Labor and Delivery It is most important that you trust your body when you go into

labor. Remember, your body was built to carry, nourish, and safely
With your pregnancy coming to a close, you are beginning to
deliver your baby. Some of the factors that affect the course of
anticipate the birth of your baby. Activities such as attending
labor include your health, nutrition, size and shape of your pelvis,
childbirth classes, having regular physician appointments, reading
size and presentation of the baby, your educational preparation for
books, talking to others, and asking lots of questions will help you
labor and birth, and the practice of exercises, relaxation and
prepare for the birth of your baby. Learning as much as possible
breathing techniques. During labor, the emotional support you
about labor and delivery, and learning what to expect will help you
receive, along with medical interventions, may also affects the
through this next step of your pregnancy.
course of labor.

In this section you will find a wealth of information about:

How Do I Know When Labor Will Begin?
• Labor - what it feels like and what to expect

• Comfort and pain management Each labor is unique. No one can predict exactly what your
• Various forms of labor individual labor will be like, or when it may begin. However, prior to

• How to recognize the early signs of labor andwhen the onset of labor, you will notice some signs that are nature's way

you should go to the hospital of telling you that labor is approaching. If you are not sure, call

• Helpful suggestions and tips for your partner in your physician or midwife to discuss your labor signs. In the event

how to support you through your labor you are evaluated at the hospital as being in very early labor and
sent home, it is common to feel disappointed, maybe even
embarrassed. It is common for first-time mothers to make more

Special Tips for First Time Mothers than one trip to the hospital. If you are in early labor and sent

Having your first baby is an extraordinary experience. We have home, the following may be helpful: walking, showering, resting,

compiled some specific information about labor and childbirth and drinking fluids, renting a video, listening to music, etc.

created these Special Delivery Tips for First-Time Mothers.

The most common signs that labor may soon begin include:

The Process of Labor • The baby "drops" or engages into the pelvis, which
is called lightening. Lightening may occur two to four
weeks prior to labor in first-time mothers and often not
until labor begins if you have previously had children.
• Your abdomen usually appears lower and more
protruding.
• You may experience a greater ease in breathing,
relief from heartburn and an ability to eat larger portions.
• However, the lower position of the baby together
with its greater size, can lead to:
• Increased backache and sacroiliac
discomfort
• Increased awkwardness in walking
• Increased frequency of urination
• Frequent bowel movements may be experienced
within 48 hours of labor, cleansing the lower bowel in
preparation for birth.
• Diarrhea or flu like symptoms without fever.
Indigestion, nausea, or vomiting are common a day or so
before labor begins.
• Increased vaginal discharge during the last few
weeks of pregnancy as the body prepares for the passage
of the baby through the birth canal.
• Increased Braxton-Hicks contractions during the
last weeks of pregnancy, which are "practice" contractions
that prepare the uterus for labor and may cause some
effacement and dilation (thinning and opening) of the
cervix. These contractions do not ordinarily cause pain but
may be sufficiently strong and regular to be confused with
true labor. This is referred to as false labor.
• Possible "bloody show" or the release of slightly
brown, pink or blood-tinged mucus from effacement and
dilation (the thinning and opening) of the cervix, causing
the mucus plug to be released from the cervix.
• Some women notice a sudden burst of energy,
sometimes called a "nesting instinct" approximately 24-48
hours before the start of labor. You may feel a strong
desire to clean the house and prepare for the baby. Try not
to tire yourself as nature gives you this extra energy to
help you during labor. If you must be active, be careful not
to overexert yourself!
• A loss or leveling off in weight may be noticed in
the last few days before labor begins. It is common to lose
1-3 pounds of fluid before labor begins as a result of
hormonal shifts.
• Mother just feels "different," not quite herself.The
bag of water may break. Depending on the location of the
break in the amniotic sac, the break can feel like a gush, or
an uncontrolled trickle of fluid coming from the vagina.
Anxiety and disappointment are very common feelings for mothers
as the "due date" approaches or passes without labor beginning.
Try to keep occupied and active, but do not wear yourself out!
Variations of Labor indication as to whether or not this is really labor. Also, there may
be residual back pain
between contractions. The pushing stage may be longer due to the
Prodromal Labor
extra effort needed to rotate the baby to an anterior position (face
In a prodromal labor, the early phase of labor (cervix dilates from
towards mother's back). Some babies may not rotate and may
closed to approximately three-to-four centimeters) is prolonged
deliver in the posterior position.
with contractions that do not increase in intensity.

Suggestions for Dealing with Back Labor:

Prodromal labor can tire you out and use up the energy you will
• Change positions frequently - Any position in
need for active labor and delivery. Try alternating activities such as
which the weight of the baby is taken off your back is
walking or showering with periods of rest to conserve your energy.
helpful, such as sitting, leaning forward and putting your
While resting you can also drink fluids, watch a movie, or listen to
weight on your elbows, kneeling in bed with the head of
music until you progress to a more active labor. Your physician or
bed elevated, kneeling on your hands and knees.
midwife may suggest prescribing medication to help you sleep,
which can cause the contractions to become stronger and your • Use counter pressure - firm constant pressure

labor to progress. applied to your lower back where the pain is localized. This
can be given by your partner or nurse or by leaning against
a firm object, such as a rolled towel or tennis balls.
Back Labor
• A hot water bottle or an ice pack applied to your
Back labor refers to labor in which much of the pain or discomfort
back may offer some relief.
is felt in the mother's back. Sometimes, the baby is in a posterior
A warm shower or bath may be helpful.
position (facing the mother's abdomen).
• Sterile water injections into the skin of the lower
back. Discuss this with your healthcare provider
How is Back Labor Different?
With back labor, the onset of labor may be felt completely in your
Prolonged Labor
back and may create some confusion about whether labor has
In a prolonged labor, the entire labor progresses at a rate that is
really begun. Feeling your abdomen for "hardening or tightening"
slower than average. A prolonged labor may be due to many
when experiencing rhythmic back discomfort may offer some
factors such as the size or position of the baby or having an
epidural very early in labor.
Relax as much as possible and avoid tiring yourself. Change
positions frequently and use gravity-assisted positions (such as
standing and squatting) during a contraction. Walking and relaxing
in the shower or tub may be helpful. Every woman and her labor
are unique. If your progress is slower than
anticipated, try not to be discouraged. Recognize that this is the
natural progression for your particular labor. Relax and allow
yourself to work with each contraction one at a time.
Precipitous Labor
A precipitous labor progresses very rapidly. Call your physician or
midwife if your contractions suddenly occur one right after the
other of if the intensity of the contractions are not manageable. If
birth appears imminent, CALL 911 and follow the dispatcher's
instructions.
Augmented Labor
Occasionally your labor may not progress even though you have
had frequent contractions. If your bag of waters has not broken,
your physician or midwife may attempt to augment (stimulate)
your labor by breaking the bag of waters. If this is not effective in
stimulating labor, you may be given intravenous pitocin as
described above.
The four stages of the childbirth process are based on changes in
the uterus and cervix as labor progresses. The beginning and end
of each stage are described below:
First Stage of Labor
• Begins at the onset of labor and ends when the
cervix is 100 percent effaced and completely dilated to 10
centimeters.
• Average length ranges for a first-time mother is
from ten-to-fourteen hours and shorter for subsequent
births.
• Read more in our Health Libarary
Labor, Delivery, and Postpartum Period
Active Labor, First Stage
The first stage of active labor starts when the cervix is about 3 cm
(1 in.) to 4 cm (2 in.) dilated. This stage is complete when the
cervix is fully dilated and effaced and the baby is ready to be
pushed out. See a picture ofcervical effacement . During the last
part of this stage (transition), labor becomes particularly intense.
Compared with early labor, the contractions during the first stage
of active labor are more intense and more frequent (every 2 to 3
minutes) and longer-lasting (50 to 70 seconds). Now is the time to
be at or go to the hospital or birthing center. If your amniotic
sac hasn't broken before this, it may now.

As your contractions intensify, you may:
1. Feel restless or excited.
2. Find it difficult to stand.
3. Have food and fluid restrictions. Some hospitals
allow you to drink clear liquids. Others may only
allow you to suck on ice chips or hard candy. Solid
food is often restricted, because the stomach
digests food more slowly during labor. An empty
stomach is also best in the rare event that you may
need general anesthesia.
4. Want to start using breathing techniques,laboring
in water, acupuncture, hypnosis, or other calming
measures that you've chosen to manage pain and
anxiety.
5. Feel the need to shift positions often. This is good
for you, because it improves your circulation. You
may not know which birthing position is right for
you for a while.
6. Want pain medicine, such as epidural anesthesia.
7. Be given intravenous (IV) fluids.
Pregnancy: Should I have an epidural during
childbirth? (For more information about pain medicine
options, see the Labor and Delivery: Your Birthing Options
section of this topic.)
Transition phase
The end of the first stage of active labor is called the transition
phase. As the baby moves down, your contractions become more
intense and longer and come even closer together than before.
When you reach transition, your delivery is not far off. During
transition, you will be self-absorbed, concentrating on what your
body is doing. You may be annoyed or distracted by others'
attempts to help you but still feel you need them nearby as a
support. You may feel increasingly anxious, nauseated, exhausted,
irritable, or frightened.
A mother in first-time labor will take up to 3 hours in transition, and
a mother who has vaginally delivered before will usually take no
more than an hour. Some women have a very short, if intense,
transition phase.
Cervical Effacement and Dilatation
What are effacement and dilatation?
As labor nears, the cervix begins to thin or stretch (efface) and
open (dilate) to prepare for the passage of the baby through the
birth canal (vagina). How fast the cervix thins and opens varies
from woman to woman. In some women, the cervix may efface and
dilate slowly over a period of weeks. A first-time mother often will
not dilate until active labor begins.
Late in your pregnancy, your health professional may manually
check (wearing sterile gloves) how much your cervix has effaced
and dilated.

Effacement
As the baby's head drops down into the pelvis, it pushes against
the cervix and causes the cervix to relax and thin out, or efface.
See a picture of cervical effacement .
Throughout your pregnancy, your cervix has been closed and
protected by a plug of mucus. When the cervix effaces, the mucus
plug is loosened and passes out of the vagina. The mucus may be
tinged with blood. This passage of the mucus plug is called "show"
or "bloody show." You may or may not notice when the mucus plug
passes.
Effacement is described as a percentage. For example, if your
cervix is not effaced at all, it is 0% effaced. If the cervix has
completely thinned, it is 100% effaced.
Dilatation
After the cervix begins to efface, it will also begin to open (cervical
dilatation).
Cervical dilatation is expressed in centimeters from 0 to 10. Zero
means that the cervix is closed, and 10 means that it is completely
dilated.
Second Stage of Labor
• Begins when the cervix is completely effaced and
dilated and ends with the birth of the baby.
• Average length for a first time mother ranges from
1 to-2 hours and shorter for subsequent births.
• Read more in our Health Library
Labor, Delivery, and Postpartum Period
Active Labor, Second Stage
The second stage of active labor is the actual birth, when the baby
is pushed out by the tightening uterine muscles (contractions).
During the second stage:
1. Uterine contractions will feel different. Though they
are usually regular, they may slow down to every 2 to 5
minutes, lasting 60 to 90 seconds. If your labor stalls,
changing positions may help. If not, your doctor may
recommend using medicine to stimulate (augment) uterine
contractions.
2. You may have a strong urge to push or bear down
with each contraction.
3. The baby's head is likely to create great pressure
on your rectum.
4. You may need to change position several times to
find the right birthing position for you.
5. You can have a mirror positioned so you can watch
your baby crown and emerge from the birth canal.
6. When the baby's head passes through the vagina
(crowns), you will feel a burning pain. The head is
the largest part of the baby and the hardest part to
 deliver. If this is happening quickly, your doctor
may advise you not to push every time, which may
give the perineum, or area between the vulva and
the anus, a chance to stretch without tearing. Or
he or she may make an incision in the perineum
(episiotomy). This is not recommended unless
there is a medical need.
7. Your medical staff will be ready to handle anything
unexpected. If an urgent problem comes up,
people will move quickly. You may suddenly have
more people and equipment in the room than
before. This is a time when your doctor or nurse-
midwife will be deciding what is best for you and
your baby.
This pushing stage can be as short as a few minutes or as long as
several hours. You are more likely to have a fast labor if you have
given birth before.
Third Stage of Labor
• Begins with the birth of the baby and ends with the
delivery of the placenta.
• Average length for all vaginal deliveries ranges
from five-to-fifteen minutes.
Fourth Stage of Labor
• Begins with delivery of the placenta and ends one-
to-two hours after delivery.
How Will I know if I am Making Progress?
The progress of labor and the baby's position is determined by an
internal vaginal exam. These exams are not done frequently and
may be done during a contraction. Internal vaginal exams assess:
• Cervical effacement (thinning measured as 0 to
100 percent)
• Cervical dilation (opening measured as 0 to 10
centimeters)
• Baby's presentation (the part of the baby to move
to the pelvis first, e.g. head, buttocks, feet)
• Position of the baby's presenting part (described as
anterior, facing your back, or posterior, facing your front)
• Station (baby's progress down through the pelvis
or birth canal. Measured in minus to plus numbers)
Labor Contractions
Labor contractions are the periodic tightening and relaxing of the
uterine muscle, the largest muscle in a woman's body. Something
triggers the pituitary gland to release a hormone called oxytocin
that stimulates the uterine tightening. It is difficult to predict when
true labor contractions will begin.
Contractions are often described as a cramping or tightening
sensation that starts in the back and moves around to the front in
a wave-like manner. Others say the contraction feels like pressure
in the back. During a contraction, the abdomen becomes hard to
the touch. In the childbirth process, the work of labor is done
through a series of contractions. These contractions cause the
upper part of the uterus (fundus) to tighten and thicken while the
cervix and lower portion of the uterus stretch and relax, helping
the baby pass from inside the uterus and into the birth canal for
delivery.
How Contractions are Timed
Contractions are intermittent, with a valuable rest period for you,
your baby, and your uterus following each one. When timing
contractions, start counting from the beginning of one
contraction to the beginning of the next.
The easiest way to time contractions is to write down on paper the
time each contraction starts and its duration, or count the seconds
the actual contraction lasts, as shown in the example below.
Writing down the time and length of the contraction is extremely
helpful for describing your contraction pattern to your physician,
midwife or hospital labor and delivery personnel.
TIME CONTRACTION STARTS DURATION OF CONTRATION
10:00 45 seconds
10:10 45 seconds
10:15 60 seconds
10:20 55 seconds
What Contractions Feel Like
Many mothers describe contractions that occur in early labor as
similar to menstrual cramps, or as severe gas pains, which may be
confused with flu symptoms or intestinal disorders. Imagine your
contractions as looking like a wave. Each contraction will gradually
gain in intensity until the contraction peaks, then slowly subside
and go away. As your body does the work of labor, it is likely that
the time in between contractions will become shorter.
As the strength of each contraction increases, the peaks will come
sooner and last longer. There should be some regularity or pattern
when timed. Persistent contractions that have no rhythm but are
five-to-seven minutes apart or less should be reported to your
physician or midwife.
Try to visualize contractions as positive
Think of each contraction as something positive—it is bringing you
that much closer to the birth of your baby. Visualize what the
contractions are accomplishing, the thinning and opening of the
cervix and the pushing of the baby downward. Try to work with
your body rather than against it by staying as relaxed as possible
during the contractions.
Typical Length or Duration
A typical labor for a first time mother is eight-to-fourteen hours,
and is usually shorter for a second or subsequent birth. For many
women, rocking in a chair or swaying during a contraction assists
them with this relaxation.
Breathing techniques for labor and delivery
As your due date draws nearer, learn and practice controlled
breathing techniques for pain management during childbirth.
Concentrating on your breathing will help distract you from pain,
relax both your muscles and your mind, and keep your oxygen
supply up.
If you haven't learned specific breathing techniques (such as
Lamaze) in a childbirth education class, practice the following
breathing patterns before you go into labor:
1. In early labor, use abdominal breathing, at about 6
to 9 breaths per minute. As you inhale, expand your
abdomen outward; as you exhale, relax your abdomen
downward.
2. As your contractions become more intense, exhale
in a "pant-pant-blow" pattern, about 6 cycles per
minute.
Laboring in water
Laboring in water
Some hospitals and birthing centers offer tubs or whirlpools for
laboring. If yours does, talk to your health professional about
laboring in water. The warm water supports your body and helps
you to relax. For many women, laboring in water has been proved
to:1
1. Reduce labor pain.
2. Reduce the use of or need for pain medicine.
3. Lower the mother's blood pressure.
 4. Help some women move along a slow labor and
avoid a need for forceps, vacuum, or cesarean
delivery.2
Some time before you are ready to push your baby out, you will
have help getting out of the tub.
2. Kneeling, getting down on your knees and hands,
or leaning onto a birthing ball may help to take
pressure off your back. This position might help
with back labor.
3. Squatting may help you push more effectively.

4. Lying on your back in a semi-reclining position with

Delivering in water
your legs supported by stirrups is a common
A water birth is described as a "gentle birth" for the mother and
birthing position used in the United States. While
baby. There is limited experience with this technique in the
pushing, your health professional may have you
American medical community, and few studies have been done.
grab behind your knees and pull up.
If you are thinking of a water birth, discuss it with your doctor or
5. Lying on your side is helpful if you are tired of lying
nurse-midwife.
on your back.
Some birthing centers use a birthing stool or chair during the
Birthing positions
second stage of labor. A birthing chair may make you feel more
You may find that certain positions are more comfortable than
comfortable. One study has demonstrated a higher incidence of
others during the second stage of labor. Speak to your health
heavy bleeding in women who used a birthing chair (sitting
professional about different birthing positions before your labor
compared with delivering in bed), and in another birthing chair
begins.
study women had no unusual bleeding problems.1

Changing positions often during labor is a good idea.

Laboring in water
1. Sitting in an upright position during labor may be
Some hospitals and birthing centers offer tubs or whirlpools for
more comfortable than lying down. Sitting on a "birthing
early active laboring (though not normally for pushing and
ball," which is typically used for physical therapy or
delivering). If your hospital does, talk to your health professional
exercise, can comfortably help your back and pelvis stay
about laboring in water. The warm water supports your body and
loose while supporting the area between your vagina and
helps you to relax. Among large groups of women, this has been
anus (perineum).
proven to:1
1. Reduce labor pain.
 2. Reduce the use of or need for pain medication. pain that you have depends on the amount of anesthetic used.
Less anesthetic (often called a light epidural) will allow you to be
3. Lower the mother's blood pressure.
more active in your labor and feel enough to push effectively. With
4. Help some women move along a slow labor and
higher levels of anesthetic, you will feel little or no pain from your
avoid a need for forceps, vacuum, or cesarean
contractions. You may be required to remain in bed when an
delivery.2
epidural is used. You will also have a tube placed in a vein
Some time before you are ready to push your baby out, you will
(intravenous, or IV tube) and a fetal monitor.
have help to move from the tub or whirlpool.

Before delivery, the epidural medication dose can be decreased so

Epidural anesthesia for childbirth
that you can push more effectively while remaining alert and
Epidural anesthesia has become a popular and effective form of
relatively comfortable. The epidural catheter can also be used to
childbirth pain relief. It can be used for either a vaginal birth or
numb the area between the vagina and anus (perineum) just
a cesarean delivery (C-section).
before delivery.
Because the amount of medicine given at one time is small,
A doctor trained in the use of anesthesia (anesthesiologist)
epidural anesthesia wears off during labor unless additional
administers epidural anesthesia.
medication is given. Therefore, the use of epidural infusion pumps
Epidural anesthesia involves the insertion of a sterile guide needle
has become more common. With an infusion pump, the epidural
and a small tube (epidural catheter) into the space between the
medication is given continuously in small amounts so that you
spinal cord and outer membrane of the spinal cord (epidural
don't have to worry that the pain relief will wear off during your
space). The epidural catheter is placed at or below the waist. The
delivery.
doctor first uses a local anesthetic to numb the area where the
needle will be inserted. Then the guide needle is inserted and
In addition to more constant pain relief, another benefit of having
removed, while the catheter remains in place. The catheter is
an infusion pump is that it allows you to have more control of your
taped in place up the center of your back with the end taped in
abdominal and leg muscles. It also reduces the chance of side
place on top of your shoulder.
effects related to a standard epidural.

An anesthetic medication is injected into the catheter to numb

Side effects
your body below the insertion site. The amount of discomfort or
The most common side effect from epidural anesthesia is lowering
of the mother's blood pressure. Less common side effects may
include severe headache after delivery, difficulty urinating or
walking after delivery, fever, and prolonged labor. A rare side
effect is seizure.
Because a standard epidural can decrease your ability to push,
a forceps delivery or cesarean delivery (C-section) may sometimes
be necessary. Using less anesthesia (called a light epidural) may
reduce the likelihood of needing a cesarean delivery.
The epidural catheter may be removed right after delivery, or it
may be left in place for several hours to a day and used to give you
pain-relieving medication. This is usually done after a cesarean
delivery. If you are planning to have a tubal ligation before you
leave the hospital (to prevent future pregnancy), the catheter will
be left in place.
Labor Induction and Augmentation
Labor induction
As the end of pregnancy nears, the cervix normally becomes soft
(ripe) and begins to open (dilate) and thin (efface), preparing for
labor and delivery. When labor does not naturally start on its own
and vaginal delivery needs to happen soon, labor may be started
artificially (induced).
Even though inducing labor is a fairly common practice, childbirth
educators encourage women to learn about it and about the
medicine for stimulating a stalled labor (augmentation) so that the
women can help decide what is right for them.
When labor does not happen as expected or as necessary, inducing
labor is preferred over delivering by cesarean section. If labor
induction isn't successful, another attempt may be possible. In
some cases, a cesarean delivery is best for the mother and baby,
depending on their conditions.
Your labor may be induced for one of the following reasons:
1. Your pregnancy has gone 1 to 2 weeks past the
estimated due date.
2. You have a condition (such as high blood
pressure, placenta abruptio, infection, lung
disease, preeclampsia, or diabetes) that may
threaten your health or the health of your baby if
the pregnancy continues.1
3. Your water (amniotic sac) has broken but active
labor contractions have not started.
4. Your baby has a condition that needs treatment,
and the risks of vaginal delivery are low. Induction
and vaginal delivery are not attempted if the baby
may be harmed or is in immediate danger. In such
cases, a cesarean delivery (C-section) is usually
performed.
There are several ways to induce labor contractions.
1. Medicine may be used to soften the cervix and especially in first-time mothers. If oxytocin does
help it thin (efface). not induce labor or if the baby's heart rate

2. Medicine may be used to cause the uterus to indicates distress, a cesarean delivery (C-section)

contract. may be necessary.

3. A balloon catheter (such as a Foley catheter) may 3. Dinoprostone (such as Cervidil or Prepidil Gel) can

be used to help the cervix open. be inserted as a suppository into your vagina
(intravaginally). It can also be given as a gel that is
4. If your cervix is soft and slighty open, sweeping the
gently squirted into the opening of the cervix
membranes or rupturing theamniotic
(intracervically). When the cervix is ripe, labor may
sac (amniotomy) may start or increase
start on its own.
contractions.
5. If labor does not progress after an amniotomy,
The cervix is considered ripe and ready for active labor when it is
medicine such as oxytocin (Pitocin) can be used to
soft, well-dilated, and effaced, and when the cervix and baby are
stimulate contractions.
positioned low in the pelvis. If the cervix is not ripe enough,
medicines may be continued until it is.
Medicine to ripen the cervix and induce labor
1. Misoprostol (Cytotec) is a pill taken by mouth or
Balloon catheter to help induce labor
placed in the vagina (using a smaller dose). It is a medicine
A balloon catheter, such as a Foley catheter, is a narrow tube with
currently approved for treating ulcers. Using it for cervical
a small balloon on the end. The doctor inserts it into the cervix and
ripening is a widely accepted but unlabeled use of this
inflates the balloon. This helps the cervix open (dilate). The
medicine.
catheter is left in place until the cervix has opened enough for the
2. Oxytocin (Pitocin) can be given through a vein balloon to fall out (about 3 cm).
(intravenously) in small amounts to ripen the
cervix. But it usually is given after the cervix Sweeping of the membranes to help induce labor
softens, to cause the uterus to contract. Labor that Sweeping, or stripping, of the amniotic membranes is a simple first
is induced by oxytocin usually starts off harder and step used to try to start labor. Sweeping of the membranes
progresses faster than labor that starts on its own, separates the amniotic membrane from the uterus enough so that
the uterus starts makingprostaglandins. This type of chemical
helps trigger contractions and labor. After the cervix is open a
little, this step can easily be done in your doctor's or nurse-
midwife's office.
Sweeping the membranes works in 1 out of 8 women. This means
that it starts labor without needing to use oxytocin or artificially
2
rupture the membranes. To sweep the membranes, your doctor or
nurse-midwife reaches a gloved finger through the cervix. He or
she then "sweeps" the finger around the inside edge of the
opening.
Sweeping the membranes is low-risk. It does not raise your risk of
infection. You may start to feel uncomfortable afterward, with
2
irregular contractions and some bleeding.
Artificial rupture of the membranes to induce labor
To help start or speed up labor, your doctor may rupture your
amniotic sac (rupture of the membranes). This should only be done
after your cervix has started to open (dilate) and the baby's head
is firmly descended (engaged) in your pelvis. If the membranes are
ruptured too early, there is a risk of the umbilical cord slipping
down around or below the baby's head (cord prolapse). If the cord
gets squeezed between the baby's head and the pelvis bones, the
blood supply to the baby may be reduced or stopped.
To rupture your amniotic sac (amniotomy), your doctor inserts a
sterile plastic device into your vagina. This device may look like a
long crochet hook or may be a smaller hook attached to the finger
of a sterile glove. The hook is used to pull gently on the amniotic
sac until the sac breaks. This procedure is usually not painful. A
large gush of fluid usually follows the rupture of the amniotic sac.
The uterus continues to produce amniotic fluid until the baby's
birth, so you may continue to feel some leaking, especially right
after a hard contraction.
Augmentation
If active labor has started on its own but contractions have slowed
down or completely stopped, steps need to be taken to help labor
progress (augmentation). Augmentation will be done when:
1. Active labor has started, but your contractions are
weak or irregular or have stopped entirely.
2. You have gone into active labor, but the amniotic
sac has not ruptured on its own. In this case, your
doctor or nurse midwife may rupture the amniotic
sac (amniotomy) to augment labor. If labor still
does not progress, oxytocin (Pitocin) may be given
to make the uterus contract.
3. Active labor has started and the amniotic sac has
ruptured on its own, but labor still is not
progressing. Oxytocin (Pitocin) may be given to
make the uterus contract.
For some women, laboring in a warm tub or whirlpool (under
medical care) helps with a slow labor. This can make augmentation
unnecessary.
If labor fails to progress in spite of membrane sweeping, an
amniotomy, oxytocin, or a combination of these measures, delivery
by cesarean section may be considered.
Pre Labor vs. True Labor
If you have never experienced labor before, you may find it difficult
to know if you are in labor. Before heading to the hospital, call your
physician or midwife to discuss your labor symptoms.
It is common for first time mothers to make more than one trip to
the hospital. If you are in early labor and sent home, the following
activities may be helpful: walking, showering, resting, drinking
fluids, listening to music, etc.
Pre-labor vs. True Labor
"How Do I know if I'm Really in Labor?"
Pre-labor can only be differentiated from true labor by an
internal examination of the cervix. True labor contractions become
stronger, difficult to talk through, last longer, and are closer
together as labor progresses. These will effect changes in the
cervix, causing it to thin out and open while encouraging the
descent of the baby through the pelvis.
True Labor
Contractions
• May be irregular at first
• Usually become regular
• Get longer, stronger, and closer together as time
progresses
• Walking usually makes them stronger
• Lying down does not make them go away
• Often begin in your back and move to the front
Cervix
• Changes by becoming thinner and starts to open
(dilates)
False (or "Practice") Labor
Contractions
• Usually are irregular and short
• Do not get longer, stronger, or closer together
• Can last several minutes in length
• Walking does not make them stronger, may even
cause them to stop
• Lying down may make them go away
• May be felt more in the front area and in the groin
area
• Beneficial in preparation for true labor
Cervix
• Very little change or no change; does not thin or
open
Prodromal Labor
Contractions
• May begin irregular and become regular
• Usually stay five or greater minutes apart
• May feel strong, but usually do not get closer
together
• Lying down does not usually make them go away
• May last 24-36 hours without significant cervical
changes
• Resting and sleeping may be challenging
• It is common proactice to be sent home to rest or
to await stronger labor
Cervix
May thin out but not dilate more than
Onset of Labor
Several theories exist as to why labor begins:
• The physical aging of the placenta may cause
insufficient nutrients to reach the fetus.
• The uterus reaches a crucial point of distension,
which may cause tension on muscle fibers and stimulate
their activity.
• Nerve impulses from the uterus to the posterior
pituitary gland may bring about release of oxytocin (a
hormone which causes the uterus to contract).
• Decrease in the level of the hormone pregesterone,
may cause uterine changes.
• Adrenal glands of the fetus, when mature, may
release a substance to stimulate labor.
• The release of prostaglandin from the wall of the
uterus may initiate labor.
When to go to the hospital
Most physicians and midwives suggest contacting them when your
contractions are five minutes apart and lasting 60 seconds and you
have had this activity for about an hour. When you reach your
doctor or midwife, be prepared to tell him/her:
• How far apart the contractions are, their length and
intensity, and if you are using breathing techniques
• Whether or not the bag of waters has broken, the
time it broke, and the color of the fluid
• If a bloody show is present.
Your physician or midwife will instruct you when to leave for the
hospital. If you are a first-time mother and are able to manage the
contractions at home, new research is suggesting that first-time
mothers should continue to stay at home until it is difficult to
breathe through the contractions. However, if you live a great
distance from the hospital, are concerned about not getting there
on time or have other special concerns, plan on leaving sooner. Premature Labor

Occasionally, labor may begin prematurely. Although you may not

What to Expect when you arrive at the Hospital
be at risk for premature labor, it is important to know the signs and
When you arrive in labor and delivery, a nurse will check your
symptoms that may indicate an early onset of labor. Many
blood pressure, temperature, may obtain both blood and urine
pregnancy symptoms, such as backache, are common discomforts
samples, and place devices on your abdomen that monitor the
throughout pregnancy and may or may not indicate premature
baby's heart rate and your contractions. The nurse, your on-call
labor. The following information will help you understand what is
physician, or midwife will then perform a vaginal exam to evaluate
normal and when you need to call your health care provider.
the dilation and effacement of your cervix. It is best to be admitted
when active labor begins, especially if you are a first-time mother.
What is premature labor?
In active labor, the contractions are less than five minutes apart,
Premature labor is labor that occurs before the 37th week of
lasting 45-60 seconds and the cervix is dilated three centimeters
pregnancy due to uterine contractions that cause the cervix
or more.
(mouth of the uterus) to open earlier than normal. This can result
in the birth of a premature baby.
Depending on your stage of labor, contraction pattern, how far
dilated you are and fetal heart tracing, your physician or midwife
may admit you to the hospital, or suggest returning home until the What is a contraction?
contractions are closer together. In the event you are in early labor When any muscle in your body contracts, it becomes tight and
and sent home, it is common to feel disappointed, maybe even hard to the touch. As the muscles of your uterus contract, you will
embarrassed. Activities such as walking, showering, resting, feel your abdomen harden. As the contraction goes away, your
drinking fluids, renting a video, or listening to music, can be very uterus and abdomen soften.
helpful in early labor.
It is normal for your uterus to contract during your pregnancy. The
If you are admitted and have had a positive culture for Group B muscle layers of the uterus tighten sporadically from the early
Beta Strep during your pregnancy, or have any risk factors, you weeks and throughout pregnancy. You may feel them as early as
will receive antibiotics prior to delivery. four months, but many women do not notice them until seven or
eight months. Usually, these contractions are not painful. You may
notice more contractions when you first lie down, after orgasm, if
you have a full bladder, or after you walk up and down stairs. Also
known as Braxton-Hicks, these normal contractions are usually
irregular and do not change or open the cervix. If these
contractions become regular (e.g., every 10 to 12 minutes for at
least one hour), they may be preterm labor contractions, which
can cause the cervix to change or actually open.
How do I check for contractions?
Lie down and place your hand on your uterus to feel the tightening
and softening. Usually during contractions, your entire abdomen
will feel hard, not just one area. Sometimes you may confuse the
baby’s movement with contractions, especially as the baby grows.
It is common for your abdomen to be firm over the baby’s head
and buttocks, but in the absence of uterine contractions, your
abdomen should be soft in all other areas.
Timing contractions
If your uterus is tightening and softening at regular intervals, you
may want to time these contractions. Start timing from the
beginning of one tightening to the start of the next tightening for
about one hour. Some tightening feels harder or stronger than
others. It is not normal to have frequent contractions (more than
five in an hour) before your baby is due.Call your health care
provider immediately if you think you may be in premature
labor.
Warning signs of premature labor
Below are signs and symptoms of premature labor. Call your
health care provider if you suspect you are in premature
labor. Waiting too long to call for help could result in your
baby being born too early.
Premature Labor Signs and Symptoms
• A contraction every 10 minutes or more often
within one hour (five or more uterine contractions in an
hour)
• Watery fluid leaking from your vagina (could
indicate that your water bag is broken)
• Menstrual-like cramps
• Low, dull backache
• Pelvic pressure that feels like the baby is pushing
down
• Abdominal cramps that may occur with or without
diarrhea
• Unusual or sudden increase of vaginal discharge
• Blood from your vagina
If you think that you may be in premature labor, call your
health care provider immediately and:
• Empty your bladder
• Lie down on your left side and drink fluids
Risk factors associated with premature labor
Some risk factors have been associated with a higher chance of
premature labor. However, just because you have some risk
factors does not mean that you will experience premature labor.
Review the following risks factors and let your health care provider
know if any apply to you.
Possible risk factor for premature labor:
• Premature labor or delivery during a previous
pregnancy
• Misshapen uterus
• DES (Diethylstilbestrol) daughter (If your mother
was prescribed this medication during her pregnancy to
prevent miscarriage, you are considered a DES daughter.
DES has been linked to shortening of the cervix.)
• Abdominal surgery during pregnancy and/or
cervical cerclage (a stitch in your cervix)
• More than two second trimester miscarriages or
elective abortions
• Previous Cone Biopsy or LEEP (procedures used to
diagnose and/or treat the cervix of women with abnormal
Pap tests)
• Carrying more than one baby
• Dehydration
• History of cervical change and/or excessive uterine
contractions at less than 33 weeks in a previous pregnancy
• Serious infections with fever (greater than 101
degrees Fahrenheit) during this pregnancy
• Recurring bladder and/or kidney infections
• Excessive amount of amniotic fluid
• Unexplained vaginal bleeding after 20 weeks of
pregnancy
• Using recreational drugs, such as cocaine or
amphetamines
• Domestic violence
• Smoking more than 10 cigarettes per day
• Extreme emotional or physical stress
Induced Labor
Your physician or midwife may consider initiating your labor for
several reasons:
• To decrease the risk of infection if your bag of
waters has broken
• You are more than one week overdue
• You have other medical conditions such as
diabetes or high blood pressure (pre-eclampsia).
Inductions can occur either by your physician or midwife initially
breaking your bag of water or by intravenous administration of a
medication calle pitocin. Pitocin is a synthetic form of the natural
hormone oxytocin, which stimulates the uterus to contract. Often a
medication, misoprostol, is inserted vaginally prior to induction to
increase elasticity of the cervix, to stimulate the contractions and
enhance the effect of the pitocin.
Continuous fetal monitoring is necessary when pitocin is used. An
intravenous pump carefully controls the quantity of pitocin given.
Usually, the pitocin is increased in small increments to gradually
intensify the quality of contractions, somewhat like a spontaneous
labor. Many women, however, find contractions with pitocin are
stronger, peak more rapidly, and are more intense and painful.
Because of these intense contractions, the labor may also be
shorter. First-time mothers refer toSpecial Tips for First-Time
Mothers for more information.
Pushing: The Second Stage of Labor
The pushing stage occurs after the cervix is completely dilated and
no longer in front of the baby's head. A smooth passageway now
exists through which you can push your baby from the uterus and
down through the birth canal to delivery.
Your contractions may decrease just prior to getting the urge to
push. You should take this time to rest prior to pushing. The length
of this stage varies with the position and size of the baby and your
ability to push with the contractions. For first-time mothers the
average length of pushing is one-to-two hours. In some instances,
pushing can last longer than two hours if mother and baby are
tolerating it. Normally, the baby is born with his face looking
toward mother's back (referred to as an anterior position).
However, some babies are facing the mother's abdomen (referred
to as a posterior position). Posterior babies may have a more
difficult time passing through the pelvis, which may cause pushing
to be more difficult or require more than two hours of pushing.
Contractions during the Pushing Stage
During the second stage of labor, the uterus continues to contract
about every five minutes and each contraction lasts 45-to-90
seconds. The contractions are usually strong and forceful and may
or may not be accompanied by an urge to push. This can make this
phase somewhat more enjoyable since you are now working with
each contraction. A renewed sense of energy may occur as you
feel the closeness of your baby's birth!
However, sometimes after a long or difficult labor, the pushing
stage can be exhausting and uncomfortable.
Most women will feel increased pressure in their perineum, rectum,
and low back at this stage. For many women, the rectal pressure
feels the same as having a bowel movement.
As the baby's head begins to appear, you may feel a stretching or
burning sensation. You may want a mirror positioned so that you
can see your progress.
Delayed Pushing
Pushing is most effective when the mother feels the urge to push.
Women who receive epidural anesthesia may have the sensation
to bear down numbed by the anesthetic. The practice of "delayed
pushing" (waiting for the baby to passively come through the birth
canal) has been studied as an alternative to start pushing at 10
centimeters. If you and your baby are doing well, a one-to-two hour
period of "passive descent" is safe and may make your pushing
more effective.
Positions for Pushing
There are many different positions that may be used for pushing.
In all positions, keep your chin down and use a rounded back to
help your abdominal muscles assist your uterus in pushing your
baby.
The following suggestions of various positions for pushing and
advantages of each one. You may be able to speed the progress of
the labor if you try positions where gravity assists you (i.e. sitting,
or squatting). However, if the baby is delivering quickly, you may
be able to slow the stretching of the perineum by trying positions
where gravity is neutral (i.e. lying on your side, or getting on your
hands and knees). It is important for your comfort to experiment
with pushing in different positions. Many women find pulling a
towel or sheet held by a partner or tied on the squat bar to be very
effective during a pushing contraction.
Stopping your Pushing
There may come a time when you may be asked not to push with a
contraction. This is for reasons such as the cervix is not fully
dilated or the baby is crowning and the perineum needs to stretch
gradually. Usually these situations require you to stop pushing for
a short time. During this time, relax your neck, shoulders and legs
and pant or blow out during the contraction. Visualize blowing out
candles. Your partner may need to hold your face, look directly in
your eyes, and pant or blow with you to keep you from pushing.
Pushing, for many mothers, is a powerful reflex that requires
considerable effort to breathe through rather than to push through.
Breathing Techniques for Pushing
The breathing techniques used for pushing are varied and depend
upon which works best for you. Your health care provider and labor
nurse(s) will offer suggestions and are your most valuable
resources in evaluating your progress as you push your baby
through the birth canal.
Work with your contractions to enable yourself to maximize your
efforts at the peak of the contraction. Grunting or groaning may be
helpful while pushing. Allow yourself the freedom to make the
sounds that come naturally. It is unnatural and possibly damaging
to you and your baby to hold your breath for a long time. Holding
your breath while pushing is fine to do if you feel it assists with
bearing down.

Breathing and Relaxation
During labor you will find that there are several tools available for
you to use that might make the labor more comfortable and more
efficient. As labor becomes stronger, and the contractions more
intense, you may find the following three tools very helpful:
1. Relaxation — This is the main key for labor. It
allows you to save energy for the stronger, harder labor to
come, and provides increased oxygen for you and your
baby.
2. Positioning — Frequent position changes with
particular emphasis on positions that are upright and work
effectively with gravity. Read about different labor
positions
3. Breathing Techniques — Laboring mothers will
find that as the contractions get stronger and labor
intensifies, and using specific breathing techniques can be
very helpful.
Fetal Monitoring
Fetal monitoring is by and large done electronically in birthing
facilities. Electronic Fetal Monitors are used to detect and trace the
fetal heart rate and uterine contractions. These are usually
monitored at the same time however, each one can be obtained
separately. In terms of electronic fetal monitoring, it is either
external or internal.
Fetal monitoring is a valuable tool for measuring fetal well being
and assessing labor progress. Due to the sensitivity of the monitor,
it may indicate a contraction is diminishing even before you notice
the pain subsiding. This information can be a very useful energy
saving tool and source of encouragement for you and your partner.
Continuous electronic fetal monitoring does limit your mobility
regarding walking around, however, if you are able, sitting up in a
chair or on the side of the bed with your legs supported are options
to staying confined to the bed.
External Fetal Monitoring
External fetal monitoring means that the baby's heartbeat is
detected by placing a small round ultrasound (high-speed sound
waves) disc with ultrasound gel on your abdomen and held in place
by a lightweight stretchable band or belt. Uterine contractions are
recorded from a pressure-sensitive device that is placed on your
abdomen and also held by a lightweight stretchable band or belt.
External monitoring of contractions in this manner only tells how
often your contractions are occurring and how long each is lasting,
but not their actual strength.
When you first arrive at the hospital or birthing center, part of the
initial assessment of you and the baby is 20-30 minutes of
externally monitoring your uterine contraction pattern and the
baby's heart rate in response to them. Usually, if the initial fetal
heart rate and contraction pattern show that both mom and baby
are doing well, the monitor is removed and used intermittently. If
there are no indications for continuous fetal monitoring, it is OK to
ask the nurse to remove the monitor to allow you to walk.
Internal Fetal Monitoring
If your physician, midwife or labor nurse(s) feel a need to observe
the baby's heartbeat more closely, internal monitoring may be
used. A smallelectrode is attached to the baby's scalp to directly
monitor the baby's heartbeat. This is possible only after the bag of
water has/or is broken. Internal fetal heart rate monitoring may be
more comfortable since one of the pieces places around the
mother's abdomen will be removed, which allows more freedom of
movement.
Depending on your labor progress, it may also become necessary
for your provider and labor nurse(s) to know the actual strength of
your contractions. This is done internally by performing a vaginal
exam and placing a thin, catheter-shaped monitoring device inside
the uterus.
Internal fetal monitoring is a valuable tool for measuring fetal well-
being and strength of contractions. Due to the sensitivity of the
monitor, it may indicate a contraction is diminishing even before
you notice the pain subsiding. This information can be seen on the
fetal monitor graph paper and can be a very useful energy saving
tool and source of encouragement for you and your partner.
Continuous electronic fetal monitoring does limit your mobility
regarding walking around. However, if you are able, sitting up in a
chair or standing at the bedside are options to staying confined to
lying in the bed.
Episiotomy
An episiotomy is a surgical incision made in the perineum (the area
between the vagina and the rectum) to enlarge the vaginal
opening. An episiotomy may or may not be needed. Techniques
such as perineal massage or warm compresses may assist in
softening and stretching the skin of the perineum. However, if the
delivery is imminent, the numbing effect of the baby’s head
pressing against the perineum may enable the incision to be
performed without discomfort and the use of local anesthesia.
Discuss management of pushing with your physician or midwife
prior to delivery.
Activities to try in the prenatal period that may assist
relaxation of the perineum are:
• Kegels/Pelvic-Floor Bulging
• Education - Know what to expect during the
pushing stage and effective pushing techniques
Activities to try during the pushing stage to help relax the
perineum:
• Release the perineum by doing a Kegel squeeze
and relax.
• Use various positions. Gravity assisted positions Rather than discuss episiotomy during delivery, it's a good idea to
are the most advantageous. go over it with your health professional at one of your prenatal

• Cooperate with your physician, midwife and labor visits.

nurse(s) during the birth (i.e. lie back and blow if instructed
not to push to allow your baby to come out slowly, and Cesarean Birth (C-section)

stretch the perineum gradually). Having a cesarean birth, means your baby is delivered through
incisions in the abdominal wall and uterus instead of being
• Warm compression on perineum by your coach.
delivered vaginally. Some cesarean births are planned because it is
known prior to labor that a vaginal delivery is not recommended
Episiotomy or perineal tear
for the safety of the mother and/or baby. Many however are not
An episiotomy is an incision made in the tissue between the vagina
planned and occur because of events in labor that indicate a
and anus (perineum). It is sometimes done just before a baby's
vaginal delivery is not possible or may jeopardize the safety of the
head emerges from the birth canal to speed up delivery of the
mother and/or baby. Because many cesarean births are not
baby. The incision is stitched up after delivery. Episiotomies are
planned, it is important to discuss this with your healthcare
more commonly used during first-time deliveries.
provider or childbirth educator and become familiar with the
Routine episiotomy is not recommended. Experts say that
procedures involved in a cesarean birth at your hospital.
episiotomy:1
1. Usually is not needed, especially during routine
Indications for Cesarean Birth
deliveries.
 Cephalopelvic Disproportion (CPD) — Occurs when the
2. Does not tend to heal faster than a perineal tear
baby's head will not fit through the pelvis. This diagnosis may also
and typically causes more pain.
be used to indicate a labor that fails to progress, (a prolonged
3. Can cause more damage to the muscles around labor, an extended period of time since rupture of membranes or
the vagina and rectum than a tear does. weak, ineffective contractions.)
There are times when an episiotomy is urgently necessary. The
decision about whether to have an episiotomy cannot be made
 Fetal Distress — The baby is not receiving enough oxygen. It
until delivery. If your health professional decides that an
may be indicated by an abnormal fetal tracing, or a drop in the
episiotomy is necessary, it will be just before delivery.
fetal heart rate when your healthcare provider or labor nurse
listens to the rate during or after a contraction. his/her oxygen supply.

A good way to become more familiar with cesarean birth is to

 Abnormal Position of the Baby — Instead of the baby's head
attend a class. Check with your hospital to see if one is offered.
presenting first in the pelvis with his/her chin tucked inward, the
presenting part of the baby may be his/her head extended
Assisted Delivery
outward, the shoulder, bottom (breech) or leg(s).
Occasionally your pushing efforts may need assistance. This may
occur in situations such as:
 Prolapsed Cord — When the umbilical cord is in the vagina
ahead of the baby. This most commonly occurs after the
• There is a sudden change in the fetal heart rate or
maternal condition that require immediate delivery. (In this
membranes rupture and the baby is in a breech position or his/her
situation, the baby is often low enough in the birth canal to
head is not well engaged in the pelvis. This is an emergency and
accommodate immediate vaginal delivery rather than
an immediate cesarean section is necessary to prevent the
cesarean delivery.)
presenting part from compressing the cord and cutting off the
oxygen supply to the baby. • The baby is turned and in a difficult position for
delivery, such as a posterior position.
• There is ineffective pushing due to numbness from
 Abruptio Placentae — The placenta partially or completely
anesthesia.
separates from the uterine wall before the baby is born. This is an
• The mother is exhausted and unable to continue to
emergency and an immediate cesarean birth is necessary to
push effectively.
prevent the mother from hemorrhaging, which can cause the baby
to lose all or part of his/her oxygen supply.
When delivery is assisted with either forceps or vacuum
extraction, some form of anesthesia is administered before the
 Placenta Previa — A condition in which the placenta partially forceps or vacuum is applied. Assisted deliveries should be
or completely covers the cervix. The degree of severity determines discussed with your physician or midwife, however, a physician
whether or not a cesarean birth is indicated. If the cervix is performs assisted deliveries.
completely covered, a cesarean is mandatory since the placenta
would deliver first in a vaginal delivery and the baby would lose Forceps
Forceps are instruments that are placed on the baby's head to turn
the baby and/or assist the mother with delivery. Forceps are most
commonly used when the baby is in the lower portion of the
vaginal outlet (low forceps delivery). Only on rare occasions would
forceps be applied in a higher position. If forceps marks (small
reddened areas on the baby's cheeks) appear, they tend to fade
quickly.
Vacuum Extractor
Suction is applied to the baby's head to help turn his head and/or
assist with delivery. The baby may have a bruise on the area in
which the suction cup was attached. This bruise will gradually fade.
Amniotic Fluid/Bag of Water
Amniotic fluid is a clear odorless liquid, which surrounds and
protects the baby in the uterus and provides a protective barrier
from the outside environment.
Why is the Amniotic Fluid/Bag of Waters Important?
The amniotic fluid, or bag of waters, surrounds and protects the
baby in the uterus and provides a protective barrier from the
outside environment. Once the bag of waters breaks, bacteria now
has a way of entering the uterus through the vagina and could
cause an infection in either the baby, the mother or both.
Therefore, you should not douche, or have intercourse after the
bag of water breaks.
How Will I Know the Bag of Waters has broken?
The bag of waters could break spontaneously with either a gush of
fluid or a continuous, uncontrollable trickle of fluid from the vagina.
It is sometimes difficult to determine, even for physicians,
midwives and labor nurses, if the fluid you are leaking is amniotic
fluid or urine. If you are unsure, follow these steps:
1. Empty your bladder.
2. As more fluid leaks, collect some on a sanitary pad.
3. If it has a yellow color, it is probably urine.
Amniotic fluid is usually colorless and odorless.
4. Do a Kegel exercise by holding the pelvic floor
muscle tight and see if the fluid stops leaking. If the fluid
stops, it is probably urine.
If there is any question that your water may have broken,
contact your healthcare provider.
What do I do if My Water Breaks?
Note the color of the fluid and the time when the water broke
and call your physician or midwife. If the fluid is clear and your are
having only mild contractions or none at all, your physician or
midwife may have you stay home for awhile. If the amniotic
fluid is green, brownish-yellow, or anything other than
clear in color, notify your physician or midwife and come to
the hospital as soon as possible.
Although most physicians and midwives prefer babies to be
delivered 24 hours (or less) after the rupture of membranes to
prevent infection, some physicians and midwives allow women to
labor longer. Check with your physician or midwife regarding the
timeframe they follow with ruptured membranes and how they
monitor for infection.
There is no such thing as a "dry birth." Approximately one third of
the liquid is replaced every hour.
Rupture of the membranes
During pregnancy, your membranes break (rupture) when a hole or
tear develops in the fluid-filled bag (amniotic sac) that surrounds
and protects the fetus. The rupture of the membranes is also called
“breaking of the waters.”
Your membranes can break by themselves (spontaneous rupture of
the membranes), or they may be ruptured by the doctor or nurse-
midwife to start or speed up labor (artificial rupture of the
membranes). The spontaneous rupture of the membranes most
often happens once active labor has started, not prior to the start
of labor.
Your contractions may get stronger after your membranes rupture.
A large gush of fluid usually follows the rupture of the membranes.
The uterus continues to produce amniotic fluid until the baby's
birth, so you may continue to feel some leaking, especially right
after a hard contraction (tightening of the muscles of the uterus).
Spontaneous rupture of the membranes
Sometimes it is hard to tell if your membranes have ruptured. As
you approach your due date, your uterus puts increasing pressure
on your bladder. A strong Braxton Hicks contraction or sneeze can
cause some leakage of urine. This is sometimes mistaken for a
rupture of the membranes.
If you are lying down when your membranes break, you are more
likely to experience the rupture as a gush of liquid. If it happens
when you are standing up, it's more likely to be just a trickle
because the baby's head gets pushed down against the cervix and
acts like a cork when you stand.
If you believe your membranes have ruptured:
1. Contact your health professional. Your health
professional may want to evaluate you as soon as your
membranes rupture.
2. Avoid letting anything enter your vagina. Do not
have sexual intercourse or flush the vagina with
fluid (douche).
You can also go to the place you have selected for the delivery of
your baby. The health professionals there will test the drainage to
determine if it is amniotic fluid.
Amniotic fluid is normally a cloudy-white to an amber-straw color.
Let your health professional know if the leaking fluid is:
1. Dark or greenish. Meconium (from a baby's first
bowel movement) may be present. Bloody show

2. Foul-smelling. This could be a sign of infection in Bloody show is blood-tinged mucus that may come from the vagina

the uterus. as labor begins. When the cervix thins (effaces) and opens (dilates)
during early labor, the mucus plug that has been in the cervix will
3. Bloody. Small streaks of blood are normal, but if
loosen and pass out of the vagina, along with a small amount of
the entire fluid is stained with blood, it could be a
blood.
sign of a problem with the placenta.

Cervix
Artificial rupture of the membranes to induce labor
The cervix is the lower part of the uterus that opens into the
To start (induce) or speed up labor, the health professional may
vagina. It is also called the neck of the uterus.
rupture your membranes. This should only be done after
your cervix has started to open (dilate) and the baby's head is
Amniotic sac
firmly descended (engaged) in your pelvis. If the membranes are
The amniotic sac, or amnion, is a lining (membrane) inside the
ruptured too early, there is a risk of the umbilical cord slipping
uterus that contains the fetus and the fluid that cushions the fetus
down around or below the baby's head (cord prolapse). If the cord
(amniotic fluid). The amniotic sac is also called the “bag of waters.”
gets squeezed between the baby's head and the pelvis bones, the
blood supply to the baby may be decreased or stopped.
Perineum
The perineum is the muscle and tissue near the anus. In a woman,
To rupture your amniotic sac (amniotomy), your health
the perineum is between the anus and the vulva, while in a man, it
professional inserts a sterile plastic device into yourvagina; the
is between the anus and the scrotum.
device may look like a long crochet hook, or it may be a smaller
hook attached to the finger of a sterile glove. The hook is used to
Intravenous
pull gently on the amniotic sac until the sac breaks. This procedure
Intravenous means occurring within or by way of a vein.
is usually not painful. A large gush of fluid usually follows the
Medications or fluids may be given by inserting an intravenous (IV)
rupture of the amniotic sac. The uterus continues to produce
needle into a vein, usually in the back of the hand or on the
amniotic fluid until the baby's birth, so you may continue to feel
forearm
some leaking, especially right after a hard contraction.

Cesarean section
A cesarean section, or C-section, is the surgical delivery of an
infant through an incision in the mother's abdomen and uterus.
Some cesarean sections are planned when a known medical
problem would make labor dangerous for the mother or baby,
while others are done when a quick delivery is needed to ensure
the mother's and infant's well-being.
Situations in which a cesarean section may be used include:
• Fetal distress.
• Stalled labor that doesn't respond to medications or other
methods.
• Breech delivery.
• Placenta problems.
• A mother's HIV or active genital herpes infection.
• Some multiple pregnancies.
• Umbilical cord problems that reduce blood flow to the
fetus.
• Maternal illness that makes it dangerous to undergo the
stress of a vaginal birth.
The incision may be made across the bottom of the abdomen
above the pubic area (transverse) or, in certain cases, in a line
from the navel to the pubic area (vertical). In many cases, a
woman delivering by cesarean can remain awake during the
childbirth and be with her newborn soon afterward.
A cesarean section is a surgical procedure, and recovery takes
longer than after a vaginal delivery. A woman recovering from a
cesarean delivery requires extra help during the first week or so
after delivery.
High blood pressure (hypertension)
High blood pressure, or hypertension, is a condition in which the
force of blood against artery walls is too strong. Over time, high
blood pressure can damage the arteries, heart, and kidneys and
can lead to heart disease and stroke.
High blood pressure can be treated effectively with lifestyle
changes and medications that can reduce the risk of complications.
Blood pressure readings consist of an upper number and a lower
number (such as 120 over 90 or 120/90). The upper number is
systolic blood pressure; the lower number is diastolic blood
pressure. Blood pressure readings are measured in units called
millimeters of mercury (mm Hg). Normal blood pressure is 119 mm
Hg systolic over 79 mm Hg diastolic or below.
A person has high blood pressure (hypertension) when either or
both of the following are present:
• The top number (systolic) is 140 mm Hg or higher.
• The bottom number (diastolic) is 90 mm Hg or higher.
Placenta abruptio
Placenta abruptio is the separation of the placenta from the uterus
before a baby is delivered, typically in the third trimester of
pregnancy but sometimes earlier. This can lead to preterm birth,
low birth weight [at or below 2500 g (5.5 lb)], and major maternal
blood loss.
Since the placenta delivers oxygen and nutrients from the mother's
bloodstream to the fetus and carries waste products away from the
fetus, placenta abruptio can be life-threatening for a mother (from
severe bleeding), her fetus, or both.
Separation of the placenta from the uterus may be partial or
complete. A partial separation may cause only minor bleeding and
not endanger the lives of the fetus or mother. In rare cases, a
complete separation may lead to fetal death and severe bleeding
that can endanger the mother's life.
Symptoms of placenta abruptio can include light or heavy vaginal
bleeding, uterine tenderness or pain, or signs of preterm labor. A
pregnant woman with any of these symptoms must seek
emergency medical attention.
Certain factors increase the risk of placenta abruptio, including
high blood pressure, a previous placenta abruptio, smoking or drug
use while pregnant, injury to the abdomen, multiple pregnancy, a
blood-clotting disorder, and a fibroid or scar tissue on the uterus
where the placenta grows.
Preeclampsia
Preeclampsia (which used to be called toxemia of pregnancy) is a
pregnancy-related blood circulation problem that causes high
blood pressure and affects the mother's kidneys, liver, brain, and
placenta. Its cause is unknown.
Preeclampsia most commonly occurs during first pregnancies.
Signs of preeclampsia include:
• Elevated blood pressure (generally 140/90 millimeters of
mercury [mm Hg] or higher). This could be higher systolic
blood pressure (the first number), or higher diastolic blood
pressure (the second number), or both. Any large increase
in blood pressure should alert a woman and her doctor to
possible risk.
• Persistent headache.
• Vision problems.
• Pain in the upper right abdomen.
• Lab results indicating elevated uric acid and/or protein in
the urine (proteinuria).
• Swelling of the hands and face that does not go away
during the day. This symptom of normal pregnancy may be
a sign of preeclampsia if it is accompanied by other signs
of preeclampsia.
Preeclampsia typically occurs after the 20th week of pregnancy. It
can develop much earlier in a multiple or molar pregnancy than in
a normal pregnancy. Preeclampsia can develop gradually or
suddenly and may remain mild or become severe. If untreated,
preeclampsia may damage the mother's liver or kidneys, deprive
the fetus of oxygen, and cause eclampsia (maternal seizures).
A woman with any signs of preeclampsia is closely monitored by
her doctor or nurse-midwife. Preeclampsia can be treated in the
hospital with bed rest, medication, and close monitoring of the
mother and fetus. If not treated, preeclampsia may damage the
mother's liver or kidneys and can cause seizures (eclampsia). In
rare cases, coma and death of the mother and fetus can follow.
Delivery is the only true “cure” for preeclampsia. This has to be
balanced with how far along the pregnancy is and whether it is
safe for the fetus to be delivered. Within the first few days
following delivery, the mother's blood pressure usually returns to
normal. With severe preeclampsia, it may take at least 6 weeks for
blood pressure to return to normal.
Diabetes
Diabetes is a lifelong condition in which sugar (glucose) remains in
the blood rather than entering the body’s cells to be used for
energy. This results in persistently high blood sugar, which, over
time, can damage many body systems.
Symptoms of diabetes include increased thirst and frequent
urination (especially at night); unexplained increase in appetite;
unexplained weight loss; fatigue; erection problems; blurred vision;
and tingling, burning, or numbness in the hands or feet.
People who have diabetes are at increased risk for many serious
health problems, including hardening of the arteries
(atherosclerosis) and heart problems, eye problems that can lead
to blindness, circulation and nerve problems, and kidney disease
and kidney failure.
Pregnant women with uncontrolled diabetes have an increased risk
of miscarriage and birth defects.
Diabetes is treated with diet and lifestyle changes and with
medications (such as insulin or oral medications). If blood sugar
levels are kept within the recommended range, the risk for many
complications from diabetes decreases.
Unlabeled use
An unlabeled use of a drug is when a doctor prescribes a
medication for a purpose other than that for which it has been
specifically designed and approved. Sometimes a drug is
prescribed for a specific unlabeled use so often that doctors
consider it a common practice.
In the United States, the Food and Drug Administration (FDA)
approves drugs for specific uses.
Intravenous
Intravenous means occurring within or by way of a vein.
Medications or fluids may be given by inserting an intravenous (IV)
needle into a vein, usually in the back of the hand or on the
forearm.
Vulva
The vulva is the area surrounding the opening of the vagina. The
vulva includes the small, sensitive structure (clitoris) that becomes
stimulated during sexual activity and the folds of skin or lips (labia)
that cover the vagina and the opening of the tube leading from the
bladder (urethra).
Rectum, Anus, and Anal Sphincter
The rectum is a muscular tube about 5 in. (12.7 cm) long that is at
the end of the large intestine (colon). The rectum connects the
colon to the anus, which is the opening where stool exits the body.
The internal and external anal sphincters are rings of muscle at the
opening of the anus. The sphincters keeps the anus closed as stool
collects in the rectum. Eventually the pressure on the rectum wall
causes the internal anal sphincter to relax. Conscious control over
the external anal sphincter allows stool to pass out of the body
through the anus.

Episiotomy
An episiotomy is an incision made in the tissue between the vagina
and anus (perineum) during childbirth, just before the baby's head
is delivered. An episiotomy may be done to help deliver the baby
or to help prevent the muscles and skin from tearing.
After delivery, an episiotomy incision is stitched closed.
Episiotomies can be different depths. For instance, a second-
degree episiotomy is a relatively small incision, while a fourth-
degree episiotomy extends from the vagina into the rectum.
Smaller episiotomies heal faster and with less pain.