Two Different Labors

We talked the other day about how long labor takes and it reminded me of this story I wrote about two different women and how strikingly different their labors were.

Samuel

The head seemed to be growing larger each minute. I had been so thrilled when the doctor said it was time for my patient to push because by all natural evidences, this moment should have never happened.

Suzy had already been in labor for twelve hours when I wheeled her through the door of the labor room to admit her and her progress throughout the day had continued to be exceptionally slow. The pattern of her contractions -- the rhythmic tightening of the uterine muscle-- was extremely inefficient, or dysfunctional, as we call it, and the strength of her contractions was woefully short of the mark considered "adequate" to open, or dilate, the cervix. Looking through human eyes, she should never have reached the ten centimeters dilation necessary to begin pushing to deliver a baby. Her labor was exactly the opposite of Amanda's.

Amanda’s labor was a remarkably fast as Suzy’s was long and drawn out. Amanda had visited us before; in fact this was her fifth visit since her cervix began to dilate six weeks too early in her pregnancy. Her dilation had been halted and she had spent the next four weeks on pins and needles, expecting labor to occur at any second. I had taken care of Amanda once previously on a run of false labor, and I remembered thinking then that her labor would probably be unusual.

It seemed to me that sometimes when a woman started dilating more than a couple centimeters before labor started, that something was not quite right. As part of her admission process, I performed a vaginal exam to determine if her cervix was more dilated than the three to four centimeters she had been for weeks. Now this might be confusing to some people. Most people naturally assumed that if a woman’s cervix is dilated to a significant amount that she is in labor, but that is not true. It is also not true that if a woman is having “regular” contractions she is in labor. The true definition of labor is when a woman is having contractions which cause a readily measurable change in the cervix. Some women come in having contractions, but they don’t change the dilation of the cervix, that is what is referred to as false labor. Some women can be dilated a centimeter or two before labor even begins without the first contraction, occasionally even more. Amanda had been in preterm labor weeks before her baby was ready to be delivered and we were able to stop her contractions. Then she just waited and waited. Now her baby was term and she was contracting, we just needed to see if these contractions were actually labor.

Her contractions were fairly close, so I thought she just might be one or two more centimeters dilated, but her cervix was exactly as it had been a few days before in the office. She was scheduled for an induction in a few days, so her physician decided to just do the induction this day instead.

I started her IV and gave her as strong a dose of pain medication as I could, and for a few moments she seemed more comfortable, but within a short while she was once again hurting and asking for more medication. At that point her baby's heart rate dropped down precipitously. I reached for a glove to do a vaginal exam and I was surprised to find she had already dilated to six centimeters! It couldn't have been the result of the Pitocin, the synthetic hormone used to induce labor, because we started it at a miniscule dose and I hadn’t even increased it the first time. Five minutes later the baby's heart rate plummeted again. Again I examined her, and again I was surprised --- now she was nine centimeters! We had already called her physician and anesthesia, both who had to come from home. Five minutes later, less than an hour since Amanda had arrived, and only two hours since her contractions started, she was completely dilated and ready to push! The anesthesia doctor had not yet arrived and I knew from experience that it would feel much better to Amanda if she pushed with her contractions, and I encouraged her to do so. After all, her baby was still fairly high in her pelvis; it would probably take her a couple hours to bring the baby down by pushing. I should have known that Amanda's baby wasn't going to do anything slowly. Within fifteen minutes we were seeing a head full of blonde hair. I wish I had taken a picture of her doctor's face when he poked his head around the curtain. He had meant to just say hello and then after she had received her epidural, examine her. Instead he saw a patient who was ready to deliver! He scurried off to get his hat, mask and booties and we put Amanda's legs up in stirrups. A few minutes later, almost as we were delivering the baby, we heard the voice of the anesthesiologist on the other side of the curtain asking if we were ready for an epidural. No, instead of an epidural, we were going to have a baby, and with the next contraction, Amanda's baby, who seemed to be in a great hurry, was delivered and placed in her mother's arms.

At this point in her labor, Suzy would have probably loved to have only had to push for twenty minutes. Here she was, pushing with all her might until her face turned a deep red, with a large amount of dark brown baby hair to show for her efforts. But this baby's birth had not been put in the hands of mere doctors and nurses. Earlier in the afternoon, when discouragement hung thick in the air, I was preparing Suzy for the possibility of a Cesarean Section, doing the pre- and post-operative teaching we usually do to prepare our patients, Suzy asked everyone in the room to start praying that her son would be born "normally". She was so determined that she would not have a C-Section, and I wanted that for her too, but I just didn’t see any hope for that happening. Yet silently I, too, prayed for the apparent miracle.

As the minutes passed by there was no improvement in her contraction pattern, they didn’t get closer, they didn’t get stronger, they didn’t last longer. The measurement we take of the total strength of contractions, taken only when a mother has an internal uterine pressure catheter in place, called Montevideo units, did not increase at all. There were no telltale sign from the baby that birth was close, no drop in the heart rate in conjunction with the peak of the contraction, which can be a sign of pressure on the baby’s head as it moves down the birth canal. Nothing, nothing at all seemed different. Everything stayed dismally the same, in essence, no hope. Her doctor had already told me he planned to do a C-Section on Suzy and this next examination would only be a formality. I had all my paper work ready, and her pre-operative medications were already sitting on the counter waiting to be given. Dr. Otto came in to examine her, and when he did, his eyes widened. What a surprise when he told us, almost gleefully, to "Start pushing!"

Her progress after that was rapid until the last few moments when it seemed like that baby boy's head would never end. With each push I thought we would see the baby's face and we would know the hardest part was over and with each push we only saw more of the dark-haired head. Finally, almost twenty-five hours after the beginning of labor, little baby Samuel's face first felt the rush of air and his parents felt a joy previously unknown as their nine pound and thirteen ounce son was placed in the arms of his mother. So in the face of an apparently hopeless situation, the faith and prayers of a young mother were beautifully answered.

May they be the first of many.

"And all things whatsoever ye shall ask in prayer,

believing ye shall receive."

Matthew 21:22

How Will I Know I'm In Labor?

This is a common question, particularly among first-time mothers. Unfortunately, our perception of the onset of labor has been skewed by popular television sitcoms and movies in which the pregnant woman has one horrific contraction, grips her abdomen and announces to everyone "This is it!"

BRAXTON-HICKS CONTRACTIONS

Determining labor in real life can often be much more difficult. One reason for this is the fact that toward the end of the pregnancy, the uterus begins to have periodic contractions, or Braxton-Hicks contractions. These contractions, first described in 1872 by British gynecologist John Braxton Hicks, are often cited in references as being "painless, intermittent" contractions, but speak to many pregnant women and they will tell you these contractions can definitely be very uncomfortable.

The truth of the matter is that labor contractions and Braxton-Hicks contractions are both just contractions of the uterine muscle. The uterus is simply that, a muscle. Prior to pregnancy it weighs an average of about two ounces. At the end of pregnancy, just the muscles itself -- no baby, no amniotic fluid, no placenta, just muscle -- weighs on average about two pounds! Toward the end of pregnancy, maternal hormones, triggered by no one knows exactly what, cause the uterus to begin contracting periodically. These contractions may hurt, they may not. They may come at regular intervals, they may not. Often, they will just go away.

PROGRESSIVE CONTRACTIONS

The key to whether contractions could be true labor or not is this: are the contractions progressive? Now this may be a word you aren't familiar with when thinking about contractions, but it is a much better word than "regular". Braxton-Hicks contractions may often start out at regular intervals and then just disappear, but Braxton-Hicks contractions are almost never progressive.

So what do I mean by progressive? By that I mean that over time, even a couple hours, the contractions will gradually begin to last longer. They will gradually begin to come closer. They will gradually become more intense. To determine if they are progressive, it will be necessary to time contractions every now and then.

TIMING CONTRACTIONS

To time a contraction, begin timing at the beginning of the contraction. Time until the end of the contraction. This will give you the duration of the contraction. Then time from the beginning of one contraction to the beginning of another contraction. This is the frequency of the contractions. Now I realize that the phrase "how far apart are the contractions" is often used, and this would seem to indicate the time from the ending of one contraction to the beginning of the next would be used, but that is not how health care providers time them and you will want to use the same method that we use.

Once you have timed the contractions for a little bit, set the watch aside. Then come back to it a little later and time some more. Are the contractions closer? Are they lasting longer? You can also use a pain scale to rate the intensity of the contractions. Many places use a pain scale of 0 to 10. Zero would be totally comfortable, no pain at all. Ten would be the most terrible pain ever experienced by that person. By adding a pain scale, over time you can also track the increasing intensity of the contractions as well.

If you begin to see a pattern that the contractions are progressive over time, you can have a good idea that this might actually be labor. You want to be sure that you know when your health care provider wants to be contacted by you. Some want to hear from you when the contractions are at a particular interval and have been that way for a particular time frame, say 5-7 minutes apart for 1-2 hours. Sometimes they want you to just go to the birthing center or hospital when you feel like you need to and let the nurses call them. Be sure to talk with your Provider to find out exactly what he/she would like you to do if you think you are in labor.

RUPTURE OF MEMBRANES

If your membranes should rupture, or your "water breaks" of course, you need to contact your health care provider right away, regardless of the status of your contractions. By the way, if your water should break (I just like that term so much better than "rupture of membranes". It sounds gentler and like something that should just naturally happen.) instead of trying to stop the flow with a towel or a tiny sanitary pad, get one of your baby's diapers. Yes, that's right, a baby diaper. They are made to be highly absorbent, they have that nice hour-glass shape and they are lined with plastic. They are the perfect thing to wear to keep from getting the car, your pants and everything else in sight soaked with amniotic fluid!


BLOODY SHOW

Many times women are told that if they have "bloody show", a pink or red streaked mucousy discharge, that they should go to the hospital because that is a sign of labor. Bloody show is usually an indication that labor may occur in the next couple of weeks. As the pregnancy nears the end, the cervix has some natural thinning which can occur even without labor. As this thinning occurs, the capillaries in the cervix can rupture causing a tiny amount of pink-tinged or red-streaked discharge. Heavy bleeding like a period, however, is never normal and should be evaluated immediately by your health care provider.

THE MUCOUS PLUG

Sometimes women are very concerned about "loosing" their mucous plug. This small plug of mucus in the cervix helps to protect the baby during pregnancy by blocking the opening of the cervix. I can't think of anything else in Labor & Delivery which gives pregnant women more concern and is at the same time of such little consequence to obstetric health care providers.

The mucus plug sometimes comes out so gradually that a woman never even notices it. Sometimes it comes out more all at once, so it is seen when wiping as a very mucousy discharge, similar to as if one had blown their nose. Really, the whole situation is like a cold. Some people with a cold have to blow their nose all the time and there is alot of mucus to be dealt with. Others seem to have very little mucus issues with their cold. This is sort of the same thing.

If you loose your mucous plug, what does it mean? Nothing, or maybe that you might go into labor in a couple weeks. If you don't loose your mucous plug, what does it mean? Nothing, or that it probably came out so gradually that you never even noticed it. Is it important to your health care provider when you come in to the hospital? No, you will likely be asked a multitude of questions about yourself, but the status of your mucous plug will not change anything your health provider does or have any influence on any decision that is made about your care.


PURPOSEFUL VAGUENESS

Now you might have noticed in all this that I have been purposefully vague in saying that you might be in labor if this or that happens. That's because even if everyone of these "ifs" were to happen and it absolutely looked like you were in labor, you still could be having Braxton-Hicks contractions. Remember, the definition of labor is not having contractions, but having contractions that cause a readily measurable change in the cervix. And for every time I have been right guessing whether a woman was in labor or not, I have been wrong as many times, too.

It's a mysterious thing, birth. The Bible says, "The LORD hath called me from the womb; from the bowels of my mother hath he made mention of my name. " (Isaiah 49:1) There is a sacredness of birth, an awe that is present every time a baby is born, at least that's true for me. There are just things about it we don't know and for all the things we understand perfectly, there is so much that is still an incredible mystery.

I have seen over 2600 babies born and each time I see those sweet little toes and that precious face come into the light of day, I realize I have just witnessed a miracle...a beautiful, mysterious, marvelous miracle.

How Will I Know I'm In Labor?

This is a common question, particularly among first-time mothers. Unfortunately, our perception of the onset of labor has been skewed by popular television sitcoms and movies in which the pregnant woman has one horrific contraction, grips her abdomen and announces to everyone "This is it!"

BRAXTON-HICKS CONTRACTIONS

Determining labor in real life can often be much more difficult. One reason for this is the fact that toward the end of the pregnancy, the uterus begins to have periodic contractions, or Braxton-Hicks contractions. These contractions, first described in 1872 by British gynecologist John Braxton Hicks, are often cited in references as being "painless, intermittent" contractions, but speak to many pregnant women and they will tell you these contractions can definitely be very uncomfortable.

The truth of the matter is that labor contractions and Braxton-Hicks contractions are both just contractions of the uterine muscle. The uterus is simply that, a muscle. Prior to pregnancy it weighs an average of about two ounces. At the end of pregnancy, just the muscles itself -- no baby, no amniotic fluid, no placenta, just muscle -- weighs on average about two pounds! Toward the end of pregnancy, maternal hormones, triggered by no one knows exactly what, cause the uterus to begin contracting periodically. These contractions may hurt, they may not. They may come at regular intervals, they may not. Often, they will just go away.

PROGRESSIVE CONTRACTIONS

The key to whether contractions could be true labor or not is this: are the contractions progressive? Now this may be a word you aren't familiar with when thinking about contractions, but it is a much better word than "regular". Braxton-Hicks contractions may often start out at regular intervals and then just disappear, but Braxton-Hicks contractions are almost never progressive.

Image via Wikipedia

So what do I mean by progressive? By that I mean that over time, even a couple hours, the contractions will gradually begin to last longer. They will gradually begin to come closer. They will gradually become more intense. To determine if they are progressive, it will be necessary to time contractions every now and then.

TIMING CONTRACTIONS

To time a contraction, begin timing at the beginning of the contraction. Time until the end of the contraction. This will give you the duration of the contraction. The time from the beginning of one contraction to the beginning of another contraction is the frequency of the contractions. Now I realize that the phrase "how far apart are the contractions" is often used, and this would seem to indicate the time from the ending of one contraction to the beginning of the next, but that is not how we time them and you will want to use the same method that we use.

Once you have timed the contractions for a little bit, set the watch aside. Then come back to it a little later and time some more. Are the contractions closer? Are they lasting longer? You can also use a pain scale to rate the intensity of the contractions. Many places use a pain scale of 0 to 10. Zero would be totally comfortable, no pain at all. Ten would be the most terrible pain ever experienced by that person. By adding a pain scale, over time you can also track the intensity of the contractions over time.

If you begin to see a pattern that the contractions are progressive over time, you can have a good idea that this might actually be labor. You want to be sure that you know when your health care provider wants to be contacted by you. Some want to hear from you when the contractions are at a particular interval and have been that way for a particular time frame, say 5-7 minutes apart for 1-2 hours. Sometimes they want you to just go to the Birthing Center or hospital when you feel like you need to and let the nurses call them. Be sure to talk with your Provider to find out exactly what he/she would like you to do if you think you are in labor.

RUPTURE OF MEMBRANES

If your membranes should rupture, or your "water breaks" of course, you need to contact your health care provider right away, regardless of the status of your contractions. By the way, if your water should break (I just like that term so much better than "rupture of membranes". It sounds gentler and like something that should just naturally happen.) instead of trying to stop the flow with a towel or a tiny sanitary pad, get one of your baby's diapers. Yes, that's right, a baby diaper. They are made to be highly absorbent, they have that nice hour-glass shape and they are lined with plastic. They are the perfect thing to wear to keep from getting the car, your pants and everything else in sight soaked with amniotic fluid!

BLOODY SHOW

Many times women are told that if they have "bloody show", a pink or red streaked mucousy discharge, that they should go to the hospital because that is a sign of labor. Bloody show is usually an indication that labor may occur in the next couple of weeks. As the pregnancy nears the end, the cervix has some natural thinning which occurs even without labor. As the cervix thins, the capillaries in the cervix can rupture causing a tiny amount of pink-tinged or red-streaked discharge. Heavy bleeding like a period, however, is never normal and should be evaluated immediately by your health care provider.

THE MUCOUS PLUG

Sometimes women are very concerning about "loosing" their mucous plug. This small plug of mucus in the cervis helps to protect the baby during pregnancy by blocking the opening of the cervix. I can't think of anything else in Labor & Delivery which gives pregnant women more concern and is at the same time of such little consequence to obstetric health care providers.

The mucus plug sometimes comes out so gradually that a woman never even notices it. Sometimes it comes out more all at once, so it is seen when wiping as a very mucousy discharge, similar to as if one had blown their nose. Really, the whole situation is like a cold. Some people with a cold have to blow their nose all the time and there is alot of mucus to be dealt with. Others seem to have very little mucus issues with their cold. This is sort of the same thing.

If you loose your mucous plug, what does it mean? Nothing, or maybe that you might go into labor in a couple weeks. If you don't loose your mucous plug, what does it mean? Nothing, or that it probably came out so gradually that you never even noticed it. Is it important to me when you come in to the hospital? No, I will ask you a multitude of question about yourself , but personally, your mucous plug will not change anything I do or have any influence on any decision I have to make about your care.

PURPOSEFUL VAGUENESS

Now you might have noticed in all this that I have been purposefully vague in saying that you might be in labor if this or that happens. That's because even if everyone of these "ifs" were to happen and it absolutely looked like you were in labor, you still could be having Braxton-Hicks contractions. Remember, the definition of labor is not having contractions, but having contractions that cause a readily measurable change in the cervix. And for every time I have been right guessing whether a woman was in labor or not, I have been wrong as many times, too.

It's a mysterious thing, birth. The Bible says, "The LORD hath called me from the womb; from the bowels of my mother hath he made mention of my name. " (Isaiah 49:1) There is a sacredness of birth, an awe that is present every time a baby is born, at least that's true for me. I have seen over 2600 babies born and each time I see those sweet little toes and that precious face come into the light of day, I realize I have just witnessed a miracle...a beautiful, mysterious, marvelous miracle.