Labor, Delivery, and Postpartum Period

Labor and Delivery: Your Birthing Options

During your prenatal visits, talk with your health professional about your labor and delivery options. As you identify your preferences, you may want to write them down as a birth plan. A birth plan is not so much a "plan" as it is an ideal picture of what you would like to happen. Since no labor and delivery can be predicted or planned in advance, be flexible. As you consider how you'd handle possible complications, give yourself permission to change your mind at any time. And be prepared for your childbirth to be different than you planned.

A birth plan isn't a contract for your health professional to follow—if an emergency situation arises, he or she has a responsibility to ensure both your safety and your baby's safety. You may still be allowed to share in some decisions, but your choices may be limited.

When you are writing your birth plan, first consider the location of your delivery, who will deliver your baby, and whether you want continuous labor support from a designated health professional or a doula, a friend, or family members. If you haven't already, this is also a good time to decide whether you'll attend a childbirth education class, starting in your 6th or 7th month of pregnancy. After you've set the stage, think through your preferences for comfort measures, pain relief, and medical procedures and fetal monitoring, as well as how you'd like to handle your first hours with your newborn.

Comfort measures

There are many ways to reduce the stresses of labor and delivery. Consider:

• Continuous labor support from early labor until after childbirth, which has a proven, positive effect on childbirth. Women who have continuous one-on-one support (for example, from a mother's support person, or doula; nurse; midwife; or childbirth educator) are more likely to give birth without pain medication and are less likely to describe their birthing experience negatively.¹ Although there is not a proven direct connection between continuous support and less labor pain, having a support person does help you feel more control and less fear, which are strong elements of mental pain control.
• Walking during labor, including whether you prefer continuous electronic fetal heart monitoring or occasional monitoring. Most women prefer the freedom to walk and move around, but a high-risk delivery would require constant monitoring.
• Nonmedication pain management ("natural" childbirth), such as continuous labor support, focused breathing, distraction, massage, and imagery, which can reduce pain and help you feel a sense of control during labor.
• Early laboring in water, which helps with pain, stress, and sometimes slow, difficult labor (dystocia).^{2, 3} Giving birth in water needs more study to show how safe or risky it is for mother and baby.²
• Issues about eating and drinking during labor. Some hospitals allow you to drink clear liquids while others may only allow you to suck on ice chips or hard candy. Solid food is often restricted because the stomach digests food more slowly during labor. An empty stomach is also best in the rare event that you may need general anesthesia.
• Playing music during labor.
• Acupuncture and hypnosis, which are low-risk ways of managing pain that work for some women.⁴

Pain relief with medication

Your medication options for pain relief may include:

• Opioids (narcotics), which are used to reduce anxiety and partially relieve pain. An opioid is less likely than epidural anesthesia to lead to an assisted (forceps or vacuum) delivery.⁵ But they are usually used well before delivery, since an opioid can affect a newborn's breathing.
• Epidural anesthesia, which is an ongoing injection of pain medication into the epidural space around the spinal cord. This partially or fully numbs the lower body. A "light" epidural allows you to feel enough that you can push, which reduces full-dose epidural risks of stalled labor and assisted (forceps or vacuum) delivery.⁶
• Pudendal and paracervical blocks, which are injections of pain medication into the pelvic area to reduce labor pain. Pudendal is one of the safest forms of anesthesia for numbing the area where the baby will come out. It can be helpful with fast labor when a little pain medicine is needed close to delivery. It does not affect the baby. Paracervical has been generally replaced by epidural, which is more effective.

Should I use epidural anesthesia during childbirth?

Some pain relief medications are not the type that you would request during labor. Rather, they are used as part of another procedure or for an emergency delivery. But it's a good idea to know about them.

• Local anesthesia is the injection of numbing pain medication into the skin. This is done before inserting an epidural or before making an incision (episiotomy) that widens the vaginal opening for the birth.
• Spinal block is an injection of pain medication into the spinal fluid, which rapidly and fully numbs the pelvic area for assisted births, such as a forceps or cesarean delivery (no pushing is possible).
• General anesthesia is the use of inhaled or intravenous (IV) medication, which makes you unconscious. It has more risks, yet it takes effect much faster than epidural or spinal anesthesia. General anesthesia is therefore only used for some emergencies that require a rapid delivery, such as when an epidural line (catheter) has not been installed in advance.

Birthing positions

Birthing positions for pushing include sitting, squatting, reclining, leaning on a ball, or using a birthing chair, stool, or bed. See illustrations of various birthing positions:

• Walking
• Leaning
• Sitting
• Squatting
• Kneeling
• Kneeling on all fours
• Downward from knees
• Side-lying

Medical procedures for labor and delivery

While fetal heart monitoring is a standard practice during labor, other procedures are used as needed.

• Labor induction and augmentation includes a simple "sweeping of the membranes" just inside of the cervix, rupturing the amniotic sac, using medication to soften (ripen) the cervix, and using medication to stimulate contractions. This is not always, but can be, a medically necessary decision—such as when a mother is about 2 weeks past her due date or when the mother or her baby has a condition that requires immediate delivery.
• Antibiotics if you tested positive for group B strep during your pregnancy.
• Electronic fetal heart monitoring may be either continuous for a high-risk delivery or periodic to check for signs that the baby might be in distress.
• Episiotomy widens the perineum with an incision. This is sometimes used to deliver the baby's head more quickly, when there are signs of distress. (Perineal massage and controlled pushing can also prevent or reduce tearing.⁷)
• Forceps delivery or vacuum extraction is used to assist a vaginal delivery, such as when labor is stalled at the pushing stage or when the baby shows signs of distress at the pushing stage and needs to be delivered quickly.
• The need for a cesarean birth during a labor in progress is primarily based on the baby's and mother's conditions. (For more information, see the topic Cesarean Section.)

If you have had a cesarean delivery before, you may have a choice between a vaginal trial of labor and a planned cesarean birth. For more information, see the topic Vaginal Birth After Cesarean (VBAC).

Newborn care decisions

Before your baby is born, plan ahead about:

• Keeping your baby with you for at least 1 hour after birth, for bonding. (Many hospitals allow rooming-in, with no mother-baby separation during the entire hospital stay. A rooming-in policy also allows you to request time alone for rest, if you need it.)
• Preventing breast-feeding problems. You can plan ahead for breast-feeding support in case you need it. Check around for a lactation consultant. Some hospitals have them in-house. You can also make sure that hospital staff knows not to give your baby supplemental formula, unless there is a medical need.
• Delaying certain procedures, such as a vitamin K injection, a heel prick for a blood test, and the use of eye medicine, so that your newborn has a more calm transition after delivery.
• Whether and when you'd like visitors, including children in your family.
• Whether to bank your baby's umbilical cord blood after the birth for possible use as a stem cell treatment. (This requires advance planning early in your pregnancy.)

Should I breast-feed my baby?

Should I bank my baby's umbilical cord blood?

Consider taking a childbirth education class, and tour the labor and delivery area of your hospital or birthing center. This will help you feel more comfortable when the time for delivery comes.

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Author:	Bets Davis, MFA Kathe Gallagher, MSW	Last Updated: December 5, 2007
Medical Review:	Sarah Marshall, MD - Family Medicine Adam Husney, MD - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology
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