Variations of Labor, Unusual Presentations, and Interventions

June 26, 2017

The type of labor you experience may be considered normal even if it does not progress exactly as you have anticipated. You should be prepared for any situations that may arise during labor. Having a baby should be a joyful event, not one marked by disappointment, unhappiness, or guilt. But it is also an uncertain experience; you do not know exactly how the delivery will go, how you and your coach will react, and how your baby will respond to labor. We have written this chapter to discuss variations in normal labor patterns and the possible interventions that may be necessary to assist you in having a healthy baby.

Keep an open mind about yourself, your baby, and your labor. If you don’t expect particular things from your baby in advance, you’ll both be a great deal happier, as will your coach.

Variations of Labor

Premature Birth
The premature baby is one who is born before it has had an opportunity to mature sufficiently. A baby born before 36 weeks of gestation is often small and less prepared for life outside the uterus. Medications that tend to depress the baby will be avoided in premature labor. Because the baby’s head is softer, forceps may be used to protect the baby’s head during delivery.
You may not have the opportunity to hold your infant right after delivery if she/he requires immediate pediatric attention. As soon as possible, however, you and your baby will be able to spend time together in the nursery.

Precipitate Labor
Precipitate labor lasts less than three hours. While this may sound appealing to you, it is accompanied by some special problems.
Your contractions may be quite intense, and you may have difficulty controlling discomfort. Moreover, you may feel confused and fearful because of the rapidity of the labor itself. If you feel you are in hard labor, be sure to request a vaginal examination from your physician or nurse midwife, and if the precipitate labor process begins at home, you must come to the hospital immediately to be examined.

In some cases, labor progresses so rapidly that you may feel that you don’t have time to get to your hospital or birth center. If this happens to you, call your physician, nurse midwife, or the hospital emergency room for assistance.

Prolonged Labor
Any labor that lasts longer than 24 hours is termed prolonged labor. Some causes of prolonged labor are ineffective contractions, breech presentation, posterior position, a large baby, small pelvis, extreme anxiety, or when large amounts of medication are given to the mother during the labor process.

We ask that you try to remain patient during prolonged labor. Fatigue is difficult to combat, but dozing between contractions may make it difficult to control your discomfort. If you experience a prolonged labor, we ask that you and your coach work together with all of the techniques and comfort measures that you have been taught in your classes. It is absolutely mandatory for your coach to remain with you to encourage you to relax, help you walk, and generally be supportive of your laboring efforts.

During prolonged labor, a nurse or a fetal heart rate monitor will carefully monitor the baby’s condition. You will be given intravenous (IV) fluids to provide nourishment and prevent dehydration.

In case you do experience a prolonged or extremely difficult labor, be sure that you understand what is happening to you and consider the available interventions that your physician or nurse midwife may suggest. Remember, labor is not a contest. You want to do what is best for you and your baby’s health.

Multiple Births
Many of the problems of labor already discussed can occur more frequently in pregnancies complicated by two or more fetuses. We will discuss with you the alternatives in managing multiple birth pregnancies.
Most people feel that in the majority of cases—except where both twins present in the head first or vertex position—cesarean delivery is the safest method of delivery for these infants. Therefore, we would ask that you prepare for the possibility both of a difficult and prolonged labor and/or cesarean birth if you know you are pregnant with twins.

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Unusual Presentations

The Breech Presentation
Presentation refers to the position the baby assumes in the uterus. The part of the baby closest to the cervix is called the presenting part. The usual presenting part is the top of the head. This is called a cephalic or vertex position.

In approximately 3%–4% of all deliveries, a breech presentation occurs, in which the buttocks present first. Labors with breech presentation may be longer than with vertex, because the buttocks do not descend through the birth canal as easily as the head.

There are several variations in the breech position, from a cross-legged or a complete breech to a frank breech, in which the baby assumes jackknife dive position with legs straight and feet near the face. Also possible is a footling breech presentation, where a foot presents through the opening of the cervix.

Risks of birth injury to the baby are greater with breech than with vertex deliveries. Some physicians feel that cesarean section is appropriate for all breech babies. Should your baby present in breech position, we at the Women’s Clinic will discuss the available options with you in detail.

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We may include a trial of rotating the baby, called external version, where the baby may be manipulated into a head first presentation. This is done at the hospital using ultrasound guidance and medications to relax the uterus.

Transverse Lie
Rarely encountered is a position or presentation called a transverse lie, where a shoulder is presenting through the opening of the cervix. In this case, cesarean delivery is mandatory since the baby will not deliver through the vagina in a sideways position.

Face or Brow
Occasionally, the baby’s face or forehead presents through the opening of the cervix instead of the back of the head. This type of labor may be longer, or it may be impossible to deliver vaginally, requiring a cesarean delivery.

Occiput Posterior Position
The position of the baby as an obstetrical term refers to the relation of the presenting part to the mother’s pelvis.

In a normal vertex presentation, the back of the head, or occiput, is the point of reference, and the most common position for the occiput is anterior. In this case, the back of the baby’s head is toward the mother’s abdomen.

A less common position, known as posterior position, occurs when the back of the baby’s head, or occiput, is against the mother’s tailbone. This position often results in prolonged labor and is accompanied by greater back discomfort.

Most babies will spontaneously rotate to an anterior position during the labor process.

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Back Labor
Approximately one in every four women experiences a labor that is felt primarily in the lower back. This is called back labor, and it may be caused by a posterior position, breech presentation, anxiety, variations in anatomy, or laboring while lying flat on your back.

Greater discomfort may be felt between contractions with back labor than with standard labor, and you may find it more difficult to relax. Your labor process may also last longer, increasing the discomfort you have to cope with.

The most important thing to do with back labor is to try changing positions often and to make sure that you do not lie flat on your back. Lying on your side with pillows under your head, uterus, and upper leg may provide relief. Also, sitting in a tailor position (cross-legged) may help you deal more effectively with the discomfort of your contractions. You may find it helpful if your coach applies heat or cold to your back, or counter pressure to the lower back, to relieve the discomfort associated with back labor.

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Your physicians/nurse midwives have various procedures at their disposal that can provide diagnostic information, prevent possible complications, and even alter the course of your labor. Any intervention carries with it some degree of risk and, therefore, should never be used unless medically necessary.

Please become familiar with the possible procedures that may be used during your labor, along with the purpose of each.

Intravenous Fluids
An intravenous solution (IV) is a mixture of water, salt, and occasionally sugar that is fed into your body through a vein. It may be necessary in prolonged labor to prevent dehydration. It is also necessary to have an IV during an induction, epidural, spinal, or general anesthetic since it provides easy access to administer medications to you as needed.
Most frequently, a small needle will be inserted into your vein, but the needle will not be connected to an intravenous fluid bottle. This small needle is called a buffalo cap, and it allows us to give you fluids intermittently during the labor process, but it does not restrict your activity. This needle is also referred to as a heparin lock.

Amniotomy, an artificial rupture of the membranes or amniotic sac, is performed by inserting a long hook into the vagina and making a small tear in the membrane surrounding the baby. This is a painless procedure since there are no nerves in these membranes, but it does present some risk. If labor does not begin, both the mother and baby have an increased chance of infection, and for this reason labor must be induced. This procedure may be used to stimulate contractions or increase the strength of contractions.

Induced Labor
Induced labor is one that is started artificially by either chemical or physical stimulation. Induction is medically indicated in situations where continuation of the pregnancy would adversely affect either the mother or the baby. Such conditions include high blood pressure in pregnancy, diabetes, long overdue babies, or post-mature infants with a diagnosed aging placenta, Rh sensitization, prolonged rupture of the membranes with no labor starting and, in some rare cases, when a baby has already died.

A hormone called prostaglandin (Prostin, Prepidil, Cytotec) may be used to soften the cervix and encourage labor. It is applied to the vagina and cervix in a gel form or vaginal suppository, and it is often used as a precursor to Pitocin.

The hormone oxytocin (Pitocin) is most frequently used to induce labor, especially if an amniotomy has been unsuccessful. It is usually given through an intravenous drip with a solution of glucose and water.

Induced contractions tend to start out stronger than naturally occurring contractions. Some women feel that induced labors are more difficult, since there is no gradual build-up of the natural labor process to help them acclimate to the discomfort of contractions.

Contractions tend to be more frequent, longer in duration, and often peak immediately rather than in the middle of the contraction. This may make labor more difficult to control, and you and your coach must be on top of the contractions from the very beginning or you will lose control.

Encouragement and support are essential during induced labors. Your coach’s assistance will be valuable in keeping you comfortable and relaxed while you conserve the energy that you will need later.

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An episiotomy is a surgical incision from the vagina towards the rectum. It is used to enlarge the vaginal outlet and thus decrease the risk of tearing during birth. The incision is usually straight, between the vaginal opening and the rectum. The need for an episiotomy cannot be determined until the baby’s head begins to stretch the perineum, which is the tissue between the rectum and the vagina. Your physician/nurse midwife does not perform episiotomies routinely—only when it is essential to prevent extensive tearing.

Forceps Deliveries, Rotations and Extractions
Two obstetrical tools, forceps and a vacuum extractor, can be used to rotate the head of the baby to a more advantageous position for birth and to assist in moving the baby down the birth canal.

Indications for the use of these instruments include the baby’s persistent occiput posterior position, a woman’s diminished ability to push because of anesthesia or fatigue, and fetal distress.

Forceps are curved metal tongs that are inserted into the vagina and placed on either side of the baby’s head. They are smooth and allow for ease of manipulation and extraction of the baby. Occasionally, a small amount of bruising may occur, but this disappears one or two days after delivery.

Forceps can also serve to protect the head of a premature baby from prolonged exposure to pressure during vaginal delivery.

The vacuum extractor is a cap-like device that uses suction to attach to the baby’s head. The pressure of the suction can be adjusted. The suction cup fits over a portion of the head and aids in easing the baby out through the contours of the birth canal. As a safety factor, too much tension on the vacuum extractor results in loss of suction and failure of the extractor to remain attached.

Cesarean Delivery
Cesarean delivery is the birth of a baby through an incision in the abdominal and uterine walls. It is also called an abdominal birth and is a major surgical procedure. Nevertheless, it is still the birth of a child, the start of a new family unit, and one of the most significant events in the life of a couple. It can be just as happy, fulfilling, and satisfying as any other delivery if you know why and how it is happening, and if you realize that it is designed to deliver a normal, healthy baby that might have had a difficult or impossible vaginal birth.

It can no longer be considered unusual, since approximately 20% of babies born in the United States are delivered by cesarean section.

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Why You May Need Cesarean Birth
Most first-time cesareans are not planned or even suspected in advance. In many of these cases, you will go into the hospital following the onset of labor, expecting a vaginal delivery and be surprised or perhaps disappointed when we suggest it may be necessary to perform a cesarean birth.

The most common reason for a cesarean is that the baby’s head is too large to pass through your pelvic opening; this is termed cephalopelvic disproportion. Though we may have suspected there would be this disproportion, it is usually impossible to be sure until after labor has progressed for a while.

Sometimes labor continues for many hours, but because the uterus fails to contract efficiently or completely, the cervix then fails to dilate as it should. If there is little or no progress after a few hours of stimulation, and especially if the amniotic membranes have been ruptured for a prolonged period of time, a cesarean may be necessary.

Very rarely, a muscle tumor of the wall of the uterus, called a fibroid, may obstruct the birth canal so that the fetus cannot safely make its way past. Or, a woman may have had surgery on her uterus, which can leave a fragile scar. In these cases, cesarean birth is almost always the best method of delivery.

There are some maternal illnesses that may make a cesarean delivery likely, though even when these diseases are present, most deliveries can still be done vaginally with very careful supervision. The most common diseases requiring cesarean delivery are diabetes, high blood pressure, toxemia, severe heart disease, Rh disease, and possible herpes infection of the birth canal.

Fetal distress is a major reason for an unplanned cesarean birth. Fetal distress refers to a reduced supply of oxygen for the baby, signaled by changes in the fetal heart rate, usually a slowing of the baby’s heart rate after a contraction.

In the vast majority of cases, the baby will make its entrance into the world headfirst. Sometimes, however, the baby’s buttocks (breech position) may come first. Even less frequently, the baby’s face will come first, or perhaps a shoulder, hand, or foot. These abnormal positions may also require a cesarean birth. Rarely, the umbilical cord descends ahead of the presenting part of the baby. This is referred to as a prolapsed umbilical cord; it causes a drastic reduction in the baby’s oxygen supply, and cesarean birth is usually necessary.

Because twins often begin labor with one of the babies in an abnormal position, cesarean is often considered the safest method of delivery for these babies.

Finally, bleeding may be excessive during early labor or sometimes even before labor begins. There are two common causes for uterine hemorrhage during labor. The first is called placenta previa and means that the placenta is abnormally implanted over the cervix. The other cause is abruptio placentae, the premature separation of a normally implanted placenta from the uterine wall.

Making The Decision To Have A Cesarean Birth
Initially, your physician or nurse midwife will discuss with you the possibility of a cesarean delivery. Should you decide to have your baby by cesarean, your physician will explain the risks and ask you to sign a surgical consent form.

Of course, the major risk of any operation is death. This is a very rare occurrence, less than one in every 10,000 cesarean births. Other major risks include excessive blood loss, infection, and anesthetic problems. All of these complications occur quite infrequently.

Another significant risk is that many hospitals still require women who have had cesarean birth to have all their babies via cesarean. Fortunately, at Poudre Valley Hospital, we are able to deliver many babies vaginally from women who have previously had a cesarean birth. This VBAC (Vaginal Birth After Cesarean) procedure should be discussed with your physician or nurse midwife if you are considering it.

The major risk to your baby with cesarean birth is a slightly greater chance of the baby aspirating (breathing) amniotic fluid into the lungs. In the case of a scheduled cesarean, another major risk is that the baby may not be mature. This is a very rare complication.

Benefits to the baby are increased survival in cases of distress or bleeding, along with lower incidence of birth injury or complications (such as distress) when mothers have severe medical illnesses.

What Happens After The Decision Has Been Made
After you have discussed these risks with your physician and signed the consent form, the nurse will place a small rubber tube called a catheter into your bladder; this tube will generally remain in place 12–24 hours after your surgery. You will not have to leave the bed in order to urinate.

Fluids will be given intravenously to prevent blood pressure problems with your anesthesia. This tubing also allows the anesthesiologist to administer necessary medication.

Then your abdomen will be gently shaved to remove hair from the area where the incision will be made; this greatly decreases the chance of infection. Generally, the incision is made along the top of the pubic hairline and is frequently referred to as a bikini incision.

You will then receive liquid antacid to lower the risk of infection in your lungs should vomiting occur.

Your coach will be asked to change into a surgical outfit like your physician’s so that she/he may accompany you to the delivery room. Your coach will wait outside the operating room until after your anesthesia is administered and will then join you. Choose the anesthesia that is comfortable for you.

Most mothers want to see their babies at birth. Being awake for the birth does initiate bonding. With support and information from physicians, nurses, and the coach, most anxieties can be alleviated so that spinal or epidural anesthesia can be used comfortably. Since the coach is able to attend the birth, mother and coach are able to rejoice in the birth together.

In some cases, the mother or physician may choose a general anesthetic (the mother is asleep). When the mother is exhausted from labor, a medical emergency arises, or due to the mother’s health history, general anesthesia may be the choice. Always remember that you will have a voice in the decision.

A complete discussion of different forms of anesthesia is located in the “Medications and Anesthesia” chapter.

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The Delivery Itself
When you are completely anesthetized, the delivery will begin. The abdominal wall and uterus are opened in an appropriate fashion and the infant is delivered. While your pediatrician and family physician cares for your baby, the uterus and remainder of your incision will be closed in layers. This generally takes longer than the actual delivery of the baby itself.

You will then be taken to the recovery room for a period of one to two hours. There the nurse will attend to and monitor you. You will have your baby with you, and your coach and immediate family members may join you in the recovery room.

You will be transferred to your regular hospital room after your blood pressure and pulse have stabilized and sensation has returned to your lower abdomen and legs (in the case of a spinal or epidural anesthetic), or you have awakened sufficiently (in the case of a general anesthetic).

The Coach’s Role In Cesarean Birth

Couples who have prepared themselves to be partners in a vaginal delivery are usually the most eager to go through a cesarean birth together. At Poudre Valley Hospital, your coach may accompany you to the surgery/delivery room.

Sometimes, however, coaches may feel useless, afraid, or powerless in the case of an emergency cesarean birth. Often these feelings cannot be avoided. Usually, though, there is a chance for some discussion and an explanation of what is happening and why, which may help alleviate these feelings.

The process of identifying the child as your own begins in the surgery/ delivery room. The presence of the coach in the operating room helps to welcome the baby and allows for sensual contact of both mother and coach. This aids in bonding with your child and reduces your anxiety during surgery. The coach will also be able to re-live this moment with you over and over again in the days ahead. This is very important since exhaustion, medications, and/or anesthesia may dull your memory.

Photographs may be taken. We advise the use of ASA 400 or 1000 film and no flashes. These pictures will be especially important if you are not able to see the birth, and they may complete your experience of the birthing process.

Your coach may accompany the pediatrician to the nursery. Carrying the baby to the nursery and participating in the care of the newborn is a joy for the new parent.

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Bonding And Breastfeeding
While you may be using more pain-relieving medication than if you had had a vaginal delivery, you will still be able to see and hold your baby as soon as you desire.

Touching the baby soon after birth initiates the bonding between parents and the infant. Because you are assured of the baby’s well-being, you are usually more relaxed and comfortable.

Certainly you will need to be realistic about discomfort, but that will not prevent you from enjoying and beginning to nurse your baby immediately.

Your Recovery
There are several things that you can do to help yourself recover from a cesarean delivery. Should you need a cesarean delivery, the nursing staff will explain these recommendations, and you will be given a specific handout. Your physician and nurse practitioner will spend sufficient time with you so that you feel comfortable moving about.

Your Feelings After Cesarean Birth

Most cesarean parents have their babies without any serious or long lasting psychological trauma and settle down with their new family member(s) fairly easily. Occasionally, however, parents find that the experience of having a cesarean baby haunts them. If this is the case, the physician and lay support groups will be most willing to help you work through these feelings so that your cesarean experience will seem more acceptable.

We are just as concerned as you are that your birth be a human, personal, and warm experience, regardless of the method by which your baby is delivered. Please feel free to talk with us at any time about questions regarding cesarean birth.

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