Prelabor, False Labor, Real Labor It always seems so simple on TV. Somewhere around 3 a.m., the pregnant woman sits up in bed, puts a knowing hand on her belly, and reaches over to rouse her sleeping husband with a calm, almost serene, "Honey, it's time."

But how, you wonder, does this woman know it's time? How does she recognize labor with such cool, clinical confidence when she's never been in labor before? What makes her so sure she's not going to get to the hospital, be examined by the resident, found to be nowhere near her time, and be sent home, amid snickers from the night shift, just as pregnant as when she arrived? The script, of course.

On our side of the screen (with no script in hand), we're more likely to awaken at 3 a.m. with complete uncertainty. Are these really labor pains or just more Braxton Hicks? Should I turn on the light and start timing? Should I bother to wake my spouse? Do I drag my practitioner out of bed at 1 a.m. to report what might really be false labor? If I do and it isn't time, will I turn out to be the pregnant woman who cried "labor" once too often, and will anybody take me seriously when it's for real? Or will I be the only woman in my childbirth class not to recognize labor? Will I leave for the hospital too late, maybe giving birth in the back of a taxicab (and ending up on the evening news)? The questions multiply faster than the contractions.

The fact is that most women, worry though they might, don't end up misjudging the onset of their labor. The vast majority, thanks to instinct, luck, or no-doubt-about-it killer contractions, show up at the hospital or birthing center neither too early nor too late, but at just about the right time. Still, there's no reason to leave your judgment up to chance. Becoming familiar in advance with the signs of prelabor, false labor, and real labor will help allay the concerns and clear up the confusion when those contractions (or are they?) begin.

Prelabor Symptoms Before there's labor, there's prelabor-a sort of preshow that sets things up before the main event. The physical changes of prelabor can precede real labor by a full month or more-or by only an hour or so. Prelabor is characterized by the beginning of cervical effacement and dilation, which your practitioner can confirm on examination, as well as by a wide variety of related signs that you may notice yourself: Dropping. Usually somewhere between two and four weeks before labor starts in first-time mothers, the fetus begins to settle down into the pelvis. This milestone is rarely reached in second or later births until labor is about to kick off. Usually somewhere between two and four weeks before labor starts in first-time mothers, the fetus begins to settle down into the pelvis. This milestone is rarely reached in second or later births until labor is about to kick off.

Sensations of increasing pressure in the pelvis and rectum. Crampiness (similar to menstrual cramps) and groin pain are common-and particularly likely in second and later pregnancies. Persistent low backache may also be present.

Loss of weight or no gain. Weight gain might slow down in the ninth month; as labor approaches, you might even lose a bit of weight, up to 2 or 3 pounds.

A change in energy levels. Some ninth-monthers find that they are increasingly exhausted. Others experience energy spurts. An uncontrollable urge to scrub floors and clean out closets has been related to the "nesting instinct," in which the female of the species-that's you-prepares the nest for the impending arrival (see page 346 page 346).

A change in vaginal discharge. If you've been keeping track, you may find that your discharge increases and thickens.

Loss of the mucous plug. As the cervix begins to thin and open, the "cork" of mucus that seals the opening of the uterus becomes dislodged (see page 362 page 362). This gelatinous chunk of mucus can be passed through the vagina a week or two before the first real contractions, or just as labor begins.

Pink, or bloody, show. As the cervix effaces and dilates, capillaries frequently rupture, tinting the mucus pink or streaking it with blood (see page 363 page 363). This "show" usually means labor will start within 24 hours-though it could be as much as several days away.

Intensification of Braxton Hicks contractions. These practice contractions (see page 311 page 311) may become more frequent and stronger, even painful.

Diarrhea. Some women experience loose bowel movements just before labor starts.

False Labor Symptoms Is it or isn't it? Real labor probably has not begun if: [image] Contractions are not at all regular and don't increase in frequency or severity. Real contractions won't necessarily fall into a neat textbook pattern, but they will become more intense and more frequent over time. Contractions are not at all regular and don't increase in frequency or severity. Real contractions won't necessarily fall into a neat textbook pattern, but they will become more intense and more frequent over time.[image] Contractions subside if you walk around or change your position (though this can sometimes be the case in early "real" labor, too). Contractions subside if you walk around or change your position (though this can sometimes be the case in early "real" labor, too).[image] Show, if any, is brownish. This kind of discharge is often the result of an internal exam or intercourse within the past 48 hours. Show, if any, is brownish. This kind of discharge is often the result of an internal exam or intercourse within the past 48 hours.[image] Fetal movements intensify briefly with contractions. (Let your practitioner know right away if activity becomes frantic or jerky.) Fetal movements intensify briefly with contractions. (Let your practitioner know right away if activity becomes frantic or jerky.) Keep in mind that false labor (though it isn't the real thing) isn't a waste of time-even if you've driven all the way to the hospital or birthing center. It's your body's way of getting pumped, primed, and prepped for the main event, so when the time comes, it'll be ready-whether you are or not.

Real Labor Symptoms No one knows exactly what triggers real labor (and more women are concerned with "when" than "why"), but it's believed that a combination of factors are involved. This very intricate process begins with the fetus, whose brain sets off a relay of chemical messages (which probably translate into something like, "Mom, let me out of here!") that kick off a chain reaction of hormones in the mother. These hormonal changes in turn pave the way for the work of prostaglandins and oxytocin, substances that trigger contractions when all labor systems are "go."

You'll know that the contractions of prelabor have been replaced by true labor if: [image] The contractions intensify, rather than ease up, with activity and aren't relieved by a change in position. The contractions intensify, rather than ease up, with activity and aren't relieved by a change in position.[image] Contractions become progressively more frequent and painful, and generally (but not always) more regular. Every contraction won't necessarily be more painful or longer (they usually last about 30 to 70 seconds) than the last one, but the intensity does build up as real labor progresses. Frequency doesn't always increase in regular, perfectly even intervals, either-but it does increase. Contractions become progressively more frequent and painful, and generally (but not always) more regular. Every contraction won't necessarily be more painful or longer (they usually last about 30 to 70 seconds) than the last one, but the intensity does build up as real labor progresses. Frequency doesn't always increase in regular, perfectly even intervals, either-but it does increase.[image] Early contractions feel like gastrointestinal upset, or like heavy menstrual cramps, or like lower abdominal pressure. Pain may be just in the lower abdomen or in the lower back and abdomen, and it may also radiate down into the legs (particularly the upper thighs). Location, however, is not as reliable an indication, because false labor contractions may also be felt in these places. Early contractions feel like gastrointestinal upset, or like heavy menstrual cramps, or like lower abdominal pressure. Pain may be just in the lower abdomen or in the lower back and abdomen, and it may also radiate down into the legs (particularly the upper thighs). Location, however, is not as reliable an indication, because false labor contractions may also be felt in these places.[image] You have show and it's pinkish or blood-streaked. You have show and it's pinkish or blood-streaked.

In 15 percent of labors, the water breaks-in a gush or a trickle-before labor begins. But in many others, the membranes rupture spontaneously during labor, or are ruptured artificially by the practitioner.

When to Call the Practitioner Your practitioner has likely told you when to call if you think you're in labor (when contractions are five to seven minutes apart, for instance). Don't wait for perfectly even intervals; they may never come. If you're not sure you're in real labor-but the contractions are coming pretty regularly-call anyway. Your practitioner will probably be able to tell from the sound of your voice, as you talk through a contraction, whether it's the real thing-but only if you don't try to cover up the pain in the name of good phone manners. Even if you've checked and rechecked the above lists and you're still unsure, call your practitioner. Don't feel guilty about waking him or her in the middle of the night (people who deliver babies for a living don't expect to work only 9 to 5) or be embarrassed if it turns out to be a false alarm (you wouldn't be the first expectant mom to misjudge her labor signs, and you won't be the last). Don't assume that if you're not sure it's real labor, it isn't. Err on the side of caution and call.

Also call your practitioner immediately if contractions are increasingly strong but your due date is still weeks away, if your water breaks but labor hasn't begun, if your water breaks and it has a greenish-brown tint, if you notice bright red blood, or if you feel the umbilical cord slip into your cervix or vagina.

Ready or Not To make sure you're ready for your baby's arrival when he or she is ready to arrive, start reading up now about labor and delivery in the next chapter.

CHAPTER 15.

Labor and Delivery ARE YOU COUNTING DOWN THE days? Eager to see your feet again? Desperate to sleep on your stomach-or just plain desperate to sleep? Don't worry-the end (of pregnancy) is near. And as you contemplate that happy moment-when your baby will finally be in your arms instead of inside your belly-you're probably also giving a lot of thought to (and coming up with a lot of questions about) the process that will make that moment possible: labor and delivery. When will labor start, you're likely wondering? More important, when will it end? Will I be able to handle the pain? Will I need an epidural (and when can I have one)? A fetal monitor? An episiotomy? What if I want to labor-and deliver-while squatting? Without any meds? What if I don't make any progress? What if I progress so quickly that I don't make it to the hospital or birthing center in time? days? Eager to see your feet again? Desperate to sleep on your stomach-or just plain desperate to sleep? Don't worry-the end (of pregnancy) is near. And as you contemplate that happy moment-when your baby will finally be in your arms instead of inside your belly-you're probably also giving a lot of thought to (and coming up with a lot of questions about) the process that will make that moment possible: labor and delivery. When will labor start, you're likely wondering? More important, when will it end? Will I be able to handle the pain? Will I need an epidural (and when can I have one)? A fetal monitor? An episiotomy? What if I want to labor-and deliver-while squatting? Without any meds? What if I don't make any progress? What if I progress so quickly that I don't make it to the hospital or birthing center in time?

Armed with answers to these (and other) questions-plus the support of your partner and your birth attendants (doctors, midwives, nurses, doulas, and others)-you'll be prepared for just about anything that labor and delivery might bring your way. Just remember the most important thing that labor and delivery will bring your way (even if nothing else goes according to plan): that beautiful new baby of yours.

What You May Be Wondering About Mucous Plug "I think I lost my mucous plug. Should I call my doctor?"

Don't send out for the champagne just yet. The mucous plug-the clear, globby, gelatinous blob-like barrier that has corked your cervix throughout your pregnancy-occasionally becomes dislodged as dilation and effacement begin. Some women notice the passage of the mucous plug (what exactly is is that in the toilet?); others don't (especially if you're the flush-and-rush type). Though the passage of the plug is a sign that your body's preparing for the big day, it's not a reliable signal the big day has arrived-or even that it's around the corner. At this point, labor could be one or two days, or even weeks, away, with your cervix continuing to open gradually over that time. In other words, there's no need to call your practitioner or frantically pack your bags just yet. that in the toilet?); others don't (especially if you're the flush-and-rush type). Though the passage of the plug is a sign that your body's preparing for the big day, it's not a reliable signal the big day has arrived-or even that it's around the corner. At this point, labor could be one or two days, or even weeks, away, with your cervix continuing to open gradually over that time. In other words, there's no need to call your practitioner or frantically pack your bags just yet.

No plug in your pants or your toilet? Not to worry. Many women don't lose it ahead of time (and others overlook it), and that doesn't predict anything about the eventual progress of labor.

Bloody Show "I have a pink mucousy discharge. Does it mean labor's about to start?"

Sounds like it's bloody show time-and happily, this particular production is a preview of labor, not of a gory horror movie. Passing that bloody show, a mucous discharge tinged pink or brown with blood, is usually a sign that the blood vessels in the cervix are rupturing as it dilates and effaces and the process that leads to delivery is well under way (and that's something to applaud!). Once the bloody show has made its debut in your underwear or on the toilet paper, chances are your baby's arrival is just a day or two away. But since labor is a process with an erratic timetable, you'll be kept in suspense until the first true contractions strike.

If your discharge should suddenly become bright red, contact your practitioner right away.

Your Water Breaking "I woke up in the middle of the night with a wet bed. Did I lose control of my bladder, or did my water break?"

Asniff of your sheets will probably clue you in. If the wet spot smells sort of sweet (not like urine, which has the harsher odor of ammonia), it's likely to be amniotic fluid. Another clue that the membranes surrounding your baby and containing the amniotic fluid he or she's been living in for nine months have probably ruptured: You continue leaking the pale, straw-colored fluid (which won't run dry because it continues to be produced until delivery, replacing itself every few hours). Another test: You can try to stem the flow of the fluid by squeezing your pelvic muscles (Kegel exercises). If the flow stops, it's urine. If it doesn't, it's amniotic fluid.

You are more likely to notice the leaking while you are lying down; it usually stops, or at least slows, when you stand up or sit down, since the baby's head acts as a cork, blocking the flow temporarily. The leakage is heavier-whether you're sitting or standing-if the break in the membranes is down near the cervix than if it is higher up.

Your practitioner has probably given you a set of instructions to follow if your water breaks. If you don't remember the instructions or have any doubts about how to proceed-call, night or day.

"My water just broke, but I haven't had any contractions. When is labor going to start, and what should I do in the meantime?"

It's likely that labor's on the way-and soon. Most women whose membranes rupture before labor begins can expect to feel the first contraction within 12 hours of that first trickle; most others can expect to feel it within 24 hours.

About 1 in 10, however, find that labor takes a little longer to get going. To prevent infection through the ruptured amniotic sac (the longer it takes for labor to get going, the greater the risk), most practitioners induce labor within 24 hours of a rupture, if a mom-to-be is at or near her due date, though a few induce as early as six hours after. Many women who have experienced a rupture actually welcome a sooner-than-later induction, preferring it to 24 hours of wet waiting.

The first thing to do if you experience a trickle or flow of fluid from your vagina-besides grab a towel and a box of maxipads-is call your practitioner (unless he or she has instructed otherwise). In the meantime, keep the vaginal area as clean as possible to avoid infection. Don't have sex (not that there's much chance you'd want to right now), use a pad (not a tampon) to absorb the flow, don't try to do your own internal exam, and, as always, wipe from front to back when you use the toilet.

Rarely, when the membranes rupture prematurely and the baby's presenting part is not yet engaged in the pelvis (more likely when the baby is breech or preterm), the umbilical cord can become "prolapsed"-it is swept into the cervix, or even down into the vagina, with the gush of amniotic fluid. If you can see a loop of umbilical cord at your vaginal opening, or think you feel something inside your vagina, call 911. For more on what to do if the cord is prolapsed, see page 565 page 565.

Darkened Amniotic Fluid "My membranes ruptured, and the fluid isn't clear-it's greenish brown. What does this mean?"

Your amniotic fluid is probably stained with meconium, a greenish-brown substance that is actually your baby's first bowel movement. Ordinarily, meconium is passed after birth as the baby's first stool. But sometimes-such as when the fetus has been under stress in the womb, and more often when it is past its due date-the meconium is passed before birth into the amniotic fluid.

Meconium staining alone is not a sure sign of fetal distress, but because it suggests the possibility of distress, notify your practitioner right away. He or she will likely want to get labor started (if contractions aren't already in full swing) and will monitor your baby very closely throughout labor.

Low Amniotic Fluid During Labor "My doctor said that my amniotic fluid is low and she needs to supplement it. Should I be concerned?"

Usually, nature keeps the uterus well stocked with a self-replenishing supply of amniotic fluid. Fortunately, even when levels do run low during labor, medical science can step in and supplement that natural source with a saline solution pumped directly into the amniotic sac through a catheter inserted through the cervix into the uterus. This procedure, called amnioinfusion, can significantly reduce the possibility that a surgical delivery will become necessary due to fetal distress.

Irregular Contractions "In childbirth class we were told not to go to the hospital until the contractions were regular and five minutes apart. Mine are less than five minutes apart, but they aren't at all regular. I don't know what to do."

Just as no two women have exactly the same pregnancies, no two women have exactly the same labors. The labor often described in books, in childbirth education classes, and by practitioners is what is typical-close to what many women can expect. But far from every labor is true-to-textbook, with contractions regularly spaced and predictably progressive.

If you're having strong, long (20 to 60 seconds), frequent (mostly 5 to 7 minutes apart or less) contractions, even if they vary considerably in length and time elapsed between them, don't wait for them to become regular before calling your practitioner or heading for the hospital or birthing center-no matter what you've heard or read. It's possible your contractions are about as regular as they're going to get and you're well into the active phase of your labor.

Calling Your Practitioner During Labor "I just started getting contractions and they're coming every three or four minutes. I feel silly calling my doctor, who said we should spend the first several hours of labor at home."

Better silly than sorry. It's true that most first-time mothers-to-be (whose labors are generally slow-going at first, with a gradual buildup of contractions) can safely count on spending the first several hours at home, leisurely finishing up their packing and their baby prep. But it doesn't sound like your labor's fitting that typical first-timer pattern. If your contractions have started off strong-lasting at least 45 seconds and coming more frequently than every 5 minutes-your first several hours of labor may very well be your last (and if you're not a first-timer, your labor may be on an even faster track). Chances are that much of the first stage of labor has passed painlessly and your cervix has dilated significantly during that time. This means that not calling your practitioner, chancing a dramatic dash to the hospital or birthing center at the last minute-or not getting there in time-might be considerably sillier than picking up the phone now.

So by all means call. When you do, be clear and specific about the frequency, duration, and strength of your contractions. Since your practitioner is used to judging the phase of labor in part by the sound of a woman's voice as she talks through a contraction, don't try to downplay your discomfort, put on a brave front, or keep a calm tone when you describe what you're experiencing. Let the contractions speak for themselves, as loudly as they need to.

If you feel you're ready but your practitioner doesn't seem to think so, ask if you can go to the hospital/birthing center or to your practitioner's office and have your progress checked. Take your bag along just in case, but be ready to turn around and go home if you've only just begun to dilate-or if nothing's going on at all.

Not Getting to the Hospital in Time "I'm afraid that I won't get to the hospital in time."

Fortunately, most of those sudden deliveries you've heard about take place in the movies and on TV. In real life, deliveries, especially those of first-time mothers, rarely occur without ample warning. But once in a great while, a woman who has had no labor pains, or just erratic ones, suddenly feels an overwhelming urge to bear down; often she mistakes it for a need to go to the bathroom.

Emergency Delivery if You're Alone You'll almost certainly never need the following instructions-but just in case, keep them handy.

1. Try to remain calm. You can do this. Try to remain calm. You can do this.2. Call 911 (or your local emergency number) for the emergency medical service. Ask them to call your practitioner. Call 911 (or your local emergency number) for the emergency medical service. Ask them to call your practitioner.3. Find a neighbor or someone else to help, if possible. Find a neighbor or someone else to help, if possible.4. Start panting to keep yourself from pushing. Start panting to keep yourself from pushing.5. Wash your hands and the vaginal area, if you can. Wash your hands and the vaginal area, if you can.6. Spread some clean towels, newspapers, or sheets on a bed, sofa, or the floor, and lie down to await help (unlock the door so help can get in easily). Spread some clean towels, newspapers, or sheets on a bed, sofa, or the floor, and lie down to await help (unlock the door so help can get in easily).7. If despite your panting the baby starts to arrive before help does, gently ease him or her out by pushing each time you feel the urge. If despite your panting the baby starts to arrive before help does, gently ease him or her out by pushing each time you feel the urge.8. As the top of the baby's head begins to appear, pant or blow (do not push), and apply very gentle counterpressure to your perineum to keep the head from popping out suddenly. Let the head emerge gradually-don't pull it out. If there is a loop of umbilical cord around the baby's neck, hook a finger under it and gently work it over the baby's head. As the top of the baby's head begins to appear, pant or blow (do not push), and apply very gentle counterpressure to your perineum to keep the head from popping out suddenly. Let the head emerge gradually-don't pull it out. If there is a loop of umbilical cord around the baby's neck, hook a finger under it and gently work it over the baby's head.9. Next, take the head gently in two hands and press it very slightly downward (do not pull), pushing the baby out at the same time, to deliver the front shoulder. As the upper arm appears, lift the head carefully, feeling for the rear shoulder to deliver. Once the shoulders are free, the rest of your baby should slip out easily. Next, take the head gently in two hands and press it very slightly downward (do not pull), pushing the baby out at the same time, to deliver the front shoulder. As the upper arm appears, lift the head carefully, feeling for the rear shoulder to deliver. Once the shoulders are free, the rest of your baby should slip out easily.10. Place the baby on your abdomen or, if the cord is long enough (don't tug at it), on your chest. Quickly wrap the baby in blankets, towels, or anything else that's clean. Place the baby on your abdomen or, if the cord is long enough (don't tug at it), on your chest. Quickly wrap the baby in blankets, towels, or anything else that's clean.11. Wipe baby's mouth and nose with a clean cloth. If help hasn't arrived and the baby isn't breathing or crying, rub his or her back, keeping the head lower than the feet. If breathing still hasn't started, clear out the mouth some more with a clean finger and give two quick and extremely gentle puffs of air into his or her nose and mouth. Wipe baby's mouth and nose with a clean cloth. If help hasn't arrived and the baby isn't breathing or crying, rub his or her back, keeping the head lower than the feet. If breathing still hasn't started, clear out the mouth some more with a clean finger and give two quick and extremely gentle puffs of air into his or her nose and mouth.12. Don't try to pull the placenta out. But if it emerges on its own before emergency assitance arrives, wrap it in towels or newspaper, and keep it elevated above the level of the baby, if possible. There is no need to try to cut the cord. Don't try to pull the placenta out. But if it emerges on its own before emergency assitance arrives, wrap it in towels or newspaper, and keep it elevated above the level of the baby, if possible. There is no need to try to cut the cord.13. Keep yourself and your baby warm and comfortable until help arrives. Keep yourself and your baby warm and comfortable until help arrives.

As remote as the possibility is that this will happen to you, it's a good idea for both you and your coach to become familiar with the basics of an emergency delivery (see boxes, above and on page 370 page 370). Once that's done, relax, knowing that a sudden and quick delivery is an extremely remote possibility.

Having a Short Labor "I always hear about women who have really short labors. How common are they?"

While they make for really good labor stories, not all of the short labors you've heard about are as short as they seemed. Often, an expectant mom who appears to have a quickie labor has actually been having painless contractions for hours, days, even weeks, contractions that have been dilating her cervix gradually. By the time she finally feels one, she's well into the final stage of labor.

That said, occasionally the cervix dilates very rapidly, accomplishing in a matter of minutes what the average cervix (particularly a first-time mom's cervix) takes hours to do. And happily, even with this abrupt, or precipitous, kind of labor (one that takes three hours or less from start to finish), there is usually no risk to the baby.

If your labor seems to start with a bang-with contractions strong and close together-get to the hospital or birthing center quickly (so you and your baby can be monitored closely). Medication may be helpful in slowing contractions a bit and easing the pressure on your baby and on your own body.

Back Labor "The pain in my lower back since my contractions began is so bad that I don't see how I'll be able to make it through labor."

What you're probably experiencing is known in the birthing business as "back labor." Technically, back labor occurs when the fetus is in a posterior position, with its face up and the back of its head pressing against your sacrum, or the back of your pelvis. (Ironically, this position is nicknamed "sunny-side up" in birthing circles-though there's nothing cheerful about back labor.) It's possible, however, to experience back labor when the baby isn't in this position or to continue to experience it after the baby has turned to a head-to-the-front position-possibly because the area has already become a focus of tension.

When you're having this kind of pain-which often doesn't let up between contractions and can become excruciating during them-the cause doesn't matter much. How to relieve it, even slightly, does. If you're opting to have an epidural, go for it (there's no need to wait, especially if you're in a lot of pain). It's possible that you might need a higher dose than usual to get full comfort from the back labor pain, so let the anesthesiologist know about it. Other options (such as narcotics) also offer pain relief. If you'd like to stay med free, several measures may help relieve the discomfort of back labor; all are at least worth trying: Taking the pressure off. Try changing your position. Walk around (though this may not be possible once contractions are coming fast and furious), crouch or squat, get down on all fours, do whatever is most comfortable and least painful for you. If you feel you can't move and would prefer to be lying down, lie on your side, with your back well rounded-in a sort of fetal position. Try changing your position. Walk around (though this may not be possible once contractions are coming fast and furious), crouch or squat, get down on all fours, do whatever is most comfortable and least painful for you. If you feel you can't move and would prefer to be lying down, lie on your side, with your back well rounded-in a sort of fetal position.

Heat or cold. Have your coach (or doula or nurse) use warm compresses, a heating pad, or ice packs or cold compresses-whichever soothes best. Or alternate heat and cold. Have your coach (or doula or nurse) use warm compresses, a heating pad, or ice packs or cold compresses-whichever soothes best. Or alternate heat and cold.

Counterpressure and massage. Have your coach experiment with different ways of applying pressure to the area of greatest pain, or to adjacent areas, to find one or more that seem to help. He can try his knuckles, the heel of one hand reinforced by pressure from the other hand on top of it, a tennis ball, or a back massager, using direct pressure or a firm circular motion. Pressure or a firm massage can be applied while you're sitting or while you're lying on your side. Cream, oil, or powder can be applied periodically to reduce possible irritation. Have your coach experiment with different ways of applying pressure to the area of greatest pain, or to adjacent areas, to find one or more that seem to help. He can try his knuckles, the heel of one hand reinforced by pressure from the other hand on top of it, a tennis ball, or a back massager, using direct pressure or a firm circular motion. Pressure or a firm massage can be applied while you're sitting or while you're lying on your side. Cream, oil, or powder can be applied periodically to reduce possible irritation.

Reflexology. For back labor, this therapy involves applying strong finger pressure just below the center of the ball of the foot. For back labor, this therapy involves applying strong finger pressure just below the center of the ball of the foot.

Other alternative pain relievers. Hydrotherapy can definitely ease the pain somewhat. If you've had some experience with meditation, visualization, or self-hypnosis for pain, try these, too. They often work, and they certainly couldn't hurt. Acupuncture can also help, but you'll have to arrange ahead of time to have a therapist on call when you go into labor. Hydrotherapy can definitely ease the pain somewhat. If you've had some experience with meditation, visualization, or self-hypnosis for pain, try these, too. They often work, and they certainly couldn't hurt. Acupuncture can also help, but you'll have to arrange ahead of time to have a therapist on call when you go into labor.

Labor Induction "My doctor wants to induce labor. But I'm not overdue yet and I thought induction was only for overdue babies."

Sometimes Mother Nature needs a little help making a mother out of a pregnant woman. About 20 percent of pregnancies end up needing that kick in the maternity pants, and though a lot of the time induction is necessary because a baby is overdue, there are many other reasons why your practitioner might feel that nature needs a nudge, such as: [image] Your membranes have ruptured and contractions have not started on their own within 24 hours (though some practitioners induce much sooner). Your membranes have ruptured and contractions have not started on their own within 24 hours (though some practitioners induce much sooner).[image] Tests suggest that your uterus is no longer a healthy home for your baby because the placenta is no longer functioning optimally or amniotic fluid levels are low, or for another reason. Tests suggest that your uterus is no longer a healthy home for your baby because the placenta is no longer functioning optimally or amniotic fluid levels are low, or for another reason.[image] Tests suggest that the baby isn't thriving and is mature enough to be delivered. Tests suggest that the baby isn't thriving and is mature enough to be delivered.[image] You have a complication, such as preeclampsia or gestational diabetes, or a chronic or acute illness, that makes it risky to continue your pregnancy. You have a complication, such as preeclampsia or gestational diabetes, or a chronic or acute illness, that makes it risky to continue your pregnancy.[image] There's a concern that you might not make it to the hospital or birthing center on time once labor has started, either because you live a long distance away or because you've had a previous very short labor. There's a concern that you might not make it to the hospital or birthing center on time once labor has started, either because you live a long distance away or because you've had a previous very short labor.

If you're still unsure about your doctor's reasons for inducing labor, ask for a better explanation. To find out all you'll need to know about the induction process, keep reading.

"How does induction work?"

Induction, like naturally triggered labor, is a process-and sometimes a pretty long process. But unlike naturally triggered labor, your body will be getting some help with the heavy lifting if you're induced. Labor induction usually involves a number of steps (though you won't necessarily go through all of them): [image] First, your cervix will need to be ripened (or softened) so that labor can begin. If you arrive with a ripe cervix, great-you'll probably move right on to the next step. If your cervix is not dilated, not effaced, and not soft at all, your practitioner will likely administer a hormonal substance such as prostaglandin E in the form of a vaginal gel (or a vaginal suppository in tablet form) to get things started. In this painless procedure, a syringe is used to place the gel in the vagina close to your cervix. After a few hours or longer of letting the gel do its work, you'll be checked to see if your cervix is getting softer and beginning to efface and dilate. If it isn't, a second dose of the prostaglandin gel is administered. In many cases, the gel is enough to get contractions and labor started. If your cervix is ripe enough but contractions have not begun, the induction process continues. (Some practitioners use mechanical agents to ripen the cervix, such as a catheter with an inflatable balloon, graduated dilators to stretch the cervix, or even a botanical-called Laminaria japonicum-that, when inserted, gradually opens the cervix as it absorbs fluid around it.) First, your cervix will need to be ripened (or softened) so that labor can begin. If you arrive with a ripe cervix, great-you'll probably move right on to the next step. If your cervix is not dilated, not effaced, and not soft at all, your practitioner will likely administer a hormonal substance such as prostaglandin E in the form of a vaginal gel (or a vaginal suppository in tablet form) to get things started. In this painless procedure, a syringe is used to place the gel in the vagina close to your cervix. After a few hours or longer of letting the gel do its work, you'll be checked to see if your cervix is getting softer and beginning to efface and dilate. If it isn't, a second dose of the prostaglandin gel is administered. In many cases, the gel is enough to get contractions and labor started. If your cervix is ripe enough but contractions have not begun, the induction process continues. (Some practitioners use mechanical agents to ripen the cervix, such as a catheter with an inflatable balloon, graduated dilators to stretch the cervix, or even a botanical-called Laminaria japonicum-that, when inserted, gradually opens the cervix as it absorbs fluid around it.)[image] If the amniotic sac is still intact, your practitioner may strip the membranes by swiping a finger across the fine membranes that connect the amniotic sac to the uterus to release prostaglandin (this process isn't always pain free, and while it isn't meant to break your water, it sometimes does). Or he or she may artificially rupture your membranes (see If the amniotic sac is still intact, your practitioner may strip the membranes by swiping a finger across the fine membranes that connect the amniotic sac to the uterus to release prostaglandin (this process isn't always pain free, and while it isn't meant to break your water, it sometimes does). Or he or she may artificially rupture your membranes (see page 373 page 373) to try to get labor started.[image] If neither the prostaglandin nor the stripping or rupturing of the membranes has brought on regular contractions, your practitioner will slowly administer intravenous Pitocin, a synthetic form of the hormone oxytocin (which is produced naturally by the body throughout pregnancy and also plays an important role in labor), until contractions are well established. The drug misoprostol, given through the vagina, might be used as an alternative to other ripening and induction techniques. Some research shows giving misoprostol decreases the amount of oxytocin needed and shortens labor. If neither the prostaglandin nor the stripping or rupturing of the membranes has brought on regular contractions, your practitioner will slowly administer intravenous Pitocin, a synthetic form of the hormone oxytocin (which is produced naturally by the body throughout pregnancy and also plays an important role in labor), until contractions are well established. The drug misoprostol, given through the vagina, might be used as an alternative to other ripening and induction techniques. Some research shows giving misoprostol decreases the amount of oxytocin needed and shortens labor.[image] Your baby will be continuously monitored to assess how he or she is dealing with labor. You'll also be monitored to make sure the drug isn't overstimulating your uterus, triggering contractions that are too long or powerful. If that happens, the rate of infusion can be reduced or the process can be discontinued entirely. Once your contractions are in full swing, the oxytocin may be stopped or the dose decreased, and your labor should progress just as a noninduced labor does. Your baby will be continuously monitored to assess how he or she is dealing with labor. You'll also be monitored to make sure the drug isn't overstimulating your uterus, triggering contractions that are too long or powerful. If that happens, the rate of infusion can be reduced or the process can be discontinued entirely. Once your contractions are in full swing, the oxytocin may be stopped or the dose decreased, and your labor should progress just as a noninduced labor does.[image] If, after 8 to 12 hours of oxytocin administration, labor hasn't begun or progressed, your practitioner might stop the induction process to give you a chance to rest before trying again or, depending on the circumstances, the procedure may be stopped in favor of a cesarean delivery. If, after 8 to 12 hours of oxytocin administration, labor hasn't begun or progressed, your practitioner might stop the induction process to give you a chance to rest before trying again or, depending on the circumstances, the procedure may be stopped in favor of a cesarean delivery.

Eating and Drinking During Labor "I've heard conflicting stories about whether it's okay to eat and drink during labor."

Should eating be on the agenda when you're in labor? That depends on who you're talking to. Some practitioners red-light all food and drink during labor, on the theory that food in the digestive tract might be aspirated, or "breathed in," should emergency general anesthesia be necessary. These practitioners usually okay ice chips only, supplemented as needed by intravenous fluids. Many other practitioners (and ACOG guidelines) do allow liquids and light solids (read: no stuffed-crust pizza) during a low-risk labor, reasoning that a woman in labor needs both fluids and calories to stay strong and do her best work, and that the risk of aspiration (which only exists if general anesthesia is used, and it rarely is except in emergency situations) is extremely low: 7 in 10 million births. Their position has even been backed up by research, which shows that women who are allowed to eat and drink during labor have shorter labors by an average of 90 minutes, are less likely to need oxytocin to speed up labor, require fewer pain medications, and have babies with higher Apgar scores than women who fast. Check with your practitioner to find out what will and won't be on the menu for you during labor.

Emergency Delivery: Tips for the Coach At Home or in the Office 1. Try to remain calm while at the same time comforting and reassuring the mother. Remember, even if you don't know the first thing about delivering a baby, a mother's body and her baby can do most of the job on their own. Try to remain calm while at the same time comforting and reassuring the mother. Remember, even if you don't know the first thing about delivering a baby, a mother's body and her baby can do most of the job on their own.2. Call 911 (or your local emergency number) for the emergency medical service; ask them to call the practitioner. Call 911 (or your local emergency number) for the emergency medical service; ask them to call the practitioner.3. Have the mother start panting, to keep from pushing. Have the mother start panting, to keep from pushing.4. If there's time, wash your hands and the vaginal area with soap and water (use an antibacterial product, if you have one handy). If there's time, wash your hands and the vaginal area with soap and water (use an antibacterial product, if you have one handy).5. If there is time, place the mother on the bed (or desk or table) so her buttocks are slightly hanging off, her hands under her thighs to keep them elevated. If available, a couple of chairs can support her feet. A few pillows or cushions under her shoulders and head will help to raise her to a semi-sitting position, which can aid delivery. If you are awaiting emergency help and the baby's head hasn't appeared, having the mother lie flat may slow delivery until help arrives. If there is time, place the mother on the bed (or desk or table) so her buttocks are slightly hanging off, her hands under her thighs to keep them elevated. If available, a couple of chairs can support her feet. A few pillows or cushions under her shoulders and head will help to raise her to a semi-sitting position, which can aid delivery. If you are awaiting emergency help and the baby's head hasn't appeared, having the mother lie flat may slow delivery until help arrives.Protect delivery surfaces, if possible, with a plastic tablecloth, shower curtain, newspapers, towels, or similar material. A dishpan or basin can be placed under the mother's vagina to catch the amniotic fluid and blood.6. If there's no time to get to a bed or table, place newspapers or clean towels or folded clothing under the mother's buttocks. Protect delivery surfaces, if possible, as described in number 5. If there's no time to get to a bed or table, place newspapers or clean towels or folded clothing under the mother's buttocks. Protect delivery surfaces, if possible, as described in number 5.7. As the top of the baby's head begins to appear, instruct the mother to pant or blow (not push), and apply very gentle counterpressure to her perineum (the area between the vagina and the anus) to keep the head from popping out suddenly. Let the head emerge gradually-never pull it out. If there is a loop of umbilical cord around the baby's neck, hook a finger under it and gently work it over the baby's head. As the top of the baby's head begins to appear, instruct the mother to pant or blow (not push), and apply very gentle counterpressure to her perineum (the area between the vagina and the anus) to keep the head from popping out suddenly. Let the head emerge gradually-never pull it out. If there is a loop of umbilical cord around the baby's neck, hook a finger under it and gently work it over the baby's head.8. Next, take the head gently in two hands and press it very slightly downward (do not pull), asking the mother to push at the same time, to deliver the front shoulder. As the upper arm appears, lift the head carefully, watching for the rear shoulder to deliver. Once the shoulders are free, the rest of the baby should slip out easily. Next, take the head gently in two hands and press it very slightly downward (do not pull), asking the mother to push at the same time, to deliver the front shoulder. As the upper arm appears, lift the head carefully, watching for the rear shoulder to deliver. Once the shoulders are free, the rest of the baby should slip out easily.9. Place the baby on the mother's abdomen or, if the cord is long enough (don't tug at it), on her chest. Quickly wrap the baby in blankets, towels, or anything else that's clean. Place the baby on the mother's abdomen or, if the cord is long enough (don't tug at it), on her chest. Quickly wrap the baby in blankets, towels, or anything else that's clean.Even if your practitioner gives you the go-ahead on eating, chances are you won't be in the market for a major meal once the contractions begin in earnest (and besides, you'll be pretty distracted). After all, labor can really spoil your appetite. Still, an occasional light, easy-to-digest snack during the early hours of labor-Popsicles, Jell-O, applesauce, cooked fruit, plain pasta, toast with jam, or clear broth are ideal choices-may help keep your energy up at a time when you need it most (you probably won't be able to, or won't want to, eat during the later parts of active labor). When deciding-with your practitioner's help-what to eat and when, also keep in mind that labor can make you feel pretty nauseous. Some women throw up as labor progresses, even if they haven't been eating.10. Wipe baby's mouth and nose with a clean cloth. If help hasn't arrived and the baby isn't breathing or crying, rub his or her back, keeping the head lower than the feet. If breathing still hasn't started, clear out the mouth some more with a clean finger, and give two quick and extremely gentle puffs of air into his or her nose and mouth. Wipe baby's mouth and nose with a clean cloth. If help hasn't arrived and the baby isn't breathing or crying, rub his or her back, keeping the head lower than the feet. If breathing still hasn't started, clear out the mouth some more with a clean finger, and give two quick and extremely gentle puffs of air into his or her nose and mouth.11. Don't try to pull the placenta out. But if it emerges on its own before emergency assistance arrives, wrap it in towels or newspaper, and keep it elevated above the level of the baby, if possible. There is no need to try to cut the cord. Don't try to pull the placenta out. But if it emerges on its own before emergency assistance arrives, wrap it in towels or newspaper, and keep it elevated above the level of the baby, if possible. There is no need to try to cut the cord.12. Keep both mother and baby warm and comfortable until help arrives. Keep both mother and baby warm and comfortable until help arrives.

En Route to the Hospital If you're in your car and delivery is imminent, pull over to a safe area. If you have a cell phone with you, call for help. If not, turn on your hazard warning lights or turn signal. If someone stops to help, ask him or her to call 911 or the local emergency medical service. If you're in a cab, ask the driver to radio or use his cell phone to call for help.

If possible, help the mother into the back of the car. Place a coat, jacket, or blanket under her. Then, if help has not arrived, proceed as for a home delivery. As soon as the baby is born, proceed to the nearest hospital.

Whether you can chow down or not during labor, your coach definitely can-and should (you don't want him weak from hunger when you need him most). Remind him to have a meal before you head off to the hospital or birthing center (his mind's probably on your belly, not his) and to pack a bunch of snacks to take along so he won't have to leave your side when his stomach starts growling.

Routine IV "Is it true that I'll be hooked up to an IV as soon as I'm admitted into the hospital when I'm in labor?"

That depends a lot on the policies of the hospital you'll be delivering in. In some hospitals, it's routine to give all women in labor an IV, a flexible catheter placed in your vein (usually in the back of your hand or lower arm) to drip in fluids and medication. The reason is precautionary-to prevent dehydration, as well as to save a step later on in case an emergency arises that necessitates medication (there's already a line in place to administer drugs-no extra poking or prodding required). Other hospitals and practitioners omit routine IVs and instead wait until there is a clear need before hooking you up. Check your practitioner's policy in advance, and if you strongly object to having a routine IV, say so. It may be possible to hold off until the need, if any, comes up.

You'll definitely get an IV if an epidural is on the agenda. IV fluids are routinely administered before and during the placement of an epidural to reduce the chance of a drop in blood pressure, a common side effect of this pain relief route. The IV also allows for easier administration of Pitocin should labor need to be augmented.

If you end up with a routine IV or an IV with epidural that you were hoping to avoid, you'll probably find it's not all that intrusive. The IV is only slightly uncomfortable as the needle is inserted and after that should barely be noticed. When it's hung on a movable stand, you can take it with you to the bathroom or on a stroll down the hall. If you very strongly don't want an IV but hospital policy dictates that you receive one, ask your practitioner whether a heparin lock might be an option for you.

With a heparin lock, a catheter is placed in the vein, a drop of the blood-thinning medication heparin is added to prevent clotting, and the catheter is locked off. This option gives the hospital staff access to an open vein should an emergency arise but doesn't hook you up to an IV pole unnecessarily-a good compromise in certain situations.

Fetal Monitoring "Will I have to be hooked up to a fetal monitor the whole time I'm in labor? What's the point of it anyway?"

For someone who's spent the first nine months of his or her life floating peacefully in a warm and comforting amniotic bath, the trip through the narrow confines of the maternal pelvis will be no joyride. Your baby will be squeezed, compressed, pushed, and molded with every contraction. And though most babies sail through the birth canal without a problem, others find the stress of being squeezed, compressed, pushed, and molded too difficult, and they respond with decelerations in heart rate, rapid or slowed-down movement, or other signs of fetal distress. A fetal monitor assesses how your baby is handling the stresses of labor by gauging the response of its heartbeat to the contractions of the uterus.

But does that assessment need to be continuous? Most experts say no, citing research showing that for low-risk women with unmedicated deliveries, intermittent fetal heart checks using a Doppler or fetal monitor are an effective way to assess a baby's condition. So if you fit in that category, you probably won't have to be attached to a fetal monitor for the entire duration of your labor. If, however, you're being induced, have an epidural, or have certain risk factors (such as meconium staining), you're most likely going to be hooked up to an electronic fetal monitor throughout your labor.

There are three types of continuous fetal monitoring: External monitoring. In this type of monitoring, used most frequently, two devices are strapped to the abdomen. One, an ultrasound transducer, picks up the fetal heartbeat. The other, a pressure-sensitive gauge, measures the intensity and duration of uterine contractions. Both are connected to a monitor, and the measurements are recorded on a digital and paper readout. When you're connected to an external monitor, you'll be able to move around in your bed or on a chair nearby, but you won't have complete freedom of movement, unless telemetry monitoring is being used (see this page). In this type of monitoring, used most frequently, two devices are strapped to the abdomen. One, an ultrasound transducer, picks up the fetal heartbeat. The other, a pressure-sensitive gauge, measures the intensity and duration of uterine contractions. Both are connected to a monitor, and the measurements are recorded on a digital and paper readout. When you're connected to an external monitor, you'll be able to move around in your bed or on a chair nearby, but you won't have complete freedom of movement, unless telemetry monitoring is being used (see this page).

During the second (pushing) stage of labor, when contractions may come so fast and furious that it's hard to know when to push and when to hold back, the monitor can be used to accurately signal the beginning and end of each contraction. Or the use of the monitor may be all but abandoned during this stage, so as not to interfere with your concentration. In this case, your baby's heart rate will be checked periodically with a Doppler.

Internal monitoring. When more accurate results are required-such as when there is reason to suspect fetal distress-an internal monitor may be used. In this type of monitoring, a tiny electrode is inserted through your vagina onto your baby's scalp, and a catheter is placed in your uterus or an external pressure gauge is strapped to your abdomen to measure the strength of your contractions. Though internal monitoring gives a slightly more accurate record of the baby's heart rate and your contractions than an external monitor, it's only used when necessary (since its use comes with a slight risk of infection). Your baby may have a small bruise or scratch where the electrode was attached, but it'll heal in a few days. You'll be more limited in your movement with an internal monitor, but you'll still be able to move from side to side. When more accurate results are required-such as when there is reason to suspect fetal distress-an internal monitor may be used. In this type of monitoring, a tiny electrode is inserted through your vagina onto your baby's scalp, and a catheter is placed in your uterus or an external pressure gauge is strapped to your abdomen to measure the strength of your contractions. Though internal monitoring gives a slightly more accurate record of the baby's heart rate and your contractions than an external monitor, it's only used when necessary (since its use comes with a slight risk of infection). Your baby may have a small bruise or scratch where the electrode was attached, but it'll heal in a few days. You'll be more limited in your movement with an internal monitor, but you'll still be able to move from side to side.

Telemetry monitoring. Available only in some hospitals, this type of monitoring uses a transmitter on your thigh to transmit the baby's heart tones (via radio waves) to the nurse's station-allowing you to take a lap or two around the hallway while still having constant monitoring. Available only in some hospitals, this type of monitoring uses a transmitter on your thigh to transmit the baby's heart tones (via radio waves) to the nurse's station-allowing you to take a lap or two around the hallway while still having constant monitoring.

Be aware that with both internal and external types of monitoring, false alarms are common. The machine can start beeping loudly if the transducer has slipped out of place, if the baby has shifted positions, if the monitor isn't working right, or if contractions have suddenly picked up in intensity. Your practitioner will take all these factors and others into account before concluding that your baby really is in trouble. If the abnormal readings do continue, several other assessments can be performed (such as fetal scalp stimulation) to determine the cause of the distress. If fetal distress is confirmed, then cesarean delivery is usually called for.

Artificial Rupture of Membranes "I'm afraid that if my water doesn't break on its own, the doctor will have to rupture the membranes artificially. Won't that hurt?"