidural space around the spinal cord. At that time the needle is removed carefully leaving the catheter in place.

A “test dose” of medication is injected into the catheter to confirm the proper placement. If the placement is correct an initial dose is administered. The catheter is then taped to your back so more medication can easily be injected later. Once in place the catheter does not restrict moving side to side in bed and it is not felt in the back. The pain involved during the administration procedure may be a slight pinch or it may be painful for several minutes.

Three to five minutes following the initial dose, the nerves of the uterus begin to numb. After ten minutes you will feel the full effect. As the initial anesthesia begins to wear off, another dose can be given through the catheter before contractions become uncomfortable. This will be done every one to two hours depending on the specific anesthetic drug(s) and the amount and strength of the medication given.

As soon as the baby is born, the catheter is removed. The effect of the anesthesia usually wears off completely in one or two hours. At that time you may experience an uncomfortable burning sensation around the birth canal.

Are epidurals safe?

At this time, epidurals are thought to be safe for both mother and baby. However, there are risks, and limited studies have been done. Epidurals may require other medical procedures (such as forceps) which add to the risk. The most common side effect is a sudden drop in the woman’s blood pressure. This problem occurs 1 to 2 percent of the time and can be dangerous to a woman and baby. When it does occur, the medical staff is there to take quick action. Usually they can correct the problem. Frequent blood pressure monitoring with either a machine or by a staff member is required after each dose of medication. Some women find this comforting while others find the monitoring irritating because it disturbs the interaction with their support people.

When can I have it and Will it affect my labor?

An epidural anesthetic is administered once you are in true labor. Once started, however, it can slow your labor and make the contractions weaker. If this happens you may be given oxytocin, a drug which makes contractions stronger. If oxytocin is used you will be watched closely since oxytocin can over stimulate the uterus, causing contractions that are too severe.

Does it always work?

If the physician cannot easily locate the epidural space, it may not be possible to use epidural pain relief. This seldom happens. Sometimes labor begins so fast that there is not enough time to use an epidural. Some epidurals give “patchy” anesthesia, causing the feeling that some parts of the abdomen are anesthetized and other parts are not.

Can anyone have it?

Most women can have an epidural, although women who have had back surgery, heart or blood disorders and those who have an allergy to “-caine” medications should discuss those problems with their physicians and anesthesiologists.

Must I remain in bed after I receive the epidural?

Yes, you will be allowed to lie on your side with your head elevated 30 degrees. The epidural also anesthetizes your legs somewhat so you cannot bear your weight and stand. This means, of course, that you cannot go to the bathroom or walk about. You must also have continuous intravenous fluids and electronic fetal monitoring. Electronic fetal monitoring involves having two belts around your abdomen or a wire into your vagina which attaches to your baby’s head.

What else will be done?

Because your abdomen is anesthetized you cannot urinate as you wish. If your labor lasts more than a few hours you will probably need a urinary catheterization which requires that a tube be put into your bladder to release your urine. Catheterization increases the risk of urinary infection 1 to 2 percent each time it is done.

Will I be able to push?

Under epidural anesthesia you may not be aware that you are having a contraction. If you are aware, you can cooperate by pushing. If you cannot feel the contractions, you will probably not be able to push. The baby will then be forced down the birth canal by someone pushing down on your abdomen at the top of your uterus and/or forceps will be placed around the baby’s presenting part and pulled. Both methods produce some risks to the baby. Many experts feel that the timing of the re-injections determines whether the woman can feel her contractions.

Will it slow labor?

Some labors are slowed by the use of an epidural. For other labors, an epidural may actually speed labor because the mother is more relaxed.

Will I need forceps?

There is an increased possibility that forceps will be necessary. Forceps usually require an episiotomy which is a cut enlarging the birth opening. The use of forceps makes most episiotomies extend (get larger), requiring even more stitches and potential pain.

Advantages of an epidural

• Freedom from pain during labor and birth.
• Unlike some other drugs it does not make the mother drowsy before or after the birth.
• Little medication reaches the baby.
• Close monitoring by the hospital staff may give the laboring woman a sense of confidence

Disadvantages of an epidural

• Labor may be slowed by the woman’s inability to move about and make use of gravity.
• The woman must remain in bed on her side with her head at the same level throughout labor.The woman must have constant intravenous fluids and electronic fetal monitoring.The woman must have her blood pressure taken frequently.
• The woman will probably require catheterization which has risks.
• The baby will probably be delivered by forceps which has risks.
• The woman will have little control over her body and may not feel the birth process. This can interfere with maternal-infant bonding.
• The woman must depend totally on nurses and doctors for basic physical needs.
• Extremely rare but serious medical risks exist about which the woman and her partner must be aware.

What else can be used instead of an epidural for pain relief?

There are other ways of reducing the pain of labor. Many women are helped by techniques learned in childbirth classes – relaxation, massage, positioning, visualization, distraction, focusing and breathing that are done with the support of another person. These non-drug coping skills use your own strengths and place you in control of your own body.

Epidural anesthesia is one method that can give relief from pain and discomfort in labor. It does require that you give some control to the hospital staff. It does involve risks. The final decision is yours. Understanding this procedure can help you decide what is right for you.

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