Childbirth

Definition

Childbirth is formally divided by the medical field into three stages. The first stage is labor, which has three phases: early, active, and transitional. The first stage ends with complete dilatation (opening) of the cervix. The second stage is delivery, which involves pushing and the actual birth of the baby. The third stage is delivery of the placenta or afterbirth.

Description

A full-term pregnancy is considered to be 280 days, nine calendar months or ten lunar months calculated from the first day of the last menstrual period. This is a fairly arbitrary number that may, in fact, vary with genetic differences and depends on a normal menstrual cycle, which varies considerably from woman to woman. The average actual length from conception to birth is estimated as 267 days. Childbirth is a natural process, and it, too, varies among women. Despite what the obstetrical texts say about what to expect, there are many variations that make each woman's experience hers alone. The whole process averages about 14 hours for first-time mothers and about eight hours for mothers in their subsequent pregnancies.

Labor can be described in terms of a series of stages.

First stage of labor

During the first stage of labor, the cervix dilates (opens) from 0 to 10 centimeters (cm). This stage has an early, or latent, phase, an active phase, and a transitional phase. The latent phase usually lasts the longest and is the least intense phase of labor. This phase is characterized by dilatation (opening) of the cervix to 3–4 cm along with the thinning out of the cervix (effacement). It can take place over a period of days without being noticed or over a period of two to six hours with distinctive contractions. Most women are relatively comfortable during the latent phase, and walking around is encouraged, since it naturally stimulates the process.

With the initiation of labor, the muscular wall of the uterus begins to contract causing the cervix to open (dilatation) and thin out (efface). For a first-time mother the cervix must completely efface before dilatation continues. Effacement is reported in percentages as 50 percent or 100 percent, which is completely thinned out. The amniotic sac may or may not break during labor, and the birth attendant may rupture the bag with an amnio-hook, which looks a little like a large crochet hook. There is no pain involved with the breaking the bag of waters, although the contractions may intensify. During a contraction, the infant experiences pressure that pushes it against the cervix to assist with the dilatation. During this first phase, a woman's contractions typically increase in frequency and duration. Periodic vaginal exams are performed by the physician or nurse to determine progress. As pain and discomfort increase, however, the woman may be tempted to request pain medication. The administration of pain medication or anesthetics should be delayed until the active phase of labor begins, at which point the medication will not act to slow down or stop the labor.

The active phase of labor is usually shorter than the first, lasting an average of two to four hours. The contractions are more intense and accomplishing more in less time. They may be three to four minutes apart lasting 40–60 seconds even though the pattern may not be regular. During the active phase, dilatation continues to 7 cm. Relaxing between contractions is essential for coping because these contractions are more intense. Breathing exercises learned in childbirth classes can help the woman cope with the discomfort experienced during this phase. Pain medication offered at this point consists of either a short-term medication, such as Nubain or Stadol, or long-term such as epidural anesthesia.

The transitional phase continues dilation 7–10 cm. It is the most exhausting and demanding phase of labor. The contractions become very strong, are two to three minutes apart, and last 60–90 seconds. It may feel as if the contractions never stop, and there is no time to relax between them. Dilatation of the final 3 cm to 10 cm takes, on average, 15 minutes to an hour. Strong rectal pressure, with or without an urge to push or move the bowels, may cause the woman to grunt involuntarily. If it is a natural labor and delivery, the laboring woman at this phase becomes very inwardly focused and can lose control. It is important to breathe with her through contractions as this keeps her attention on what she needs to do.

Second stage of labor

Up to this point, the woman may feels as if her participation is small, because all she has done is breathe. Active involvement can now begin along with some emotional relief that it is almost over. Without anesthesia, there is often an overwhelming urge to push, and the mother gets a second wind. The baby's head is through the cervix and on its way down the birth canal. The uterine contractions get stronger, and the infant passes along the vagina helped by contractions of the uterus and the mother's pushing. If an epidural anesthetic is being used, many practitioners recommend decreasing the dosage so the mother has better control of her pushing. Research has shown, however, that the contractions will continue to push the baby down the birth canal without mother's help. If a woman is numb from an epidural, she cannot push effectively, and it is usually better to let the contractions work alone. This is called "laboring down."

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum (the tissues between the vagina and the rectum). This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner suctions the baby's mouth and nose to ease the baby's first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

Many practitioners argue that it is better to cut the perineum than to let it tear. This cut is called an episiotomy. In reality, it is more difficult to repair a straight cut than a small tear in much the same way it is harder to put together a puzzle with straight edges; it is more difficult to match evenly and can result in vaginal discomfort once healed. Instead, the perineum can be massaged and gently stretched to prevent tearing as the baby's head crowns. There is also less pain associated with a tear than an episiotomy. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area for repair.

Third stage

In the final stage of labor, the placenta is expelled by the continuing uterine contractions. The placenta is pancake shaped and about 10 cm (25 cm) in diameter. During pregnancy, it is attached to the wall of the uterus and served to exchange needed nourishment from the mother to the fetus and simultaneously to remove waste products from the fetus. Generally, there is a rise in the uterus due to a contraction and a gush of blood as the placenta is expelled. The placenta should be examined to make sure it is intact. Retained placenta can cause severe uterine bleeding after delivery, and it must be removed.

Breech presentation

Approximately 4 percent of babies present in the breech position when labor begins. In this presentation, the baby's bottom is the presenting part instead of the head, which is called a vertex presentation. Using a technique called a version, an obstetrician may attempt to turn the baby to a head down position. This is only successful approximately half the time, and there are possible complications with the procedure, such as umbilical cord entanglement and separation of the placenta. However, some practitioners are very successful with versions, and it does make a vaginal delivery safer.

The risks of vaginal delivery with breech presentation are much higher than with a head-first (vertex) presentation. The mother and attending practitioner need to weigh the risks to make a decision on whether to deliver via a cesarean section or attempt a vaginal birth. The degree of risk depends to a great extent on which one of the three types of breech presentations it is. In a frank breech the baby's legs are folded up against its body. This is the most common breech presentation and the safest for vaginal delivery. The others include complete breech, in which the baby's legs are crossed under and in front of the body, and footling breech, in which one leg or both legs are positioned to enter the birth canal. Neither of these is considered safe enough for a vaginal delivery.

Even with a complete breech, there are other factors to consider for a vaginal birth. An ultrasound examination should be done to determine that the baby's head is not too large and that it is tilted forward (flexed) rather than back (hyperextended). Fetal monitoring and close observation of the progress of labor are also important. A slowing of labor or any indication of difficulty in the body passing through the pelvis should be an indication that it is safer to consider a cesarean section.

Forceps delivery

Although not used as much in the early 2000s as in earlier times, forceps can be used if the baby's head is very low in the birth canal. Also, if there is some sudden change in the maternal-fetal status, the doctor may opt for a forceps delivery if it would be faster than a cesarean section. Forceps are spoon-shaped devices that can be placed around the baby's head while the doctor gently pulls the baby out of the vagina.

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the mother's bladder and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur. The use of forceps can cause vaginal lacerations in the mother.

Half of the forceps are slid into the vagina and around the side of the baby's head to gently grasp the head. When both forceps are in place, the doctor pulls on them to help the baby through the birth canal during a uterine contraction. The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth while other obstetrical services do not use forceps at all. Complications from forceps deliveries can occur, such as nerve damage or temporary bruises to the baby's face. When used by an experienced physician, forceps can save the life of a baby in distress.

Vacuum-assisted birth

This method of delivering a baby was developed as a gentler alternative to forceps. Similar to forceps deliveries, vacuum-assisted births can only be used with a fully dilated cervix and a well-descended head. In this procedure, a device called a vacuum extractor is used by placing a large rubber or plastic cup against the baby's head. A pump then creates suction that gently pulls on the cup to ease the baby out the birth canal. The force of the suction may cause a bruise or swelling on the baby's head, but it resolves in a day or two.

The vacuum extractor is less likely to injure the mother than forceps, and it allows more space for the baby to pass through the pelvis. There can be problems in maintaining the suction during the vacuum-assisted birth, however, so forceps might be a better choice if the delivery needs to be expedited.

Cesarean sections

A cesarean section, also called a c-section, is a surgical procedure in which an incision is made through a woman's abdomen and uterus to deliver her baby. This procedure is performed whenever abnormal conditions complicate labor and vaginal delivery that threaten the life or health of the mother or the baby. The procedure is performed in the United States on nearly one in every four women resulting in more than 900,000 babies each year being delivered by c-section. The procedure is often used in women who have had a previous c-section, but if the incision on the uterus is not vertical, the woman can try a vaginal birth after cesarean (VBAC).

Dysfunctional labor is commonly caused by one of the three following conditions: maternal structural abnormalities; abnormal fetal presentations; failure to progress. Non-reassuring fetal heart rate tracings represent a condition in which the fetus may not be tolerating labor and oxygen deprivation can occur. Other conditions which might indicate a need for c-section include: vaginal herpes, hypertension (high blood pressure), and uncontrolled diabetes in the mother.

Causes and symptoms

Childbirth usually begins spontaneously, but it may be started by artificial means if the pregnancy continues past 41 weeks gestation. There are three signs that labor may be starting: rhythmical contractions of the uterus; leaking of the bag of waters (amniotic sac); and bloody show. The importance of the sign of contractions is in the rhythm and not the contractions. True labor contractions may start once every ten or 15 minutes or even at longer intervals, but gradually the interval decreases until they come every three to four minutes. The most important thing a woman can do at this phase is to remain relaxed. The bag of waters may leak slowly or may suddenly burst, and there is a gush of fluid. There is no pain when the water breaks, although it may be startling. If contractions are not ongoing prior to this, they are likely to start soon after. If they do not, it may be necessary to stimulate labor as the womb is now open to possible infection. The bloody show is a slight discharge of blood and mucus. It usually occurs after the cervix has started to dilate slightly and the mucus plug that keeps the cervix sealed from potential pathogens becomes dislodged.

Diagnosis

The diagnosis of true labor can only be determined by a vaginal exam to determine if the cervix has changed in dilatation (opening). True labor is determined by whether the contractions are, in fact, changing the cervix. If a woman is experiencing contractions and makes no cervical change, then this is false labor. Dilatation is measured in centimeters and it goes from zero to ten centimeters, which is complete dilatation. Although the woman having the contractions may feel like she is really experiencing labor, true labor is determined by cervical change. Many women may experience Braxton-Hicks contractions (practice contractions) in preparation for true labor, and these can become uncomfortable at times, which prevents the woman from resting. A warm bath or warm drink may help her to relax and sleep . Inevitably she will wake up in true labor with effective contractions. Palpating contractions as they occur can assist in determining whether they are strong. A very strong contraction cannot be indented and will feel as hard as the forehead. A moderate contraction will palpate like the feel of the chin and an easy contraction feels like the end of the nose. If the contractions can be indented, they probably do not constitute true labor.

Electronic fetal monitoring

Electronic fetal monitoring (EFM) involves the use of an electronic fetal heart rate (FHR) monitor to record the baby's heart rate. The FHR is picked up by means of an ultrasound transducer and the movement of the heart valves. Elastic belts are used to hold sensors against the pregnant woman's abdomen. The sensors are connected to the monitor and detect the baby's heart rate as well as the uterine contractions. The monitor then records the FHR and the contractions as a pattern on a strip of paper, called a tracing. Electronic fetal monitoring is frequently used during labor to assess fetal well-being. EFM can be used either externally or internally. Internal monitoring does not use ultrasound, is more accurate than electronic monitoring, and provides continuous monitoring for the high-risk mother. An internal monitor requires that the bag of waters be broken and that the woman is at least two to three centimeters dilated. It is used in high-risk situations or when it is difficult to obtain an accurate FHR tracing.

Telemetry monitoring has been available since the early 1990s but is not used in many hospitals as of 2004. Telemetry uses radio waves transmitted from an instrument on the mother's thigh, which allows the mother to remain mobile. It provides continuous monitoring and does not require the patient to be in bed continuously.

Besides EFM and telemetry, which is usually continuous, there is intermittent monitoring using a hand-held Doppler to assess the FHR. This method gives the mother freedom of movement during labor. Prior to electronic gadgetry a special stethoscope was used, called a fetoscope, which is rarely seen as of 2004 because it requires more skill to use. Research on the use of intermittent monitoring and continuous monitoring found no difference in fetal outcomes with intermittent monitoring. The use of continuous monitoring does result in a higher c-section rate partly because the tracing can be misinterpreted or because the mother usually requires more interventions when she cannot be mobile.

Treatment

Many women choose some type of pain relief during childbirth, ranging from relaxation and imagery to drugs. The specific choice may depend on what is available, the woman's preferences, her doctor's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

Regional anesthetics

Regional anesthetics include epidurals and spinals. With this procedure, medication is injected into the space surrounding the spinal nerves. Depending on the type of medications used, this type of anesthesia can block nerve signals, causing temporary pain relief or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is put in place that allows continuous doses of anesthetic to be given.

This type of anesthesia provides complete pain relief and can help conserve a woman's energy, since she can relax or even sleep during labor. This type of anesthesia does require an IV and fetal monitor. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia operates on the same principle as epidural anesthesia and is used primarily in cases of c-section delivery. It is administered in the same way as an epidural, but the catheter is not left in place following the surgery. The amount of anesthetic injected is large, since it must be injected at one time. Spinals provide quick and strong anesthesia and allow for major abdominal surgery with almost no pain.

Narcotics

Short-acting narcotics can ease pain and not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea , and vomiting . Narcotics cross the placenta and can affect the baby.

Natural childbirth and preparation for childbirth

There are several methods available to prepare for childbirth. The one selected often depends on what is available through the healthcare provider. Overall, family involvement is receiving increased attention by the healthcare systems, and the majority of hospitals now offer birthing rooms and maternity centers to accommodate the entire family.

Lamaze, or Lamaze-Pavlov, is the most commonly used method in the United States as of 2004. It became the first popular natural childbirth method in the 1960s. Various breathing techniques, cleansing breath, panting and blowing, are used for different phases together with the use of a focal point to enable the laboring woman to maintain control. A partner helps by coaching the mother throughout the birthing process.

KEY TERMS

Amniotic sac —The membranous sac that contains the fetus and the amniotic fluid during pregnancy.

Breech birth —Birth of a baby bottom-first, instead of the usual head-first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as does the head.

Cervix —A small, cylindrical structure about an inch or so long and less than an inch around that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo —In humans, the developing individual from the time of implantation to about the end of the second month after conception. From the third month to the point of delivery, the individual is called a fetus.

Gestation —The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum —The area between the opening of the vagina and the anus in a woman, or the area between the scrotum and the anus in a man.

Placenta —The organ that provides oxygen and nutrition from the mother to the unborn baby during pregnancy. The placenta is attached to the wall of the uterus and leads to the unborn baby via the umbilical cord.

Vertex —The top of the head or highest point of the skull.

The Read method, named for Dr. Grantly Dick-Read (who published his book Childbirth Without Fear in 1944) involves primarily remaining relaxed and breathing normally. Dr. Dick-Read promoted this method in the 1930s to help mothers deal with apprehension and tension associated with childbirth. He emphasized the practice of tensing and relaxing muscles so that complete relaxation occurs between contractions in labor. This action also serves to promote good oxygenation to the muscles.

The Bradley method is called father-coached childbirth, because it focuses on the father serving as the coach throughout the process. It encourages normal activities during the first stages of labor without interventions and focuses on breathing and relaxation.

HypnoBirthing is becoming increasingly popular in the United States in the early 2000s and has proven to be quite effective. Based upon the work of Grantly Dick-Read, it teaches the mother to understand and release the fear-tension-pain syndrome, which so often is the cause of pain and discomfort during labor. When people are afraid, their bodies divert blood and oxygen from non-essential defense organs to large muscle groups in their extremities. Unfortunately, the body considers the uterus to be a non-essential organ. HypnoBirthing explores the myth that pain is a necessary accompaniment to a normal birthing. When a laboring woman's mind is free of fear , the muscles in her body, including her uterine muscles, relax, thus facilitating an easier, stress-free birth. In many cases, first stage labor shortens, which diminishes fatigue during labor leaving the mother stronger for pushing. The founder of HypnoBirthing, Marie Mongan, promotes the philosophy that eliminating fear allows the woman's body to work like it is supposed to.

The LeBoyer method stresses a relaxed delivery in a quiet, dimly lit room. It strives to avoid overstimulation of the baby and to foster mother-child bonding by placing the baby on the mother's abdomen and having the mother massage him or her immediately after the birth. This is followed by the father giving the baby a warm bath.

See also Apgar testing; Electronic fetal monitoring; Cesarean section.

Resources

BOOKS

Murkoff, H. I., et al. What to Expect When You're Expecting, 3rd ed. New York: Workman Publishing, 2002.

Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

Simkin, Penny, et al. The Labor Progress Handbook. Ann Arbor, MI: Blackwell Publishing, 2000.

Simkin, Penny. Pregnancy, Childbirth, and the Newborn, Revised and Updated: The Complete Guide. Minnetonka, MN: Meadowbrook Press, 2001.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. PO Box 5224, Sherman Oaks, CA 91413–5224. Web site: <www.bradleybirth.com/>.

Childbirth Enhancement Foundation. 1004 George Avenue, Rockledge, Fl 32955. Web site: <www.cefcares.org/>.

HypnoBirthing Institute. PO Box 810, Epsom, NH 03234. Web site: <www.joes.com/home/HYPNOBIRTHING/>.

International Association of Parents and Professionals for Safe Alternatives in Childbirth. Rte. 1, Box 646, Marble Hill, MO 63764. Web site: <www.napsac.org/default.htm>.

International Childbirth Education Association. PO Box 20048, Minneapolis, MN 55420. Web site: <www.icea.org/>.

Lamaze International. 2025 M Street, Suite 800, Washington DC 20036–3309. Web site: <www.lamazechildbirth.com/>.

Linda K. Bennington, MSN, CNS

Childbirth

Definition

Childbirth includes both labor (the process of birth) and delivery (the birth itself); it refers to the entire process as an infant makes its way from the womb down the birth canal to the outside world.

Description

Childbirth usually begins spontaneously, about 280 days after conception, but it may be started by artificial means if the pregnancy continues past 42 weeks gestation. The average length of labor is about 14 hours for a first pregnancy and about eight hours in subsequent pregnancies. However, many women experience a much longer or shorter labor.

Labor can be described in terms of a series of phases.

First stage of labor

During the first phase of labor, the cervix dilates (opens) from 0-10 cm. This phase has an early, or latent, phase and an active phase. During the latent phase, progress is usually very slow. It may take quite a while and many contractions before the cervix dilates the first few centimeters. Contractions increase in strength as labor progresses. Most women are relatively comfortable during the latent phase and walking around is encouraged, since it naturally stimulates the process.

As labor begins, the muscular wall of the uterus begins to contract as the cervix relaxes and expands. As a portion of the amniotic sac surrounding the baby is pushed into the opening, it bursts under the pressure, releasing amniotic fluid. This is called "breaking the bag of waters."

During a contraction, the infant experiences intense pressure that pushes it against the cervix, eventually forcing the cervix to stretch open. At the same time, the contractions cause the cervix to thin. During this first stage, a woman's contractions occur more and more often and last longer and longer. The doctor or nurse will do a periodic pelvic exam to determine how the mother is progressing. If the contractions aren't forceful enough to open the cervix, a drug may be given to make the uterus contract.

As pain and discomfort increase, women may be tempted to request pain medication. If possible, though, administration of pain medication or anesthetics should be delayed until the active phase of labor begins—at which point the medication will not act to slow down or stop the labor.

The active stage of labor is faster and more efficient than the latent phase. In this phase, contractions are longer and more regular, usually occurring about every two minutes. These stronger contractions are also more painful. Women who use the breathing exercises learned in childbirth classes find that these can help cope with the pain experienced during this phase. Many women also receive some pain medication at this point—either a short-term medication, such as Nubain or Numorphan, or an epidural anesthesia.

As the cervix dilates to 8-9 cm, the phase called the transition begins. This refers to the transition from the first phase (during which the cervix dilates from 0-10 cm) and the second phase (during which the baby is pushed out through the birth canal). As the baby's head begins to descend, women begin to feel the urge to "push" or bear down. Active pushing by the mother should not begin until the second phase, since pushing too early can cause the cervix to swell or to tear and bleed. The attending healthcare practitioner should counsel the mother on when to begin to push.

Second stage of labor

As the mother enters the second stage of labor, her baby's head appears at the top of the cervix. Uterine contractions get stronger. The infant passes down the vagina, helped along by contractions of the abdominal muscles and the mother's pushing. Active pushing by the mother is very important during this phase of labor. If an epidural anesthetic is being used, many practitioners recommend decreasing the amount administered during this phase of labor so that the mother has better control over her abdominal muscles

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First the head passes under the pubic bone. It fills the lower vagina and stretches the perineum (the tissues between the vagina and the rectum). This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner suctions the baby's mouth and nose to ease the baby's first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy

As the baby's head appears, the perineum may stretch so tight that the baby's progress is slowed down. If there is risk of tearing the mother's skin, the doctor may choose to make a small incision into the perineum to enlarge the vaginal opening. This is called an episiotomy. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area. Once the episiotomy is made, the baby is born with a few pushes.

Third stage

In the final stage of labor, the placenta is pushed out of the vagina by the continuing uterine contractions. The placenta is pancake shaped and about 10 inches in diameter. It has been attached to the wall of the uterus and has served to convey nourishment from the mother to the fetus throughout the pregnancy. Continuing uterine contractions cause it to separate from the uterus at this point. It is important that all of the placenta be removed from the uterus. If it is not, the uterine bleeding that is normal after delivery may be much heavier.

Breech presentation

Approximately 4% of babies are in what is called the "breech" position when labor begins. In breech presentation, the baby's head is not the part pressing against the cervix. Instead the baby's bottom or legs are positioned to enter the birth canal instead of the head. An obstetrician may attempt to turn the baby to a head down position using a technique called version. This is only successful approximately half the time.

The risks of vaginal delivery with breech presentation are much higher than with a head-first presentation. The mother and attending practitioner will need to weigh the risks and make a decision on whether to deliver via a cesarean section or attempt a vaginal birth. The extent of the risk depends to a great extent on the type of breech presentation, of which there are three. Frank breech (the baby's legs are folded up against its body) is the most common and the safest for vaginal delivery. The other types are complete breech (in which the baby's legs are crossed under and in front of the body) and footling breech (in which one leg or both legs are positioned to enter the birth canal). These are not considered safe to attempt vaginal delivery.

Even in complete breech, other factors should be met before considering a vaginal birth. An ultrasound examination should be done to be sure the baby does not have an unusually large head and that the head is tilted forward (flexed) rather than back (hyperextended). Fetal monitoring and close observation of the progress of labor are also important. A slowing of labor or any indication of difficulty in the body passing through the pelvis should be an indication that it is safer to consider a cesarean section.

Forceps delivery

If the labor is not progressing as it should or if the baby appears to be in distress, the doctor may opt for a forceps delivery. A forceps is a spoon-shaped device that resembles a set of salad tongs. It is placed around the baby's head so the doctor can pull the baby gently out of the vagina.

Forceps can be used after the cervix is fully dilated, and they might be required if:

• the umbilical has dropped down in front of the baby into the birth canal
• the baby is too large to pass through the birth canal unaided
• the baby shows signs of stress
• the mother is too exhausted to push

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the mother's bladder, and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur.

The obstetrician slides half of the forceps at a time into the vagina and around the side of the baby's head to gently grasp the head. When both "tongs" are in place, the doctor pulls on the forceps to help the baby through the birth canal as the uterus contracts. Sometimes the baby can be delivered this way after the very next contraction.

The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth. However, other obstetrical services do not use forceps at all.

Complications from forceps deliveries can occur. Sometimes they may cause nerve damage or temporary bruises to the baby's face. When used by an experienced physician, forceps can save the life of a baby in distress.

Vacuum-assisted birth

This method of helping a baby out of the birth canal was developed as a gentler alternative to forceps. Vacuum-assisted birth can only be used after the cervix is fully dilated (expanded), and the head of the fetus has begun to descend through the pelvis. In this procedure, the doctor uses a device called a vacuum extractor, placing a large rubber or plastic cup against the baby's head. A pump creates suction that gently pulls on the cup to ease the baby down the birth canal. The force of the suction may cause a bruise on the baby's head, but it fades away in a day or so.

The vacuum extractor is not as likely as forceps to injure the mother, and it leaves more room for the baby to pass through the pelvis. However, there may be problems in maintaining the suction during the vacuum-assisted birth, so forceps may be a better choice if it is important to remove the baby quickly.

Cesarean sections

A cesarean section, also called a c-section, is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.

Cesarean sections are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. In 2002, just over 26% of babies were born by c-section, an increase of 7% from the previous year. The procedure may be used in cases where the mother has had a previous c-section and the area of the incision has been weakened. Dystocia, or difficult labor, is the another common reason for performing a c-section.

Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; abnormalities in the labor, including weak or infrequent contractions.

Another major factor is fetal distress, a condition where the fetus is not getting enough oxygen. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus, or abnormalities in the birth canal, causing reduced blood flow through the placenta.

Other conditions also can make c-section advisable, such as vaginal herpes, hypertension (high blood pressure) and diabetes in the mother. Some parents choose to have a c-section because they fear the pain or unpredictability of labor or they want to avoid pelvic damage.

Causes and symptoms

One of the first signs of approaching childbirth may be a "bloody show," the appearance of a small amount of blood-tinged mucus released from the cervix as it begins to dilate. This is called the "mucus plug."

The most common sign of the onset of labor is contractions. Sometimes women have trouble telling the difference between true and false labor pains.

True labor pains:

• develop a regular pattern, with contractions coming closer together
• last from 15-30 seconds at the onset and get progressively stronger and longer (up to 60 seconds)
• may get stronger with physical activity
• occur high up on the abdomen, radiating throughout the abdomen and lower back

Another sign that labor is beginning is the breaking of the "bag of waters," the amniotic sac which had cushioned the baby during the pregnancy. When it breaks, it releases water in a trickle or a gush. Only about 10% of women actually experience this water flow in the beginning of labor, however. Most of the time, the rupture occurs sometime later in labor. If the amniotic sac doesn't rupture on its own, the doctor will break it during labor.

Some women have diarrhea or nausea as labor begins. Others notice a sudden surge of energy and the urge to clean or arrange things right before labor begins; this is known as "nesting."

Diagnosis

The onset of labor can be determined by measuring how much the cervix has dilated. The degree of dilation is estimated by feeling the opening cervix during a pelvic exam. Dilation is measured in centimeters, from zero to 10. Contractions that cause the cervix to dilate are the sign of true labor.

Fetal monitoring

Fetal monitoring is a process in which the baby's heart rate is monitored for indicators of stress during labor and birth. There are several types of fetal monitoring.

A special stethoscope called a fetoscope may be used. This is a simple and non-invasive method.

The Doppler method uses ultrasound; it involves a handheld listening device that transmits the sounds of the heart rate through a speaker or into an attached ear piece. It can usually pick up the heart sounds 12 weeks after conception. This method offers intermittent monitoring. It allows the mother freedom to move about and is also useful during contractions.

Electronic fetal monitoring uses ultrasound and provides a view of the heartbeat in relationship to the mother's contractions. It can be used either continuously or intermittently. It is often used in high risk pregnancies, and is not often recommended for low risk ones because it renders the mother immobile and requires interpretation.

Internal monitoring does not use ultrasound, is more accurate than electronic monitoring and provides continuous monitoring for the high risk mother. This requires the mother's water to be broken and that she be two to three centimeters dilated. It is used in high-risk situations only.

Telemetry monitoring is the newest type of monitoring. It uses radio waves transmitted from an instrument on the mother's thigh. The mother is able to remain mobile. It provides continuous monitoring and is used in high-risk situations.

Treatment

Most women choose some type of pain relief during childbirth, ranging from relaxation and imagery to drugs. The specific choice may depend on what's available, the woman's preferences, her doctor's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

Regional anesthetics

Regional anesthetics include epidurals and spinals. In this technique, medication is injected into the space around the spinal nerves. Depending on the type of medications used, this type of anesthesia can block nerve signals, causing temporary pain relief, or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is put in place that allows continuous doses of anesthetic to be given.

This type of anesthesia provides complete pain relief, and can help conserve a woman's energy, since she can relax or even sleep during labor. This type of anesthesia requires an IV and fetal monitor. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia operates on the same principle as epidural anesthesia, and is used primarily in cases of c-section delivery. It is administered in the same way as an epidural, but the catheter is not left in place. The amount of anesthetic injected is large, since it must be injected at one time. Because of the anesthetic's effect on motor nerves, most women using it cannot push during delivery. This is a disadvantage in labor, but not an issue during a c-section. Spinals provide quick and strong anesthesia and allow for major abdominal surgery with almost no pain.

Narcotics

Short-acting narcotics can ease pain and do not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea, and vomiting. Narcotics cross the placenta and may slow down a baby's breathing; they can't be given too close to the time of delivery.

Natural childbirth and preparation for childbirth

There are several methods to prepare for childbirth. The one selected often depends on what is available through the healthcare provider. Overall, family involvement is receiving increased attention by the healthcare systems, and many hospitals now offer birthing rooms and maternity centers to help the entire family. There are several choices available for childbirth preparation.

Lamaze, or Lamaze-Pavlov, is the most common in the United States today. It was the first popular natural childbirth method, becoming popular in the 1960s. Breathing exercises and concentration on a focal point are practiced to allow mothers to control pain while maintaining consciousness. This allows the flow of oxygen to the baby and to the muscles in the uterus to be maintained. A partner coaches the mother throughout the birthing process.

The Read method, named for Dick Read, is a technique of breathing that was originated in the 1930s to help mothers deal with apprehension and tension associated with childbirth. This natural childbirth method uses different breathing for the different stages of childbirth.

The LeBoyer method stresses a relaxed delivery in a quiet, dim room. It attempts to avoid overstimulation of the baby and to foster mother-child bonding by placing the baby on the mother's abdomen and having the mother massage him or her immediately after the birth. Then the father washes the baby in a warm bath.

The Bradley method is called father-coached childbirth, because it focuses on the father serving as coach throughout the process. It encourages normal activities during the first stages of labor.

KEY TERMS

Amniotic sac— The membranous sac that surrounds the embryo and fills with watery fluid as pregnancy advances.

Breech birth— Birth of a baby bottom-first, instead of the usual head first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as does the head.

Cervix— A small cylindrical organ about an inch or so long and less than an inch around that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo— The unborn child during the first eight weeks of its development following conception.

Gestation— The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum— The area between the thighs that lies behind the genital organs and in front of the anus.

Placenta— The organ that develops in the uterus during pregnancy and that links the blood supplies of mother and baby.

Resources

PERIODICALS

Stevens, Laura Roe. "Gimme a C: Is Choosing a Cesarean Section for a Nonmedical Reason Wise?" Fit Pregnancy April-May 2004: 40-42.

ORGANIZATIONS

American Academy of Husband-Coached Childbirth. P.O. Box 5224, Sherman Oaks, CA 91413. (800) 423-2397; in California (800) 422-4784.

American Society for Prophylaxis in Obstetrics/LAMAZE (ASPO/LAMAZE). 1840 Wilson Blvd., Ste. 204, Arlington, VA 22201. (800) 368-4404.

Childbirth Education Foundation. P.O. Box 5, Richboro, PA 18954. (215) 357-2792.

International Association of Parents and Professionals for Safe Alternatives in Childbirth. Rte. 1, Box 646, Marble Hill, MO 63764. (314) 238-2010.

International Childbirth Education Association. P.O. Box 20048, Minneapolis, MN 55420. (612) 854-8660.

Postpartum Support International. 927 North Kellogg Ave., Santa Barbara, CA 93111. (805) 967-7636.

Childbirth. Women controlled the childbirth experience in the Colonial Era. At the onset of labor, the expectant mother sent for her midwife and called upon her female friends and relatives to attend her in her home. They offered moral support and assisted the midwife during labor and delivery. While childbirth was acknowledged as potentially dangerous to both mother and child, birthing was viewed as a natural process, and midwives intervened as little as possible. After the birth of the baby, friends and relatives assisted the new mother during her convalescence, which was typically short if the birth was normal and free of complications.

The first major change in childbirth practices for white women began after 1750 when affluent colonists in urban areas began to call upon male doctors to attend them in their homes during delivery. Regularly trained physicians assured these women that knowledge of anatomy and access to ergot (a medicinal substance that promotes uterine contractions) and obstetrical forceps could ensure faster labors and safer deliveries. By 1850, ether and chloroform were available to reduce labor pains. Unfortunately, hiring doctors did not necessarily guarantee safety. Medical intervention was accompanied by concern over the incidence of puerperal (childbed) fever, a bacterial infection of the womb, as well as the misapplication of forceps.

Besides choosing doctors over midwives, those who could afford to do so also began hiring monthly nurses to assist during delivery and to provide postnatal services. Women who aspired to social prominence extended the confinement period before birth and the lying‐in period afterward to testify to their affluence and physical delicacy.

Economic status, geography, ethnicity, and race significantly influenced the way women experienced childbirth. The obstetrical services available to poor women depended on where they lived. Those who resided in small towns, rural areas, or urban ethnic neighborhoods continued to use midwives and to depend on their female support network for services. Urban women utterly without resources could seek obstetrical care in almshouses or charity hospitals. The prevalence of malaria and other diseases complicated the birth process for southern women, and before the Civil War they had little access to anesthesia. Slave owners had an economic interest in managing the fertility of slave women. Pioneer women delivered their own babies or sought help from whomever was available. Throughout the nineteenth century, Native American women tried to maintain their own culturally prescribed birth rituals.

In the early twentieth century, childbirth began to move from the home to the hospital. Doctors encouraged this development because hospital births centralized obstetric care, enabled them to combat infection, and provided a regular supply of patients for the clinical education of medical students. Women accepted this change in the conviction that hospitals could provide safety in the form of specialized services in cases of premature or complicated deliveries. Extended hospital stays also offered respite from household responsibilities.

The increase in hospital births resulted in a further shift in the balance of power between doctors and their obstetrical patients over who would control the childbirth experience. Doctors increasingly looked for pathology in their obstetrics cases and intervened in the childbirth process by routinely performing episiotomies and cesarean sections and using forceps. They also began to experiment with new forms of anesthesia such as scopolamine, a drug with amnesiac properties that suppressed a patient's memory of painful contractions, as well as various forms of spinal anesthetic.

Continuing concern about maternal and infant mortality prompted Congress to pass the Sheppard‐Towner Act in 1921 to provide programs for prenatal, obstetric, and postnatal care for poor women. By the mid‐1950s, the mortality rate for childbearing women had declined, partly as a result of the availability of antibiotic drugs, blood banks, safer forms of anesthesia, and X rays.

In the 1940s, women began opposing the medicalization of childbirth and demanding more control over the procedures associated with the experience. Following the lead of Dr. Grantly Dick‐Read, who argued that pain in childbirth resulted as much from anxiety as from physiology, they opposed the routine use of anesthesia, called for less medical intervention, and advocated a return to what they called “natural childbirth.” By the 1960s, reformers were promoting such innovations as Lamaze breathing techniques, birthing at home, the presence of fathers during birth, and the utilization of nurse‐midwives instead of doctors. Nevertheless, most American women continued to experience childbirth in a medicalized context over which they had only limited control.
See also Medical Education; Medicine; Midwifery; Slavery: Development and Expansion of Slavery; Slavery: Slave Families, Communities, and Culture.

Bibliography

Richard W. Wertz and and Dorothy C. Wertz , Lying‐in: A History of Childbirth in America, 1977.
Jane B. Donegan , Women & Men Midwives: Medicine, Morality, and Misogyny in Early America, 1978.
Judy Barrett Litoff , American Midwives, 1860 to the Present, 1978.
Judith Walzer Leavitt , Brought to Bed: Childbearing in America, 1750–1950, 1986.
Sylvia D. Hoffert , Private Matters: American Attitudes toward Childbearing and Infant Nurture in the Urban North, 1800–1860, 1989.
Sally G. McMillen , Motherhood in the Old South: Pregnancy, Childbirth and Infant Rearing, 1990.

Sylvia D. Hoffert

childbirth. Until the 17th century childbirth was in the hands of female midwives, who had usually learned their skills informally. In Ireland the midwife was often a ‘handy woman’ (bean chabhartha). As well as attending births, such women also sometimes worked as healers, in which role they commanded considerable respect. But, with the invention of forceps in the 17th century, male surgeons, who had a monopoly of the use of surgical instruments, came to play a larger role in childbirth. By the late 18th century these male midwives had turned a traditional female craft into a male profession.

This transformation can be traced in some detail in Ireland. The first original work in English on midwifery was published in 1671 by James Wolveridge, a graduate of Trinity College, Dublin, then working in Cork. It was addressed to women. But when Sir Fielding Ould (1710–89), a leading Dublin male midwife, published another influential text in 1742, it was addressed to male surgeons and argued that surgeons should routinely attend births.

The Irish College of Physicians had been given the power, under its 1692 charter, to license midwives, but it was a power the college seldom exercised as physicians considered midwifery beneath them. So the initiative was taken by surgeons. The Rotunda hospital was founded in 1745 by Bartholomew Mosse (1712–59), a surgeon, and in 1774 the master of the hospital began to give lectures for male medical students and female midwives. In 1785 the first chair of midwifery in Ireland was established by the new Irish College of Surgeons and in the same year grand juries were empowered to pay for the training of female midwives at the Rotunda.

A maternity hospital was opened in Belfast in 1793, one in Cork in 1798, and two more in Dublin: the Coombe in 1829, and the National Maternity hospital, Holles Street, in 1894. After 1851, with the expansion of the dispensary system, county authorities sent midwives attached to dispensaries to Dublin for training at the Rotunda or Coombe hospitals.

Legislation in 1917 prohibited unqualified ‘handy women’ from practising as midwives and established a central board to regulate training. This system was further tightened in 1931 and by the mid‐1930s it was claimed that only in Mayo did ‘handy women’ still flourish.

Bibliography

Campbell Ross, I. (ed.), Public Virtue, Public Love: The Early Years of the Dublin Lying‐in Hospital, the Rotunda (1986)
Donnison, J. , Midwives and Medical Men: A History of the Struggle for the Control of Childbirth (2nd edn., 1988)
Farmar, T. , Holles Street, 1894–1994: The National Maternity Hospital: A Centenary History (1994)

Elizabeth Malcolm

106. Childbirth

1. Artemis (Rom. Diana ) goddess of childbirth. [Gk. Myth.: Kravitz, 59]
2. Asclepius saved by his father Apollo from the body of pregnant Coronis when Apollo slays her for infidelity. [Gk. Myth.: Benét, 57]
3. Athena sprang from the head of Zeus when Hephaestus split it open with an axe. [Gk. Myth.: Benét, 60]
4. Auge Arcadian goddess of childbirth. [Arcadian Myth.: Kravitz, 59]
5. Carmenta one of Camenae; protectress of women in confinement. [Rom. Rel.: Zimmerman, 50]
6. Dionysus unborn god is saved from his dead mother and sewn into Zeus’s thigh, from which he is later born. [Gk. Myth.: Benét, 273]
7. dittany symbol of childbirth. [Herb Symbolism: Flora Symbolica, 173]
8. Egeria goddess of childbirth; protectress of the unborn. [Rom. Myth.: Avery, 425–426]
9. Eileithyia ancient Greek goddess of childbirth. [Gk. Myth.: Zimmerman, 92]
10. Hera (Rom. Juno ) goddess of childbirth. [Gk. Myth.: Kravitz, 59]
11. Lilith demon; dangerous to women in childbirth. [Jew. Trad.: Benét, 586]
12. Lucina goddess of childbirth. [Rom. Myth.: Kravitz, 59]
13. Mater Matuta goddess of childbirth. [Rorer. Myth.: Howe, 160]
14. Parca ancient Greek goddess of childbirth. [Gk. Myth.: Kravitz, 59]
15. test-tube baby Louise Brown; first successful fertilization outside the body (1978). [Br. Hist.: Facts (1978), 596–597]
16. Themis goddess of childbirth. [Gk. Myth.: Kravitz, 53]

Childlessness (See BARRENNESS .)

child·birth / ˈchīldˌbər[unvoicedth]/ • n. the action of giving birth to a child: she died in childbirth.

childbirth (chyld-berth) n. see labour.

childbirth see birth .

childbirth See labour

childbirth •berth, birth, dearth, earth, firth, girth, mirth, Perth, worth •stillbirth • childbirth • afterbirth •Edgeworth • Hepworth • Ellsworth •Whitworth • halfpennyworth •Bosworth • jobsworth • Iorwerth