Common Variations in Labor and Birth

 

Pre-Term Labor

Post-Date Pregnancy

Precipitous (Fast) Labor

Prolonged (Slow) Labor:

·    Slow Early Labor

·    Slow Active Labor

·    Prolonged Pushing

Back Labor

 

Pre-term Labor

What is it? Onset of rhythmic contractions that produce cervical dilation before 37 full weeks of gestation.

How common is it? 6-10% of births are premature.

Why is it a problem? Although modern medicine has greatly improved the survival rates of premature babies, they do have more health complications than term babies.

What increases my risk of pre-term labor? Lack of prenatal care, multiple fetuses, age under 16 or over 40, obesity or very low weight, cigarette smoking, alcohol or drug abuse, maternal medical illness, high blood pressure, strenuous physical work, unusual emotional stress or anxiety, current infection of vagina or urinary tract.

What can you do about it? Consult with caregiver. Drink several glasses of water, bed rest on your left side, avoid nipple stimulation and sexual activity.

What can your caregiver do? Prior to 37 weeks, they might suture cervix closed, recommend bedrest, or give medication to stop or slow labor. After 37 weeks, usually labor will be allowed to progress; caregiver may recommend amniocentesis to determine lung maturity, or may recommend birthing in a hospital with a newborn intensive care unit.

 

Post-date Pregnancy

What is it? A pregnancy lasting 42 or more weeks from the start of the last menstrual period.

How common is it? 4-14% of pregnancies.

Why is it a problem? Going past the due date can carry these risks: the placenta may become less able to provide baby with enough oxygen and nutrients, chance of a pinched umbilical cord increases as amount of amniotic fluid decreases, higher possibility of fetal distress, higher chance of baby inhaling meconium from a bowel movement in utero, and chance that the baby will grow too large.

However, only a small percentage of “late” babies display postmaturity syndrome. According to ACOG, 95% of babies born between 42 and 44 weeks are born safely.

Post-date pregnancy can also be frustrating and discouraging for women who are “sick of being pregnant” and who are impatient to see their babies.

What can you do about it? Stay calm, having faith in your body’s wisdom, rather than focusing on dates on the calendar. Take good care of yourself; be active for part of the day, but also rest. Indulge in your last few days of having only yourself to take care of.

What can caregivers do for it? Labor induction. (see the details)

The benefits of induction are that it starts a labor which has not begun on its own. The risks of induction are that all of the forms of induction can lead to stronger, more painful, and more frequent contractions for mom. These powerful contractions may also limit oxygen supply to the baby, so increase the risk of fetal distress and related interventions, including cesarean.  It’s important to clearly discuss these issues with your caregiver. If the induction is being done for convenience, or for unclear medical issues, then the benefits of induction may not outweigh the risks.

A few caregivers recommend labor induction shortly after the 40 week mark to avoid post-date babies; however, research indicates that typically the risks would outweigh the benefits at that point. Most caregivers recommend routine induction at 42 weeks.

Studies cited in Simkin (1993) indicate that an appropriate response might be to monitor “post-date” for fetal well-being twice a week, and inducing only if problems arise.

Ø      Tests for fetal well-being: Fetal movement counting, ultrasound, non-stress test, and contraction stress test. (For more information).  There is a risk of false positives with these tests, so consult with your caregiver about whether multiple tests should be used before intervening.

A note on due dates. A diagnosis of post-date pregnancy is based on the assumption that a normal “Term” pregnancy is 280 days (40 weeks) from last menstrual period, or 266 days from ovulation (based on a formula from the 1800’s). A recent study (Mittendorf, 1990) indicates that term for uncomplicated pregnancies in first-time, Caucasian mothers, averages 274 days from ovulation. Based on this, you might want to add 8 days to your “due date” before thinking of yourself as overdue.

  

Precipitous Labor

What is it? A labor that is less than 3 hours from start of contractions through birth.

How Common is it? Probably less than 5% of births (I do not have exact statistics). The rates for first time moms are much lower than the rates for women who have given birth before.

Why is it a problem? Emotionally stressful for the family: panic, fear, sense of being out of control. Intense contractions can be very painful, and there’s often no time for medication. Some risk of damage to the baby’s head and to the mother’s perineum.

What can you do to help prevent it? Cocaine use is clearly associated with precipitous labor. Poor nutrition might be associated. Beyond those, it appears to be a combination of anatomical issues: small babies, large bony pelvises, or soft, pliable genital tissue.

What can you do about it? If your labor begins with very rapid, intense contractions that cannot be managed with comfort techniques, call your caregiver. Go to the hospital immediately. Whenever possible, lie on your side, rather than standing or sitting.

If you feel your body pushing and you cannot stop it, or if you or your partner can see the baby’s head at the vaginal opening, call 911 and request assistance and advice.

For more information on handling an emergency birth, read the section in Simkin, Whalley, and Keppler. Or read this.

 

Prolonged Labor

How common is it? More common than precipitous labor.

If labor is moving slowly, it is probably the result of:

Powers: Insufficient strength and/or frequency of contractions.

Passages: The shape and flexibility of the mother’s pelvis and soft tissues.

Passenger: Baby is in a non-optimal position.

Pain: If mother is very tense because of pain, muscular tension can slow labor.

Psyche: Maternal stress and anxiety.

Keep these in mind as you consider solutions; look for ideas that work on each of these areas.

 

Prodromal Labor: Prolonged Early Labor

What is it? Early labor that last 24 hours or longer, before reaching 4 cm dilation.

What can you do to help with it? Stay well-nourished, drink plenty of fluids, and stay as rested as possible. Encourage your partner to do the same. Try not to worry, and get anxious; this is a normal pattern of labor for some women. Alternate quiet relaxation, with distracting activities, shifting position frequently. Walking can be helpful, but don’t exhaust yourself. Any of the non-medical induction methods (e.g. nipple stimulation, orgasm) can also help augment labor, but check with your caregiver before attempting to stimulate labor.

If you have slow progress, back pain, and/or irregular contractions (maybe “coupled” contractions), assume that your baby is occiput posterior, and look below at back labor for ideas to help your baby rotate.

What can your caregiver do for it? Caregiver may just recommend relaxing and self-care until your body goes into more active labor. Or, if you are exhausted, caregiver may recommend trying to stop contractions and help you rest, by using sedatives, tranquilizers, morphine, or alcohol. Or, caregiver may augment labor by rupturing your membranes, and/or using Pitocin.

 

Prolonged Active Labor

What is it? Labor that slows or stops after you have reached 4 cm dilation. Some caregivers diagnose dysfunctional labor if dilation averages less than 1 cm/hr; others say less than .5 cm/hour over a four hour period. One recent study says abnormal progress should not be declared unless a mother has taken more than 19.5 hours to go from 4 cm to 10 cm.

Basically, it’s a labor that’s taking longer than the people involved think it should take.

Possible causes? Exhaustion, lack of nourishment, dehydration, full bladder, anxiety, fear, cervix not effaced, baby’s position.

What can you do to help with it? Rest, eat, drink, go to the bathroom, relaxation and comfort measures, plenty of reassurance and encouragement from partner, use positions and movements where gravity can help move the baby down. Voicing your fears. Also see information under back labor below.

What can your caregiver do for it? Your caregivers will regularly monitor baby’s well-being, and may do more frequent vaginal exams. May recommend I.V. fluids for hydration, and pain medications for relaxation. May rupture membranes, or recommend Pitocin augmentation.

 

Prolonged Second Stage Labor

What is it? Labor progress that slows or stops after the cervix is fully dilated. Pushing for more than 3 hours; some caregivers say 2 hours.

What can you do to help prevent it? Use a variety of positions and movement in early labor to help the baby descend into position for birth.

What can you do to help with it? Try positions that open the pelvic outlet, and use gravity to help baby descend. Squatting, lap squatting, supported squats, and sitting on the toilet can all help. You can also try standing, semi-sitting, and hands-and-knees. If you have had an epidural, you might ask to try exaggerated Lithotomy: flat on your back with your knees drawn up toward your shoulders. This position is not normally recommended, but may be an option in this case to help the baby move beneath the pubic bone.

What can your caregiver do for it? They will carefully monitor heart rate. If baby seems to be handling the contractions well, they may not intervene. They may use pitocin to augment your contractions or use vacuum extraction, episiotomy, forceps, or cesarean section to deliver the baby.

 

Back Labor with an Occiput Posterior Baby (For lots of info, see www.spinningbabies.com)

What is it? Labor contractions that are felt mostly in the mother’s back. May be very painful. Contractions may be irregular, sometimes “coupling” (two contractions come close together, then there’s break, then a cluster of two or three more). Also can cause a very long labor.

Back labor is usually due to a posterior baby. Baby’s head is pressing on the mother’s sacrum or tailbone. Once the baby rotates, labor usually returns to normal. A baby can be delivered in the posterior position, but sometimes posterior babies require forceps or c-section delivery.

How Common is it? 25% of babies begin labor occiput posterior. 70-90% of those will rotate on their own during labor.

What can you do to help prevent it? Simkin recommends 10 daily repetitions of the pelvic tilt in late pregnancy. Also, hip circles, like in belly dancing or hula dancing. How can you tell if a baby is O.P.? Sometimes you can tell by looking at the mother’s belly. If the baby is anterior, the belly is round. If the baby is posterior, its feet may make a bulge above the navel, and its head makes another bulge below the navel. A caregiver may be able to palpate (feel) where the baby lies. Another symptom is difficulty finding the fetal heart tones, because the limbs are near the mother’s belly, rather than the back.

Basically, the easiest answer is: if you have back pain, assume the baby is posterior. Any of the techniques below will help relieve the pain, and will help the baby to rotate, if he is posterior, and won’t cause any problems if he’s anterior.

What can you do to help with it?

ü      Massage on her lower back and buttocks. Use firm, smooth strokes. Some women even like having a tennis ball or a rolling pin rolled on their back.

ü      Hot pads or ice packs on her back, warm shower spray on her back

ü      Counterpressure: partner uses the palm of his hands to press on the mother’s lower back and sacrum during contractions

ü      Double hip squeeze: partner stands behind mom, places one hand on each of her hips, with the palms resting toward the center of her back; firmly squeeze hands together and push up toward her shoulders during contractions

ü      Knee press: mother sits upright in a chair. Partner kneels on the floor in front of her, placing one hand on each knee; lean toward her so that he is pressing straight back toward her hip joints.

ü      Any position that helps take the weight of the baby off of your back will relieve some of the pain: hands and knees, leaning forward while bracing yourself on a table or on the wall; straddling a chair, and resting your head on the back of it, raising the head of the hospital bed and kneeling on the bed while resting your head. Change positions frequently.

ü      Positions that help the baby rotate: Walking, stair climbing, pelvic tilt (on hands and knees: arch back like an angry cat, while also ‘tucking your tail’ like a scared dog. Then relax, letting your back straighten); pelvic rock (on hands and knees, rock back and forth and side to side during contractions); squatting; lunge (mom stands with her side next to a chair, then puts one foot up on the chair, facing to the side; mom faces front. During a contraction, mom “lunges” or sways toward the raised leg.)

ü      Open knee-chest position: Rumored to be one of the best positions for helping a baby rotate. Start by kneeling, then place chest on floor, with head resting on folded arms. Hips should be slightly forward from knees, knees should be slightly spread. Stay in this position for up to 30 minutes. If this is tiring for the mom, or she finds her upper body is sliding forward, her partner can support her by sitting in a chair with his feet on the ground. Mother rests her shoulders against his shins, with her head between his feet.

 

 

Compiled by Janelle Durham.

Sources: Birth Education Northwest’s handout on “Coping with Common Variations in Labor” by Sheri Feld. Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). “How long is too long? The Dilemma of Post-dates Pregnancy” by Penny Simkin, Childbirth Forum, Spring 1993. Abstract for “The Length of Uncomplicated Human Gestation” by Mittendorf  et al, Obstetrics & Gynecology, V.75, N.6, June 1990. “Pregnancy past your due date” by Terri Isidro-Cloudas on americanbaby.com. “The Occiput Posterior Baby” by Henci Goer, Childbirth Instructor Magazine, Summer 1994.

 

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