Just How Long Will This Take?

Perhaps one of the most common questions we face as Labor & Delivery nurses, is "How long will my labor last?" It is difficult to answer that question with any degree of certainty for any particular woman, but there are some facts we can share with women which can help them understand how long their labor might be.

When a woman goes into labor with her first baby, we don't know if she will be a "fast laborer" or a "slow laborer", and believe me, all of us women are genetically programmed to labor in a particular way. Sometimes the way your mother or sisters labor can be clue, but not always, because while there may be genetic tendencies, there are not genetic sureties!

It helps if we know a few things about how labor itself works. First of all, usually the first labor takes the longest. This is because the tissues that have been stretched out by the first baby, have less resistance with subsequent babies. It's sort of like blowing up a balloon. Whenever you try to blow up a balloon the first time, it feels like your lungs will explode before that balloon even begins to fill up. But after the balloon has been stretched out to capacity, you can easily blow it up again with just a tiny puff of air. Our bodies function like that, too.

Another thing to keep in mind is the physics of labor. The cervix, or the opening to the uterus, begins thick and closed. The first action it takes, before ever opening up any appreciable amount, is to thin out, or efface. The muscles of the uterus pull upward toward the top and this pulls on and effaces the cervix.

A woman will usually be 90% or more effaced before she begins to dilate any significant amount. This action is similar to that of putting on a turtle-neck sweater. Most people don't begin by pulling open the turtle-neck as wide as they can and then pulling it over their head. No, they pull the sweater over their head and let the turtle-neck rest on top of their head, thick and closed. As they pull the fabric of the sweater from the bottom, the neck portion gradually thins out. Once the neck has thinned out as much as it can, then the opening will begin to open up more and more and begin to slide over the person's head, until finally, their head slides through. This is the same mechanism for labor. The uterine muscles pull on the cervix, as the baby's head, pressing against it, help it to thin out. In fact, with a first baby the cervix can get as thin as a sheet of paper! Then when the cervix is as thin as it can get, it begins to dilate, or open up, more and more until the baby finally begins to descend through it.

All this takes time, however. The process of labor is divided into four stages, but only the first two are concerning the actual birth. The first stage involves the cervix becoming completely effaced and dilated, and the second stage involves the baby descending through the pelvis and being born (usually with the aid of the mother's pushing efforts.)

The first stage of labor is further divided into three phases: early, active and transition. The early phase is the longest and the phase that is the least predictive. In a woman who is in spontaneous labor, meaning she hasn't been induced or had her labor augmented in any way, this phase can last 24 hours. It is long, but most of it is relatively easy, with the woman initially wondering if she even is in labor. Once she reaches active labor, or 4 centimeters dilated, labor speeds up. If it is her first baby and she is making "average" progress, she should dilate about a centimeter an hour. Some women will dilate faster and some will dilate slower. But at this point, as Labor & Delivery nurses, we can begin to give an "educated guess" as to the time of the baby's arrival.

Once the woman reaches 8 centimeters dilated, labor will speed up again. The last two centimeters go a little faster, and that's a good thing, because this short phase of labor is the most difficult of all. Once completely dilated, a woman can push with a first baby anywhere from 20 minutes to more than 2 hours. Much of that depends upon where the baby was in the pelvis when she began pushing, the position of the baby's head when she began pushing, the effectiveness of her pushing effort and the strength of her contractions during the second stage.

Being from a hurricane region, we often make the analogy that predicting the birth of the baby is much like predicting the landfall of a hurricane. When the hurricane is out by the Leeward Islands, no one has a idea where that storm is going. Then hours pass, and it veers into the Gulf of Mexico. The Eastern Seaboard sighs in relief, but we are watching it carefully. The predicted "cone of destruction" is wide and no one knows where the storm will land. With each successive storm update, the prediction cone moves and narrows until finally the area is more closely pinpointed. Still, no one actually knows the final destination until that storm makes landfall.

That's just how it is with our babies. Early in labor, we can only give a broad guess. But with each cervical exam, we can narrow our guess a little. The farther we go in labor, the closer we get to having an accurate time, but no one really knows exactly until those tiny little toes come into view and a Labor and Delivery nurse calls out the exact time and says, "Happy Birthday!"

The Baby Born in a Closet...

We talked yesterday about Birthing Plans, and the importance of keeping the person being delivered the most important focus of labor, and it made me think of my most memorable delivery in over thirty years.

It was one of the busiest nights at work I had ever had. There were only five nurses working that night and the patients seemed to just keep coming. Then, in the wee hours of the morning, the babies started coming, too. At the final count, we delivered seven babies in forty-three minutes!

I was rushing to prepare a new patient for delivery in what we affectionately called, "the cubbyhole". Its name fit it well, because it was merely an indentation in the wall, big enough only for the bed and a bedside table. A curtain gave a small degree of privacy and I stood behind this curtain trying to find out something about this woman before her baby made its arrival. She had done this many times before and her body certainly remembered how because her labor was progressing rapidly -- the baby would be here in a matter of minutes.

It was then that I heard the soft comment, "I've got to push." It wasn't a shout for help, it wasn't a cry. It was spoken softly, quietly, almost as if she had spoken it to herself. And it wasn't spoken by my patient! Where did it come from? There were no patient rooms on this hall, only this cubbyhole! For a moment I thought I had imagined the whole thing. Perhaps even, if I ignored it completely, it wouldn't repeat itself! But I had heard it and the nurses' heart within me had to search for the owner of that softly spoken voice.

The only other room on that hallway, besides the closed operating room, was a small closet in which the anesthesia personnel kept their supplies. There were bottles of liquid anesthetics, supplies for all types of regional anesthesia and shelves and shelves of epidural trays. Barely fitting in this dark and dusty closet was a stretcher upon which was a very pregnant woman. Her eyes latched onto mine with urgency as I passed through the doorway. She softly repeated the phrase, "I've got to push". I quickly asked a few questions while reaching for an exam glove…Who was her doctor? --A private doctor who would take twenty minutes at best to arrive. Was anyone with her? --Her husband was still on the first floor completing the admission paperwork. When she told me she would like a birthing room and an epidural, I almost bit my tongue to keep from telling her that the epidurals were on the shelf right beside her.

As examined her to determine the status of her labor, I was met by the fleeting, puzzling thought I always seem to have when my fingers meet with a hard obstacle. The baby's head was right there. There would be no birthing room; there would be no labor coach, no epidural, not even a doctor - all of the resident OB's were in deliveries! This baby was coming with the next contraction. I ran to grab an emergency delivery pack and headed back to the anesthesia closet. My patient in the cubbyhole would have to wait; this woman had beaten her to the draw. An eager or perhaps only curious, medical student followed me back to my patient. With more deliveries under my belt now than I could count, I had full intentions of letting him do this delivery when I asked him "Have you done many deliveries?" He answered, "Well, I've seen one." By the tone of his voice I had the distinct impression he hadn't paid too much attention. "Okay then," I said as I quickly decided, "You will help me".

As I opened the delivery pack and prepared my instruments, I prayed that this woman would deliver as easily as she had labored. With the next contraction, the baby made its entrance into this world almost effortlessly. After cleaning out the baby's nose and mouth and guiding the shoulders through, all the while explaining to the wide-eyed student what I was doing, I wiped down the baby and gave it to the mother. It was easy to tell it was love at first sight. Thankfully the placenta came as easily as the baby and the delivery was so graceful and gentle that there were no lacerations to be sewn. The whole process had only taken only a few minutes by the clock, but it had seemed as if time had stood still while this baby was being born.


I felt so sorry for this woman that all her expectations had not been fulfilled and I as I wheeled her to the Recovery Room, I told her so. "You didn't get a birthing room, your husband, an epidural or even a doctor". Then she replied with a sentence I will never forget. "No, but I got the most beautiful baby girl in the whole world!" Tears came to my eyes as I marveled at her wisdom and realized that this woman knew what was important; she knew how to extract the essence of life out of the situation. And to this day her delivery is my most memorable.

It was not memorable for occurring in a finely decorated birthing suite, nor because of the beauty of the relationship between husband and wife, although I have seen that type of delivery. It was not memorable because of the skill and caring of an experienced physician, yet I have seen those as well. It was memorable not because of the bond between nurse and patient, in fact, I can't even recall her name and I doubt she ever knew mine. It is memorable to me, however, even after all these years because of a mother's love for her child which was great enough to transcend the meager surroundings, the absent support and the inadequate staff.

"Love…beareth all things, believeth all things,
hopeth all things, endureth all things. Love never faileth."
I Corinthians 13:7,8

(Infant photo courtesy of Belinda Gee)

Birthing Plans

One thing that you will encounter after only a short Google search of childbirth, is the "Birthing Plan". For those who may be unfamiliar with the term, this is a plan of how you want your childbirth experience to go. In short, it is a list of desires and "do’s" and "don’ts" for your health care providers and attendants.

Over the years I have seen many different birthing plans and various reactions to them, from one extreme to the other. I’ve seen some physicians take them very seriously and try to work with the patients to accommodate what was listed on the plan as much as possible. Then I’ve had one physician who said, "Birthing plan! What the heck do I need a birthing plan for? I’ve been doing this for thirty years! I know what I’m doing!" I even know of one physician who signed a very lengthy and detailed birthing plan for a patient with a high-risk pregnancy, and yet he told me the day she was admitted in labor that he had never even read it before he signed it.

There are several things to think about as you sit down to write your birthing plan. First, the things you put on you BP should actually be important to you for some reason, it shouldn't be just a form letter printed from the internet. Why do you want this particular item on the plan? Someone, such as your health care provider, may ask you this when you present your plan to them.

In addition, you may want to investigate what the current routine practices are for the facility at which you plan to deliver. At our facility, we find that 90% of the items on the average BP are how we routinely do things anyway.

Next, make sure you and your partner agree on the items on your plan. The birth of your baby affects you both and you will both have expectations, hopes, and dreams for that special day.

When your BP is written and it is time to present it to your physician or midwife, schedule a separate office visit than your regular obstetric visit, so that you can take your time and go over the points carefully. Like the physician mentioned above, sometimes a physician in a busy OB practice will glance at a BP, or even sign one, and never have actually read what it has to say. The pregnant woman is then under the assumption that her physician is in agreement with what she has planned. Then when the day of the birth arrives, the physician, usually at the insistence of a labor room nurse, begins to actually look at the BP and address any issues he or she has with it.

Another good course of action is to take your BP to the manager of the delivery department of the facility where you plan to deliver. Let her look over the plan with you and see if there are any items which she feels might compromise safety or security for you or your baby. Oftentimes discussing the birth plan with the labor room staff prior to labor helps to work out any kinks in the plan and creates a much better plan in the end. Also, it helps to engage their knowledge as to why certain policies exist, or what strategies can be worked out to satisfy the items on your birthing plan, yet still allow the facility to feel as if they are maintaining a culture of safety for you and your baby. Having this interview before labor begins gives everyone the time that labor won’t allow and it also creates a friendlier bond between yourself and the labor staff. Labor nurses want you to have the most positive experience you can have, as long as they can feel reassured that you and baby are OK during the process.

The most important thing to remember about the plan is that it is a PLAN. No one can predict what curves labor may throw your way. Often we see patients whose labor course goes so differently than what they anticipated. Sometimes that can be a positive thing: they prepared for a long labor and they went much faster. Sometimes it can be a negative thing: in spite of everything, a baby still won’t descend, or a cervix still won’t dilate. Remember to “go with the flow” throughout your labor and keep in mind that the most important thing is that you will deliver a baby; hopefully a healthy, beautiful baby. All the wishes, plans, and hopes of the birthing plan are secondary to this one thing. The experience of the birth itself can never be more important than the person who is being birthed. If you keep the person the most important thing, you will end up satisfied, because in the end, you will end up holding that little one in your arms.

The stories of labor...

Birth is probably the event of a woman's life which gives her the most fear. To live in the "information age," I am always surprised at how many myths and how much misinformation still shroud the process of labor and birth. Considering we have access to information 24/7 at the touch of our fingertips, I suppose I expect each patient to enter the labor room being more confident of what will transpire there. But there are other forces at work as well.

Every pregnant woman has in her life other women who are ready and eager to tell their own birthing experience, or better yet, the experience of their sister's neighbor's cousin. The more horrific the experience, the more likely they are to want to tell every detail to the already nervous, expectant mother. These stories abound, from the cashier at Wal Mart, from the teller at the bank, to everyone attending each of her baby stories and for some reason, they seem to carry more weight than the factual information given by her physician or the childbirth instructor or her midwife.

It is important that every pregnant woman find a source of competent, trustworthy information that she can use to hold as a standard for all the misinformation she will find thrust her way during her 40 weeks of pregnancy. She needs someone to whom she can openly ask questions, and get reasonable answers. She needs to be able to repeat some of those "horror stories" she has heard and let an expert tell her what may be truth and what is myth. Most of all she needs a source of reassurance for her and her situation and a source of education that is specific for her needs and her medical situation.