Our Bodies, Ourselves (90 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
PUSHING WITH AN EPIDURAL
An epidural changes the second stage of labor considerably. The urge to push is often delayed and sometimes absent entirely. Pushing takes longer and can be more tiring, it's harder to change positions, and instrumental (vacuum or forceps) delivery is more common. Some of these challenges can be overcome with a more relaxed and patient approach that allows plenty of time for the baby to descend and be born.
You can decrease your chance of having a vacuum or forceps delivery or a cesarean and avoid overexhaustion by not pushing immediately when your cervix is completely dilated. If you wait until you feel the urge to push or until your baby's head has descended further, you will have more energy and will be able to push more effectively. Research suggests that the length of time before the baby is born is the same whether you allow an hour or two of passive descent of the baby (when you relax and don't consciously try to push) or start pushing immediately after you are fully dilated.
25
It may take only a few pushes, or it may take a few hours of pushing, to birth your baby. As long as both you and your baby are doing fine and the baby is moving down, there's no reason to limit this phase of labor.
Photos courtesy of Judith Bishop
Between pushes, breathe slowly and rest.
You might even fall asleep for a few minutes. Remember thatâjust as in earlier phases of laborâyour uterus works involuntarily to move the baby down and out. Work with it, and give it time. Your labor may not progress as quickly as you had imagined or as others around you expect.
COMMON LABOR INTERVENTIONS THAT CAUSE HARM WITH LITTLE OR NO BENEFIT
Although almost all interventions can be helpful in certain circumstances, harm is associated with their overuse. The interventions listed below are used in large numbers of U.S. births, despite evidence that their routine use makes labor and birth riskier for women and babies.
â¢
Laboring or pushing on your back:
The flat-on-the-back position tends to be more painful, slows down labor, results in more trauma to the perineum and vagina during birth, and reduces oxygen flow to the baby.
26
It may also make you feel like a passive recipient of medical care rather than an active participant in the birth of your baby. Even if you have a medical condition that makes walking unsafe or choose an epidural, you can still use a variety of positions in bed, such as lying on your side.
â¢
Episiotomy
, a surgical cut straight back into the perineum to enlarge the vaginal opening, has been shown to increase postpartum pain and the risk of a tear extending into the anal sphincter muscle, which can lead to incontinence (involuntary loss of urine, gas, or feces). The best evidence suggests that episiotomy should be used only when the baby is showing severe signs of distress late in the pushing phase of labor.
27
â¢
Immediate clamping of the umbilical cord
after birth deprives babies of up to one-third of their blood volume. Although most babies can withstand this amount of blood loss, it is associated with an increased likelihood of anemia for several months after birth. Delayed cord clamping has additional benefits for preterm and low-birth-weight infants and may also reduce the mother's blood loss after birth.
28
When the pushing stage of labor is nearing its end, the baby moves under your pubic arch, and your perineum, the area between the vaginal opening and the rectum, stretches slowly to accommodate the head. Gentle guidance to push slowly and with short pushes at this stage, encouragement of favorable positions, and techniques such as touch, hot compresses, and warm oils applied to the perineum for comfort all work with this process and may prevent or minimize tearing. When you feel a burning sensation, breathe lightly so as not to push too rapidly and risk tearing. Reaching down to touch your baby's head for the first time often produces an “Ahhhh” that opens you up even more.
A midwife who gave birth at home says:
I often tell women in labor that they will feel a second windâa surge of energyâwhen it is time
to push. I found that this didn't really happen when I started pushing. But I definitely felt this when I started feeling the stretching and knew [my baby] would be born soon. It was like the only thing I needed to do in the world was push with all of my might. And that was true! It was the only thing I had to do. All the wonderful people supporting me were taking care of every single other thing
.
I pushed and the burning peaked, and then, all of a sudden, nothing. My baby's head was out. It is truly amazing how quickly you can go from the most intense pain to no pain at all
.
Within seconds of birth, babies make a remarkable transition from life in the womb, where all of their needs were met by the placenta, to life outside the womb, where they must regulate their own breathing, temperature, and digestion. These transitions happen most easily when the baby is placed on your chest for skin-to-skin contact with you, with the umbilical cord intact (not clamped immediately) and in an environment of peace and calmness. Sometimes hospital routines or medical complications make it difficult or impossible for the mother and baby to remain in such close contact right after birth. Babies can overcome these disruptions when they are medically necessary, but it is best to keep the mother and baby together barring extreme circumstances.
Some babies breathe as they are being born and look pink immediately. Others take a few moments to begin breathing, a process that unfolds as blood continues to flow through the umbilical cord.
29
Gentle stimulation such as rubbing the baby's back can also help a baby begin breathing in a regular, sustained way. Healthy babies are usually able to clear their own airways of fluid and mucus without suctioning. If there was meconium (the baby's first bowel movement) in the amniotic fluid and the baby isn't breathing immediately, she or he may need suctioning right after birth to prevent the meconium from getting into her or his lungs.
Not all newborns cry. Some do for a moment and then stop. Often they breathe, blink, and look around or cough, sneeze, and snuffle. Your baby's head may appear oddly shaped, having been temporarily molded by coming through the birth canal. Her or his body may be covered with patches of vernix, a white, waxy substance that coats and protects the baby's skin inside the uterus. All babies arrive wet with amniotic fluid.
© Britt Fohrman
Mothers and babies belong together during this precious time. When you feel ready, hold your baby naked against your belly and breasts, near the familiar sound of your heart, so that she or he can touch your skin and smell, hear, and see you. You and your new child need as much peace and quiet time together as you can create. In any setting, well-meaning providers and others can interrupt this important personal time because they want to know how you and your baby are doing. In a hospital, medical personnel
may have their own schedules for evaluations. Providers can often unobtrusively examine your baby in your arms. It is usually not necessary to have tests done right away. If there is a medical reason to take your baby away from you for a short time, your partner or support person may accompany the baby.
MECHANICAL INTERVENTIONS IN BIRTH: VACUUM EXTRACTOR AND FORCEPS
The vacuum extractor and forceps can help when babies need to be born quickly or when a woman would benefit from assistance to allow vaginal birth to continue. They are important tools in skilled hands. They can be used only when the cervix is fully dilated and the baby has descended well into the vagina. With both vacuum extractors and forceps, the mother must continue to push with contractions. In most instances, anesthesia is given prior to the use of these instruments so the pelvic area is numb.
The vacuum extractor is a small, flexible suction cup that fits on the baby's head. Use of the vacuum extractor will result in an exaggeration of the natural elongation of the baby's head caused by labor for a short period. Even when done properly, it can cause a blood-filled swelling (cephalohematoma) on the baby's head.
Forceps are two metal branches that are slipped onto each side of the baby's head and then locked together so as to fit snugly. Forceps are much more likely to cause injury to the woman's vagina and perineum (the tissue between the vagina and rectum) than a vacuum delivery and can also cause injuries in babies. They are particularly risky when used inappropriately or by unskilled providers.
The use of vacuum extraction has increased. A number of factors account for this, including the increase in the use of epidural anesthesia, which lengthens the pushing stage; a maximum time limit for pushing allotted to women in some hospitals; hospital efforts to lower the cesarean section rate; and reduction in the use of forceps as fewer providers have forceps skills. Vacuum extraction is often used with epidurals because epidurals can interfere with pushing.
Before using an extraction delivery method, if there is no immediate emergency, move into different positions that open your pelvis. Try squatting to make your pushing more efficient or nipple stimulation to increase the strength of contractions.
