Most women actually don't feel a thing when their membranes are artificially ruptured, particularly if they're already in labor (there are far more significant pains to cope with then). If you do experience a little discomfort, it'll more likely be from the introduction into the vagina of the Amniohook (the long plastic device that looks like a sharp-pointed crochet hook and is used to perform the procedure) than from the rupture itself. Chances are, all you'll really notice is a gush of water, followed soon-at least that's the hope-by harder and faster contractions that will get your baby moving. Artificial rupture of the membranes is also performed to allow for other procedures, such as internal fetal monitoring, when necessary.

Though the latest research seems to indicate that artificially rupturing the membranes doesn't shorten the length of labor or decrease the need for Pitocin, many practitioners still turn to artificial rupture in an attempt to help move a sluggish labor along. If there's no compelling reason to rupture them (labor's moving along just fine), you and your practitioner may decide to hold off and let them rupture naturally. Occasionally, membranes stay stubbornly intact throughout delivery (the baby arrives with the bag of waters still surrounding him or her, which means it will need to be ruptured right after birth), and that's fine, too.

An Episiotomy "I heard episiotomies aren't routine anymore. Is that true?"

Happily, you've heard right. An episiotomy-a surgical cut in your perineum (the muscular area between your vagina and your anus) to enlarge the vaginal opening just before the baby's head emerges-is no longer performed routinely at delivery. These days, in fact, midwives and most doctors rarely make the cut without a good reason.

It wasn't always that way. The episiotomy was once thought to prevent spontaneous tearing of the perineum and postpartum urinary and fecal incontinence, as well as reduce the risk in the newborn of birth trauma (from the baby's head pushing long and hard against the perineum). But it's now known that infants fare just fine without an episiotomy, and mothers, too, seem to do better without it. An average total labor doesn't seem to be any longer, and mothers often experience less blood loss, less infection, and less perineal pain after delivery without an episiotomy (though you can still have blood loss and infection with a tear). What's more, research has shown that episiotomies are more likely than spontaneous tears to turn into serious third- or fourth-degree tears (those that go close to or through the rectum, sometimes causing fecal incontinence).

But while routine episiotomies are no longer recommended, there is still a place for them in certain birth scenarios. Episiotomies may be indicated when a baby is large and needs a roomier exit route, when the baby needs to be delivered rapidly, when forceps or vacuum delivery need to be performed, or for the relief of shoulder dystocia (a shoulder gets stuck in the birth canal during delivery).

If you do need an episiotomy, you'll get an injection (if there's time) of local pain relief before the cut, though you may not need a local if you're already anesthetized from an epidural or if your perineum is thinned out and already numb from the pressure of your baby's head during crowning. Your practitioner will then take surgical scissors and make either a median (also called midline) incision (a cut made directly toward the rectum) or a mediolateral incision (which slants away from the rectum). After delivery of your baby and the placenta, the practitioner will stitch up the cut (you'll get a shot of local pain medication if you didn't receive one before or if your epidural has worn off).

To reduce the possibility that you'll need an episiotomy and to ease delivery without one, some midwives recommend perineal massage (see page 352 page 352) for a few weeks before your due date if you're a first-time mom. (If you've delivered vaginally before, you're already stretched, so do-ahead massage probably won't accomplish much.) During labor, the following can also help: warm compresses to lessen perineal discomfort, perineal massage, standing or squatting and exhaling or grunting while pushing to facilitate stretching of the perineum. During the pushing phase, your practitioner will probably use perineal support-applying gentle counterpressure to the perineum so your baby's head doesn't push out too quickly and cause an unnecessary tear.

If you haven't already, discuss the episiotomy issue with your practitioner. It's very likely he or she will agree that the procedure should not be performed unless there's a good reason. Document your feelings about episiotomies in your birth plan, too, if you like. But keep in mind that, very occasionally, episiotomies do turn out to be necessary, and the final decision should be made in the delivery or birthing room-when that cute little head is crowning.

Forceps "How likely will it be that I'll need forceps during delivery?"

Pretty unlikely these days. Forceps-long curved tong-like devices designed to help a baby make his or her descent down the birth canal-are used in only a very small percentage of deliveries (vacuum extraction is more common; see next question). But if your practitioner does decide to use forceps, rest assured; they are as safe as a C-section or vacuum extraction when used correctly by an experienced practitioner (many younger doctors have not been trained in their use, and some are reluctant to use them).

Forceps are considered when a laboring mom is just plain exhausted or if she has a heart condition or very high blood pressure that might make strenuous pushing harmful to her health. They might also be used if the baby needs to be delivered in a hurry because of fetal distress (assuming the baby is in a favorable position-for example, close to crowning) or if the baby's in an unfavorable position during the pushing stage (the forceps can be used to rotate the baby's head to facilitate the birth).

Your cervix will have to be fully dilated, your bladder empty, and your membranes ruptured before forceps are used. Then you'll be numbed with a local anesthetic (unless you already have an epidural in place). You'll also likely receive an episiotomy to enlarge the vaginal opening to allow for placement of the forceps. The curved tongs of the forceps will then be cradled one at a time around the temples of the baby's crowning head, locked into position, and used to gently deliver the baby. There may be some bruising or swelling on the baby's scalp from the forceps, but it will usually go away within a few days after birth.

If your practitioner attempts delivery with forceps, but the attempt is unsuccessful, you'll likely undergo a C-section.

Vacuum Extraction "My friend's ob used a vacuum extractor to help deliver her baby. Is that the same as forceps?"

It does the same job. The vacuum extractor is a plastic cup placed on the baby's head, and it uses gentle suction to help guide him or her out of the birth canal. The suction prevents the baby's head from moving back up the birth canal between contractions and can be used to help mom out while she is pushing during contractions. Vacuum extraction is used in about 5 percent of deliveries and offers a good alternative to both forceps and C-section under the right circumstances.

Your practitioner would use vacuum extraction for the same reason forceps would be used during delivery (see previous question). Vacuum deliveries are associated with less trauma to the vagina (and possibly a lower chance of needing an episiotomy) and less need for local anesthesia than forceps, which is another reason why more practitioners opt for them over forceps these days.

Babies born with vacuum extraction experience some swelling on the scalp, but it usually isn't serious, doesn't require treatment, and goes away within a few days. As with forceps, if the vacuum extractor isn't working successfully to help deliver the baby, a cesarean delivery is recommended.

Vacuum Extractor

If during delivery your doctor suggests the need for vacuum extraction to speed things up, you might want to ask if you can rest for several contractions (time permitting) before trying again; such a break might give you the second wind you need to push your baby out effectively. You can also try changing your position: Get up on all fours, or squat; the force of gravity might shift the baby's head.

Before you go into labor, ask your practitioner any questions you have about the possible use of vacuum extraction (or forceps). The more you know, the better prepared you'll be for anything that comes your way during childbirth.

Labor Positions "I know you're not supposed to lie flat on your back during labor. But what position is best?"

There's no need to take labor lying down, and in fact, lying flat on your back is probably the least efficient way to birth your baby: first because you're not enlisting gravity's help to get your baby out, and second because there's the risk of compressing major blood vessels (and possibly interfering with blood flow to the fetus) when you're on your back. Expectant mothers are encouraged to labor in any other position that feels comfortable, and to change their position as often as they can (and want to). Getting a move on during labor, as well as varying your position often, not only eases discomfort but may also yield speedier results.

You can choose from any of the following labor and delivery postures (or variations of these):

Labor Positions

Standing or walking. Getting vertical not only helps relieve the pain of contractions but also takes advantage of gravity, which may allow your pelvis to open and your baby to move down into your birth canal. While it's unlikely you'll be heading for the track once contractions are coming fast and furious, walking (or just leaning against a wall or your coach) during the early stages of labor can be an effective move. Getting vertical not only helps relieve the pain of contractions but also takes advantage of gravity, which may allow your pelvis to open and your baby to move down into your birth canal. While it's unlikely you'll be heading for the track once contractions are coming fast and furious, walking (or just leaning against a wall or your coach) during the early stages of labor can be an effective move.

Rocking. Sure, your baby's not even born yet, but he or she will still enjoy a little rocking-as will you, especially when those contractions start coming. Slip into a chair or remain upright, and sway back and forth. The rocking motion may allow your pelvis to move and encourage the baby to descend. And again, staying upright allows you to use the force of gravity to help in the process. Sure, your baby's not even born yet, but he or she will still enjoy a little rocking-as will you, especially when those contractions start coming. Slip into a chair or remain upright, and sway back and forth. The rocking motion may allow your pelvis to move and encourage the baby to descend. And again, staying upright allows you to use the force of gravity to help in the process.

Squatting. You probably won't be able to stand and deliver, but once you get closer to the pushing phase of childbirth, you might want to consider squatting. There's a reason why women have delivered their babies in a squatting position for centuries: It works. Squatting allows the pelvis to open wide, giving your baby more room to move on down. You can use your partner for squatting support (you'll probably be a little wobbly, so you'll need all the support you can get), or you can use a squatting bar, which is often attached to the birthing bed (leaning on the bar will keep your legs from tiring out as you squat). You probably won't be able to stand and deliver, but once you get closer to the pushing phase of childbirth, you might want to consider squatting. There's a reason why women have delivered their babies in a squatting position for centuries: It works. Squatting allows the pelvis to open wide, giving your baby more room to move on down. You can use your partner for squatting support (you'll probably be a little wobbly, so you'll need all the support you can get), or you can use a squatting bar, which is often attached to the birthing bed (leaning on the bar will keep your legs from tiring out as you squat).

Birthing balls. Sitting or leaning on one of these large exercise balls can help open up your pelvis-and it's a lot easier than squatting for long periods. Sitting or leaning on one of these large exercise balls can help open up your pelvis-and it's a lot easier than squatting for long periods.

Sitting. Whether in bed (the back of the birthing bed can be raised so you're almost sitting upright), in your partner's arms, or on a birthing ball, sitting can ease the pain of contractions and may allow gravity to help bring your baby down into the birth canal. You might also consider a birthing chair, if one is available, which is specifically designed to support a woman in a sitting or squatting position during delivery and, theoretically, speed labor. Another plus: Moms get to see more of the birth in this position. Whether in bed (the back of the birthing bed can be raised so you're almost sitting upright), in your partner's arms, or on a birthing ball, sitting can ease the pain of contractions and may allow gravity to help bring your baby down into the birth canal. You might also consider a birthing chair, if one is available, which is specifically designed to support a woman in a sitting or squatting position during delivery and, theoretically, speed labor. Another plus: Moms get to see more of the birth in this position.

Kneeling. Got back labor? Kneeling over a chair or over your spouse's shoulders is a great position when the back of the baby's head is pushing against your spine. It encourages the baby to move forward, taking that load off your back. Even if you don't have back labor, kneeling can be an effective labor and delivery position. Because kneeling allows you to shift and transfer some of the pressure toward the lower spine while you push your baby out, it seems to reduce childbirth pain even more than sitting does. Got back labor? Kneeling over a chair or over your spouse's shoulders is a great position when the back of the baby's head is pushing against your spine. It encourages the baby to move forward, taking that load off your back. Even if you don't have back labor, kneeling can be an effective labor and delivery position. Because kneeling allows you to shift and transfer some of the pressure toward the lower spine while you push your baby out, it seems to reduce childbirth pain even more than sitting does.

Hands and knees. Getting on all fours is another way to cope more comfortably with back labor-and to help get that puppy out faster. This position allows you to do pelvic tilts for comfort, while giving your spouse or doula access to your back for massage and counterpressure. You might even consider delivering in this position (no matter what kind of labor you're having), since it opens up the pelvis and uses gravity to coax baby down. Getting on all fours is another way to cope more comfortably with back labor-and to help get that puppy out faster. This position allows you to do pelvic tilts for comfort, while giving your spouse or doula access to your back for massage and counterpressure. You might even consider delivering in this position (no matter what kind of labor you're having), since it opens up the pelvis and uses gravity to coax baby down.

Side lying. Too tired to sit? Or squat? Just need to lie down? Lying on your side is much better than lying on your back, since it doesn't compress the major veins in your body. It's also a good delivery option, helping to slow a too-fast birth as well as easing the pain of some contractions. Too tired to sit? Or squat? Just need to lie down? Lying on your side is much better than lying on your back, since it doesn't compress the major veins in your body. It's also a good delivery option, helping to slow a too-fast birth as well as easing the pain of some contractions.

Remember that the best labor position is the one that's best for you. And what's best in the early stages of labor might make you miserable when you're in the throes of transition, so change positions as often-or as little-as you want. If you're being continuously monitored, your positions are somewhat limited. It'll be hard to walk, for instance-but you'll have no problem squatting, rocking, sitting, getting on your hands and knees, or lying on your side. Even if you have an epidural, sitting, side lying, or rocking are options available to you.

Being Stretched by Childbirth "I'm concerned about stretching during delivery. Will my vagina ever be the same again?"

Mother Nature definitely had mothers in mind when she thought up vaginas. Their incredible elasticity and accordion-like folds allow this amazing organ to open up for childbirth (and the passage of that 7- or 8-pound baby) and then-over a period of weeks following delivery-return to close to original size. In other words, your vagina's definitely designed to take it.

The perineum is also elastic but less so than the vagina. Massage during the months prior to delivery may help increase its elasticity and reduce stretching (though don't go overboard; see page 352 page 352). Likewise, exercising the pelvic muscles with Kegels during this period may enhance their elasticity, strengthen them, and speed their return to normal tone.

Most women find that the slight increase in vaginal roominess typically experienced postpartum is imperceptible and doesn't interfere at all with sexual enjoyment. For those who were previously too snug, that extra room can be a real plus-making sex more of a pleasure and in some cases, literally, less of a pain. Very occasionally, however, in a woman who was "just right" before, childbirth does stretch the vagina enough that sexual satisfaction decreases. Often, the vaginal muscles tighten up again in time. Doing Kegels faithfully and frequently helps speed that process. If six months after delivery you still find that your vagina's too slack for comfort, talk to your doctor about other possible treatments.

Apgar Score The Apgar score is your baby's first test, and it's a way to quickly evaluate your newborn's condition. At one minute and again at five minutes after birth, a nurse, midwife, or doctor check the infant's Appearance (color), Pulse (heartbeat), Grimace (reflex), Activity (muscle tone), and Respiration. Babies who score above 6, which most babies do, are fine. Those who score between 4 and 6 often need resuscitation, which generally includes suctioning their airways and administering oxygen. Those who score under 4 require more dramatic lifesaving techniques.

The Sight of Blood "The sight of blood makes me feel faint. I'm not sure if I'll be able to handle watching my delivery."

Here's some good news for the squeamish. First of all, there isn't all that much blood during childbirth-not much more than you see when you've got your period. Second, you're not really a spectator at your delivery; you'll be a very active participant, putting every ounce of your concentration and energy into pushing your baby those last few inches. Caught up in the excitement and anticipation (and, let's face it, the pain and fatigue), you're unlikely to notice, much less be unsettled by, any bleeding. If you ask friends who are new mothers, few will be able to tell you just how much blood, if any, there was at their deliveries.

If you still feel strongly that you don't want to see any blood, simply keep your eyes off the mirror at the moment of birth (and look away, too, if an episiotomy is performed). Instead, just look down past your belly for a good view of your baby as he or she emerges. From this vantage point, virtually no blood will be visible. But before you decide to opt out of watching your own delivery, watch someone else's by viewing a childbirth DVD. You'll probably be much more amazed than horrified.

Some fathers, too, worry about how they'll handle viewing the birth. If your spouse is anxious about this aspect of delivery, have him read page 483 page 483.

Childbirth Delivering a baby is the challenge of a lifetime, but it's also an emotional and physical rush like no other. It's an experience that you may be looking ahead to with trepidation (and maybe a little dread), but that you'll likely look back on-once it's all said, done, and delivered-with nothing but the purest joy (and maybe a little relief).

Fortunately, you won't be going it alone. In addition to the support of your coach, you'll have plenty of medical professionals on the scene, too. But even with all that expertise in your camp, it'll help to have some know-how of your own.

Stages and Phases of Childbirth Childbirth progresses in three stages: labor, delivery of the baby, and delivery of the placenta. Unless labor is cut short (or eliminated) by a C-section, all women go through the labor stage, which includes early labor, active labor, and transitional labor. The timing and intensity of the contractions can help pinpoint which phase of labor you're in at any particular time, and so can some of the symptoms you're experiencing along the way. Periodic internal exams will confirm the progress.

Stage One: Labor Labor Phase 1: Early (Latent)-thinning (effacement) and opening (dilation) of the cervix to 3 cm; contractions are 30 to 45 seconds long, 20 minutes apart or less.

Phase 2: Active-dilation of cervix to 7 cm; contractions are 40 to 60 seconds long, coming 3 to 4 minutes apart.

Phase 3: Transitional-dilation of cervix to 10 cm (fully dilated); contractions are 60 to 90 seconds long, about 2 to 3 minutes apart.

Stage Two: Delivery of the baby Delivery of the baby Stage Three: Delivery of the placenta Delivery of the placenta

After nine months at it-graduating from queasiness and bloating to heartburn and backache-you almost certainly know what to expect when you're expecting by now. But what should you expect when you're laboring and delivering?

That's actually hard to predict (make that impossible). Like every pregnancy before it, every labor and delivery is different. But just as it was comforting to know what you might expect during those months of growing your baby, it'll be comforting to have a general idea of what you might have in store for you during those hours of childbirth. Even if it turns out to be nothing like you expected (with the exception of that very happy and cuddly ending).

Stage One: Labor Phase 1: Early Labor This phase is usually the longest and, fortunately, the least intense phase of labor. Over a period of hours, days, or weeks (often without noticeable or bothersome contractions), or over a period of two to six hours of no-doubt-about-it contractions, your cervix will efface (thin out) and dilate (open) to 3 cm.

Contractions in this phase usually last 30 to 45 seconds, though they can be shorter. They are mild to moderately strong, may be regular or irregular (around 20 minutes apart, more or less), and become progressively closer together, but not necessarily in a consistent pattern.

For the Record Instead of grabbing the nearest piece of scrap paper to write down the timing of your contractions, flip open to the childbirth journal in The What to Expect Pregnancy Journal and Organizer The What to Expect Pregnancy Journal and Organizer to record all the info about your contractions and your labor experience (or better yet, have your spouse jot it down). This way you'll have a keepsake to help you remember the event-not that you'd ever forget. to record all the info about your contractions and your labor experience (or better yet, have your spouse jot it down). This way you'll have a keepsake to help you remember the event-not that you'd ever forget.

During early labor, you might experience any or all of the following: [image] Backache (either constant or with each contraction) Backache (either constant or with each contraction)[image] Menstrual-like cramps Menstrual-like cramps[image] Lower abdominal pressure Lower abdominal pressure[image] Indigestion Indigestion[image] Diarrhea Diarrhea[image] A sensation of warmth in the abdomen A sensation of warmth in the abdomen[image] Bloody show (blood-tinged mucus) Bloody show (blood-tinged mucus)[image] Rupture of the amniotic membranes (your water will break), though it's more likely that they'll rupture sometime during active labor. Rupture of the amniotic membranes (your water will break), though it's more likely that they'll rupture sometime during active labor.

Emotionally, you may feel excitement, relief, anticipation, uncertainty, anxiety, fear; some women are relaxed and chatty, others tense and apprehensive.

What You Can Do. Of course you're excited (and nervous), but it's important to relax-or at least try to relax. This could take a while. Of course you're excited (and nervous), but it's important to relax-or at least try to relax. This could take a while.

[image] If it's nighttime, try to sleep (you might not be able to later, when the contractions are coming fast and furious). If you can't sleep-what with all the adrenaline pumping-get up and do things around the house that will distract you. Cook a few more dishes to add to your freezer stash, fold some baby clothes, do the rest of the laundry so you can come home to an empty hamper (it'll fill up again soon enough), or log on to your favorite message board to see if anyone else is in the same boat. If it's daytime, go about your usual routine, as long as it doesn't take you far from home (don't go anywhere without your cell phone). If you're at work, you might want to head home (it's not like you're going to get anything done anyway). If you have nothing planned, find something relaxing to keep you occupied. Take a walk, watch TV, e-mail friends and family, finish packing your bag. If it's nighttime, try to sleep (you might not be able to later, when the contractions are coming fast and furious). If you can't sleep-what with all the adrenaline pumping-get up and do things around the house that will distract you. Cook a few more dishes to add to your freezer stash, fold some baby clothes, do the rest of the laundry so you can come home to an empty hamper (it'll fill up again soon enough), or log on to your favorite message board to see if anyone else is in the same boat. If it's daytime, go about your usual routine, as long as it doesn't take you far from home (don't go anywhere without your cell phone). If you're at work, you might want to head home (it's not like you're going to get anything done anyway). If you have nothing planned, find something relaxing to keep you occupied. Take a walk, watch TV, e-mail friends and family, finish packing your bag.[image] Alert the media. Okay, maybe not the media (yet)-but you'll definitely want to put your spouse on alert if he's not with you. He probably doesn't have to rush to your side just yet if he's at work-unless he really wants to-since there's not much for him to do this early on. If you have hired a doula, it would be a good idea to issue a bulletin to her, too. Alert the media. Okay, maybe not the media (yet)-but you'll definitely want to put your spouse on alert if he's not with you. He probably doesn't have to rush to your side just yet if he's at work-unless he really wants to-since there's not much for him to do this early on. If you have hired a doula, it would be a good idea to issue a bulletin to her, too.[image] Eat a light snack or meal if you're hungry (broth, toast with jam, plain pasta or rice, Jell-O, a Popsicle, pudding, a banana, or something else your practitioner has suggested)-now's the best time to stock up on energy foods. But don't eat heavily, and avoid hard-to-digest foods (burgers, potato chips). You may also want to skip anything acidic, such as orange juice or lemonade. And definitely drink some water-it's important to stay hydrated. Eat a light snack or meal if you're hungry (broth, toast with jam, plain pasta or rice, Jell-O, a Popsicle, pudding, a banana, or something else your practitioner has suggested)-now's the best time to stock up on energy foods. But don't eat heavily, and avoid hard-to-digest foods (burgers, potato chips). You may also want to skip anything acidic, such as orange juice or lemonade. And definitely drink some water-it's important to stay hydrated.[image] Make yourself comfortable. Take a warm shower; use a heating pad if your back is aching; take acetaminophen (Tylenol) if your practitioner approves. Don't take aspirin or ibuprofen (Advil, Motrin). Make yourself comfortable. Take a warm shower; use a heating pad if your back is aching; take acetaminophen (Tylenol) if your practitioner approves. Don't take aspirin or ibuprofen (Advil, Motrin).[image] Time contractions (from the beginning of one to the beginning of the next) for half an hour if they seem to be getting closer than 10 minutes apart and periodically even if they don't. But don't be a constant clock-watcher. Time contractions (from the beginning of one to the beginning of the next) for half an hour if they seem to be getting closer than 10 minutes apart and periodically even if they don't. But don't be a constant clock-watcher.[image] Remember to pee often, even if you're not feeling the urge to. A full bladder could slow down the progress of labor. Remember to pee often, even if you're not feeling the urge to. A full bladder could slow down the progress of labor.[image] Use relaxation techniques if they help, but don't start any breathing exercises yet or you'll become bored and exhausted long before you really need them. Use relaxation techniques if they help, but don't start any breathing exercises yet or you'll become bored and exhausted long before you really need them.

For the Coach: What You Can Do. If you're around during this phase, here are some ways you can help out. If a doula's also on site, she can share in any or all of these: If you're around during this phase, here are some ways you can help out. If a doula's also on site, she can share in any or all of these: [image] Practice timing contractions. The interval between contractions is timed from the beginning of one to the beginning of the next. Time them periodically, and keep a record. When they are coming less than 10 minutes apart, time them more frequently. Practice timing contractions. The interval between contractions is timed from the beginning of one to the beginning of the next. Time them periodically, and keep a record. When they are coming less than 10 minutes apart, time them more frequently.[image] Spread the calm. During this early phase of labor, your most important function is to keep your partner relaxed. And the best way to do this is to keep yourself relaxed, both inside and out. Your own anxiety can be passed on to her without your realizing it, and it can be communicated not just through words but through touch-or even expressions (so no tensed-up foreheads, please). Doing relaxation exercises together or giving her a gentle, unhurried massage may help. It's too soon, however, to have her begin using breathing exercises. For now, just breathe. Spread the calm. During this early phase of labor, your most important function is to keep your partner relaxed. And the best way to do this is to keep yourself relaxed, both inside and out. Your own anxiety can be passed on to her without your realizing it, and it can be communicated not just through words but through touch-or even expressions (so no tensed-up foreheads, please). Doing relaxation exercises together or giving her a gentle, unhurried massage may help. It's too soon, however, to have her begin using breathing exercises. For now, just breathe.

Call Your Practitioner If ...

Your practitioner probably told you not to call until you're in more active labor, but may have suggested that you call early on if labor begins during the day or if your membranes rupture. Definitely call immediately, however, if your membranes rupture and the amniotic fluid is murky or greenish, if you have any bright red vaginal bleeding, or if you feel no fetal activity (it may be hard to notice because you are distracted by contractions, so try the test on page 289 page 289). Although you may not feel like it, it's best if you-not your coach-make the call and talk to your practitioner. A lot can be lost in third-party translations.

[image]Offer comfort, reassurance, and support. She'll need them from now on.[image] Keep your sense of humor, and help her keep hers; time flies, after all, when you're having fun. It'll be easier to laugh now than when contractions are coming fast and hard (she probably won't find very much of anything funny then). Keep your sense of humor, and help her keep hers; time flies, after all, when you're having fun. It'll be easier to laugh now than when contractions are coming fast and hard (she probably won't find very much of anything funny then).[image] Try distraction. Suggest activities that will help keep both your minds off her labor: playing video games, watching a silly sitcom or reality show, checking out celebrity birthday sites to see who baby might be celebrating with next year, baking something for the postpartum freezer stash, taking short strolls. Try distraction. Suggest activities that will help keep both your minds off her labor: playing video games, watching a silly sitcom or reality show, checking out celebrity birthday sites to see who baby might be celebrating with next year, baking something for the postpartum freezer stash, taking short strolls.[image] Keep up your own strength so you'll be able to reinforce hers. Eat periodically but empathetically (don't go wolfing down a Big Mac when she's sticking to pudding). Prepare a sandwich to take along to the hospital or birthing center, but avoid anything with a strong or lingering odor. She won't be in the mood to be sniffing bologna or onions on your breath. Keep up your own strength so you'll be able to reinforce hers. Eat periodically but empathetically (don't go wolfing down a Big Mac when she's sticking to pudding). Prepare a sandwich to take along to the hospital or birthing center, but avoid anything with a strong or lingering odor. She won't be in the mood to be sniffing bologna or onions on your breath.

Phase 2: Active Labor The active phase of labor is usually shorter than the first, lasting an average of 2 to 3 hours (with, again, a wide range considered normal). The contractions are more concentrated now, accomplishing more in less time, and they're also increasingly more intense (in other words, painful). As they become stronger, longer (40 to 60 seconds, with a distinct peak about halfway through), and more frequent (generally 3 to 4 minutes apart, though the pattern may not be regular), the cervix dilates to 7 cm. With fewer breaks in the action, there's less opportunity to rest between contractions.

You'll likely be in the hospital or birthing center by now, and you can expect to feel all or some of the following (though you won't feel pain if you've had an epidural): [image] Increasing pain and discomfort with contractions (you may not be able to talk through them now). Increasing pain and discomfort with contractions (you may not be able to talk through them now).[image] Increasing backache. Increasing backache.[image] Leg discomfort or heaviness. Leg discomfort or heaviness.[image] Fatigue. Fatigue.[image] Increasing bloody show. Increasing bloody show.[image] Rupture of the membranes (if they haven't earlier), or they might be ruptured artificially now. Rupture of the membranes (if they haven't earlier), or they might be ruptured artificially now.

Emotionally, you may feel restless and find it more difficult to relax; or your concentration may become more intense, and you may become completely absorbed in your labor efforts. Your confidence may begin to waver ("How will I make it through?"), along with your patience ("Will this labor never end?"), or you may feel excited and encouraged that things are really starting to happen. Whatever your feelings, they're normal-just get ready to start getting "active."

During active labor, assuming all is progressing normally and safely, the hospital or birthing center staff will leave you alone (or stay out of your way, but in your room), checking and monitoring you as needed, but also allowing you to work through your labor with your coach and other support people without interference. You can expect them to:

On to the Hospital or Birthing Center Sometime near the end of the early phase or the beginning of the active phase (probably when your contractions are five minutes apart or less, sooner if you live far from the hospital or if this isn't your first baby), your practitioner will tell you to pick up your bag and get going. Getting to the hospital or birthing center will be easier if your coach is reachable anywhere, anytime by cell phone or beeper and can get to you quickly (do not try to drive yourself to the hospital or birthing center; take a taxi or ask a friend to drive you if your coach can't be reached); you've planned your route in advance; are familiar with parking regulations (if parking is likely to be a problem, taking a cab may be more sensible); and know which entrance will get you to the obstetrical floor most quickly. En route, recline the front seat as far back as is comfortable, if you'd like (remember to fasten your seatbelt). If you have chills, bring along a blanket to cover you.

Once you reach the hospital or birthing center, you can probably expect something like the following: [image] To get registered: If you've preregistered (and it's best if you have), the admission process will be quick and easy; if you're in active labor and in no mood to answer questions, your coach can take care of it. If you haven't preregistered, you (or better yet, your coach) will have to go through a more lengthy process, so be prepared to fill out a bunch of forms and answer a lot of questions. To get registered: If you've preregistered (and it's best if you have), the admission process will be quick and easy; if you're in active labor and in no mood to answer questions, your coach can take care of it. If you haven't preregistered, you (or better yet, your coach) will have to go through a more lengthy process, so be prepared to fill out a bunch of forms and answer a lot of questions.[image] Once on the labor and delivery floor, a nurse will take you to your room (most likely a labor, delivery, and recovery room, or LDR). Sometimes, you may be brought first to a triage (assessment) room, where your cervix will be checked, your baby's heart rate assessed, and your contractions monitored for some time to see if you're actively in labor or not. In some hospitals or birthing centers, your coach and other family members may be asked to wait outside while you are being admitted and prepped. Speak up if you'd rather your coach stay by your side; most hospitals or birthing centers are flexible. (Note to the coach: This is a good time to make a few priority phone calls or to get a snack if you haven't brought one. If you aren't called into the room within 20 minutes or so, remind someone at the nurses' station that you're waiting. Be prepared for the possibility that you will be asked to put on a clean gown over your clothes.) Once on the labor and delivery floor, a nurse will take you to your room (most likely a labor, delivery, and recovery room, or LDR). Sometimes, you may be brought first to a triage (assessment) room, where your cervix will be checked, your baby's heart rate assessed, and your contractions monitored for some time to see if you're actively in labor or not. In some hospitals or birthing centers, your coach and other family members may be asked to wait outside while you are being admitted and prepped. Speak up if you'd rather your coach stay by your side; most hospitals or birthing centers are flexible. (Note to the coach: This is a good time to make a few priority phone calls or to get a snack if you haven't brought one. If you aren't called into the room within 20 minutes or so, remind someone at the nurses' station that you're waiting. Be prepared for the possibility that you will be asked to put on a clean gown over your clothes.)[image] Your nurse will take a brief history, asking, among other things, when the contractions started, how far apart they are, whether your membranes have ruptured, and, possibly, when and what you last ate. Your nurse will take a brief history, asking, among other things, when the contractions started, how far apart they are, whether your membranes have ruptured, and, possibly, when and what you last ate.[image] Your nurse will ask for your signature (or your spouse's) on routine consent forms. Your nurse will ask for your signature (or your spouse's) on routine consent forms.[image] Your nurse will give you a hospital gown to change into and might request a urine sample. She will check your pulse, blood pressure, respiration, and temperature; look for leaking amniotic fluid, bleeding, or bloody show; listen to the fetal heartbeat with a Doppler or hook you up to a fetal monitor, if this is deemed necessary. She may also evaluate the fetus and its position. Your nurse will give you a hospital gown to change into and might request a urine sample. She will check your pulse, blood pressure, respiration, and temperature; look for leaking amniotic fluid, bleeding, or bloody show; listen to the fetal heartbeat with a Doppler or hook you up to a fetal monitor, if this is deemed necessary. She may also evaluate the fetus and its position.[image] Depending on the policies of your practitioner and the hospital or birthing center (and, ideally, your preferences), an IV may be started. Depending on the policies of your practitioner and the hospital or birthing center (and, ideally, your preferences), an IV may be started.[image] Your nurse, your practitioner, or a staff doctor or midwife will examine you internally to see how dilated and effaced your cervix is (if it wasn't already checked). If your membranes haven't ruptured spontaneously and you are at least 3 or 4 cm dilated (many practitioners prefer to wait until the cervix has dilated to 5 cm), your membranes may be artificially ruptured-unless you and your practitioner have decided to leave them intact until they break on their own or until later in labor. The procedure is generally painless; all you'll feel is a warm gush of fluid. Your nurse, your practitioner, or a staff doctor or midwife will examine you internally to see how dilated and effaced your cervix is (if it wasn't already checked). If your membranes haven't ruptured spontaneously and you are at least 3 or 4 cm dilated (many practitioners prefer to wait until the cervix has dilated to 5 cm), your membranes may be artificially ruptured-unless you and your practitioner have decided to leave them intact until they break on their own or until later in labor. The procedure is generally painless; all you'll feel is a warm gush of fluid.

If you have any questions-about hospital or birthing center policy, about your condition, about your practitioner's plans-that haven't been answered before, now is the time for you or your coach to ask them. Your coach can also take this opportunity to hand a copy of your birth plan, if you have one, to the birth attendants.

[image]Take your blood pressure.[image] Monitor your baby with a Doppler or fetal monitor. Monitor your baby with a Doppler or fetal monitor.[image] Time and monitor the strength of your contractions. Time and monitor the strength of your contractions.[image] Evaluate the quantity and quality of bloody discharge. Evaluate the quantity and quality of bloody discharge.[image] Get an IV going if you're going to want an epidural. Get an IV going if you're going to want an epidural.[image] Possibly try to augment your labor if it's progressing very slowly by the use of Pitocin or by artificially rupturing the membranes (if they are still intact). Possibly try to augment your labor if it's progressing very slowly by the use of Pitocin or by artificially rupturing the membranes (if they are still intact).[image] Periodically examine you internally to check how labor is progressing and how dilated and effaced your cervix is. Periodically examine you internally to check how labor is progressing and how dilated and effaced your cervix is.[image] Administer pain relief if you choose to have some. Administer pain relief if you choose to have some.

They'll also be able to answer any questions you might have (don't be shy about asking or having your coach ask) and provide additional support as you go through labor.

Are Things Slowing Down?

There's probably nothing you want more than to keep things moving along when it comes to labor. And making good progress during labor-which happens most of the time-requires three main components: strong uterine contractions that effectively dilate the cervix, a baby that is in position for an easy exit, and a pelvis that is sufficiently roomy to permit the passage of the baby. But, in some cases, labor doesn't progress by the book, because the cervix takes its time dilating, the baby takes longer than expected to descend through the pelvis, or pushing isn't getting you (or your baby) anywhere.

Sometimes, contractions slow down after an epidural kicks in, too. But keep in mind that expectations for the progress of labor are different for those who have an epidural (first and second stage may take longer, and that's typically nothing to worry about).

To get a stalled labor back up and running, there are a number of steps your practitioner (and you) can take: [image] If you're in early labor and your cervix just isn't dilating or effacing, your practitioner may suggest some activity (such as walking) or just the opposite (sleep and rest, possibly aided by relaxation techniques). This will also help rule out false labor (the contractions of false labor usually subside with activity or a nap). If you're in early labor and your cervix just isn't dilating or effacing, your practitioner may suggest some activity (such as walking) or just the opposite (sleep and rest, possibly aided by relaxation techniques). This will also help rule out false labor (the contractions of false labor usually subside with activity or a nap).[image] If you're still not dilating or effacing as quickly as expected, your practitioner may try to rev things up by administering Pitocin (oxytocin), prostaglandin E, or another labor stimulator. He or she might even suggest a labor booster that you can take into your own hands (or your coach's): nipple stimulation. If you're still not dilating or effacing as quickly as expected, your practitioner may try to rev things up by administering Pitocin (oxytocin), prostaglandin E, or another labor stimulator. He or she might even suggest a labor booster that you can take into your own hands (or your coach's): nipple stimulation.[image] If you're already in the active phase of labor, but your cervix is dilating very slowly (less than 1 to 1.2 cm of dilation per hour in women having their first babies, and 1.5 cm per hour in those who've had previous deliveries), or if your baby isn't moving down the birth canal at a rate of more than 1 cm per hour in women having their first babies, or 2 cm per hour in others, your practitioner may rupture your membranes and/or continue administering oxytocin. If you're already in the active phase of labor, but your cervix is dilating very slowly (less than 1 to 1.2 cm of dilation per hour in women having their first babies, and 1.5 cm per hour in those who've had previous deliveries), or if your baby isn't moving down the birth canal at a rate of more than 1 cm per hour in women having their first babies, or 2 cm per hour in others, your practitioner may rupture your membranes and/or continue administering oxytocin.[image] If you end up pushing more than two hours (if you're a first-time mother who hasn't had an epidural) or three hours (if you have had an epidural), your practitioner will reassess your baby's position, see how you're feeling, perhaps attempt to birth your baby using vacuum extraction or (less likely) forceps, or decide to do a cesarean delivery. If you end up pushing more than two hours (if you're a first-time mother who hasn't had an epidural) or three hours (if you have had an epidural), your practitioner will reassess your baby's position, see how you're feeling, perhaps attempt to birth your baby using vacuum extraction or (less likely) forceps, or decide to do a cesarean delivery.

To keep the ball (and the baby) rolling throughout labor, remember to urinate periodically, because a full bladder can interfere with the baby's descent. (If you have an epidural, chances are your bladder is being emptied by a catheter.) Full bowels may do the same, so if you haven't moved your bowels in 24 hours, give it a try. You might also try to nudge a sluggish labor along by utilizing gravity (sitting upright, squatting, standing, or walking). Ditto for trying to push along the pushing stage. A semi-sitting or semi-squatting position may be most effective for delivery.

Most physicians perform a C-section after 24 hours of active labor (sometimes sooner) if sufficient progress has not been made by that time; some will wait longer, as long as both mother and baby are doing well.

What You Can Do. It's all about your comfort now. So: It's all about your comfort now. So: [image] Don't hesitate to ask your coach for whatever you need to get and stay as comfortable as possible, whether it's a back rub to ease the ache or a damp washcloth to cool your face. Speaking up will be important. Remember, as much as he's going to want to help, he's going to have a hard time anticipating your needs, especially if this is his first time. Don't hesitate to ask your coach for whatever you need to get and stay as comfortable as possible, whether it's a back rub to ease the ache or a damp washcloth to cool your face. Speaking up will be important. Remember, as much as he's going to want to help, he's going to have a hard time anticipating your needs, especially if this is his first time.[image] Start your breathing exercises, if you plan to use them, as soon as contractions become too strong to talk through. Didn't plan ahead and practice? Ask the nurse or doula for some simple breathing suggestions. Remember to do whatever relaxes you and makes you feel more comfortable. If the exercises aren't working for you, don't feel obligated to stick with them. Start your breathing exercises, if you plan to use them, as soon as contractions become too strong to talk through. Didn't plan ahead and practice? Ask the nurse or doula for some simple breathing suggestions. Remember to do whatever relaxes you and makes you feel more comfortable. If the exercises aren't working for you, don't feel obligated to stick with them.[image] If you'd like some pain relief, now's a good time to ask for it. An epidural can be given as early as you feel you need it. If you'd like some pain relief, now's a good time to ask for it. An epidural can be given as early as you feel you need it.[image] If you're laboring without pain relief, try to relax between contractions. This will become increasingly difficult as they come more frequently, but it will also become increasingly important as your energy reserves are taxed. Use the relaxation techniques you learned in childbirth class or try the one on If you're laboring without pain relief, try to relax between contractions. This will become increasingly difficult as they come more frequently, but it will also become increasingly important as your energy reserves are taxed. Use the relaxation techniques you learned in childbirth class or try the one on page 142 page 142.[image] Stay hydrated. With your practitioner's green light, drink clear beverages frequently to replace fluids and to keep your mouth moist. If you're hungry, and again, if you have your practitioner's okay, have a light snack (another Popsicle, for example). If your practitioner doesn't allow anything else by mouth, sucking on ice chips can serve to refresh. Stay hydrated. With your practitioner's green light, drink clear beverages frequently to replace fluids and to keep your mouth moist. If you're hungry, and again, if you have your practitioner's okay, have a light snack (another Popsicle, for example). If your practitioner doesn't allow anything else by mouth, sucking on ice chips can serve to refresh.

Don't Hyperventilate With all the breathing going on during labor, some women start to hyperventilate or overbreathe, causing low levels of carbon dioxide in the blood. If you feel dizzy or lightheaded, have blurred vision or a tingling and numbness of your fingers and toes, let your coach, a nurse, your practitioner, or your doula know. They'll give you a paper bag to breathe into (or suggest you breathe into your cupped hands). A few inhales and exhales will get you feeling better in no time.

[image]Stay on the move if you can (you won't be able to get around much if you have an epidural). Walk around, if possible, or at least change positions as needed. (See page 377 page 377 for suggested labor positions.) for suggested labor positions.)[image] Pee periodically. Because of tremendous pelvic pressure, you may not notice the need to empty your bladder, but a full bladder can keep you from making the progress you'll definitely want to be making. No need to trek to the bathroom if you have an epidural (not that you could anyway), because you've probably been given a catheter to empty your bladder. Pee periodically. Because of tremendous pelvic pressure, you may not notice the need to empty your bladder, but a full bladder can keep you from making the progress you'll definitely want to be making. No need to trek to the bathroom if you have an epidural (not that you could anyway), because you've probably been given a catheter to empty your bladder.

For the Coach: What You Can Do. If a doula is present, she can help out with many of these. Discuss ahead of time who will do what for your laboring spouse. If a doula is present, she can help out with many of these. Discuss ahead of time who will do what for your laboring spouse.