If you read a book, or attended a class, or went to any prenatal appointments, or listened to other mothers talk about their birth experiences, you probably heard, if only implicitly, as many definitions of the start of labor as you read books, attended classes, went to appointments and listened to stories. While everyone seems to "know it when they see it", in practice, there are insuperable differences of opinion regarding when labor begins. I would like to tell you that you will know when you are in labor, but that statement does not necessarily help you. You may know when you are in labor, and your health care provider may not agree.
Let's start instead by saying that you will notice that things are happening, and that you can compare each new event in your pregnancy to what has come before. When you are in new territory, and it is rhythmic and increasingly difficult to focus your attention on anything but what is happening to your body, you might contact your birth attendant by telephone. Try to be as specific as possible in communicating what is happening. If you feel very unsafe where you are, now is a good time to go somewhere you feel safe (home, the birthing center, the hospital -- whatever is right for you). If you plan on giving birth in a hospital, but your birth attendant on the phone (or otherwise) suggests you would be better off laboring where you are or at home, your birth attendant likely has your best interests in mind (remember, that's why you picked them). First-time labors especially tend to take hours or days to develop; if you do this in a hospital, the people who work in the hospital are likely to feel impatient and try to speed things along.
The Cascade is a descriptive name for a process that tends to happen in hospitals, including birthing centers physically attached to hospitals and, to a lesser degree, to birthing centers near hospitals attended by M.D.s and CNMs. Traditionally trained medical professionals have a set of expectations regarding "normal" labor and delivery. These expectations include shoving an two fingers, a hand, or even more of the arm up the vagina of a laboring woman to feel up her cervix, ideally (for the purposes of the professional) during a contraction, to learn what is happening in her body. These exams can be physically very painful, much more painful than labor necessarily is without examinations. The information collected includes:
In order for the mother to give birth to her baby, her uterus contracts to push the baby into the birth canal. This process can take days or even weeks. There is now some empty space left in the uterus above the baby, and contractions are less effective at pushing the baby. Contractions slow down for a while, while the uterus gets small, to fit better around the baby. The mother's body will also experience pain that is stronger in some positions and less strong in others, helping her find a position that will enable the baby to squirm its way into a good orientation for entering the world. The compression on the baby's back encourages the baby to wiggle in this way. The compression also causes the baby to produce stress hormones, that prepare its lungs to breathe. The compression will also tend to force the amniotic fluid the baby has been breathing out of its lungs, so it is ready to make use of air after it has been born.
If the uterus is allowed time to contract around the baby, and the baby is allowed time to find its best position for entering the world, mother and baby benefit. The mother's biggest risk after the baby is born is uncontrolled bleeding, in part as a result of a uterus that has not shrunk quickly enough. If the baby is rushed, it will often enter the world in an awkward or dangerous orientation, or in a way that causes it to get stuck. If the entire process is rushed along too quickly, the baby's lungs may not be quite ready to breathe.
Once the uterus has contracted around the baby, contractions will generally start again. It is more important now that the cervix, the opening at the end of the birth canal, be open. However, if it is not completely open, and the mother feels an urge to push, her pushing may help the cervix finish opening completely. As the baby's head pushes through and begins to crown (pushing out through the vulva), the mother will feel stretching around the baby's head that may feel like burning. It is particularly important that she pay attention to this feedback. If pushing more slowly at this point reduces the burning feeling, she is almost certainly successfully avoiding a tear. A partner might massage around the vagina and rectum (perineum) to encourage relaxation. Once the baby's head has come out, and the mother can reach down and feel the baby herself, there will probably be another pause in contractions while the baby wiggles once more, turning slightly to get its shoulders lined up to best come through. Once the baby has lined up, another few pushes and the baby will likely be out. Then another brief pause, while the mother holds her baby to her breast, keeping the baby warm, providing a familiar rhythm of breathing and heart rate and massaging the waxy coating on the baby's skin (vernix) in, and contractions will likely push the placenta right out. A delay before cutting the cord, and keeping the placenta approximately level with the baby, will increase the amount of blood that goes into the baby and decrease the amount left in the cord and placenta. From when contractions restarted to the birth of the placenta can take many hours.
Years of watching bad sitcoms may result in the question, "When does the water usually break?" The waters can break at any point in this process, including after the baby has entered the world, at which point someone might need to open the amniotic sack.
You won't find this process described in precisely this way in very many books about childbirth. Most English-language descriptions emphasize measurements obtained by ramming fingers, a hand or even more of an arm up in mom while she's at her busiest. Quite a lot of childbirth techniques rely on other people loudly and persistently telling her what to do so she can't pay attention to what her body is telling her what to do. To the extent that pictures are supplied, they'll show a woman flat on her back or semi-sitting -- not a woman moving all over the room with the assistance of one or more other people and some amount of assisting gear (tubs, slings, chairs, birth balls, etc.). She might be wearing a blood pressure cuff, be attached to an IV, a computer monitor and so forth. What happens to the process I describe when it meets what actually happens in hospitals, is called the cascade.
The first step in the cascade is to make the woman nervous, to cause her to feel stress different from that of childbirth. This can be accomplished in a number of ways: separating her from her partner, shaving or clipping her pubis, giving her an enema, taking her clothes and giving her a gown, putting in an IV, telling her she should not be eating or drinking, strapping a belt on her for external electronic fetal monitoring (EFM) or sticking a hook in her, breaking her waters, and shoving a probe up her cervix (again, more painful than it sounds, by all accounts) that screws into the baby's head (really) for internal EFM. Random strangers may come and go, without introducing themselves, doing some of the above things to her without asking her permission and without attending to her strenuous efforts to decline some of the above procedures.
Stress hormones inhibit prostaglandin production. Natural prostaglandins in the body are what make the process I describe happen normally (starting and determining the duration and intensity of contractions, opening the cervix, etc.). Stress mom out and her contractions will slow, become disorganized or stop. Stress mom out and her cervix will cease to dilate and may reclose.
The next step in the cascade is to notice that something here is not right. The process has ground to a halt and must be restarted. After groping mom's cervix, numbers will be written down and a decision will be made. If the cervix is still closed, and mom's waters have not yet broken or been broken, she will be sent back home, or ignored entirely for a period of time. She may or may not be allowed to eat or drink. She may or may not be allowed or able to walk around. If the cervix is still closed, but mom's waters have broken or been broken, there will be talk starting now about the next stage of the cascade (labor augmentation) and the end stage of the cascade (C-section). Notice how one of the least technological interventions (breaking the waters, aka, artificial rupture of membranes, AROM) immediately spawns very technological interventions.
A possible intervention is to use misoprostol (cytotec) or prostaglandin gel to open the cervix (ripen). Attempts to augment labor with oxytocin (Pitocin) before the cervix has opened tend to be drastically unsuccessful and enormously painful. Again with the arm up the vagina.
Very recent research into other effects of oxytocin suggest that injecting someone with oxytocin makes them much more trusting, cooperative and compliant. A mother who wants to play an active part in decision making in her childbirth must realize that even the amounts produced within her naturally make her susceptible to social pressures from those around her; the unphysiologic amounts delivered via IV can only have a stronger effect. This makes it all the more important that this important event in her life take place surrounded by people she trusts -- not just trusts because her hormones demand she trust them, but because she has decided they are trustworthy -- and who understand and respect her values and will help her have the birth she wants to have.
Once the cervix has opened completely, if contractions have stopped (even if as part of the natural process I describe above), slowed or are viewed as inadequately progressing, oxytocin or misoprostol may be used to make the uterus contract harder, longer and with less time in between (contractions often described as having two peaks to them). The baby has less time to recover its heart rate and equilibrium between contractions, which are monitored closely, and then used as a reason for taking another step or two along the cascade.
If the baby has moved somewhat down, the cervix is open and the monitor worries someone with a medical degree, another possible step is to slice open (episiotomy) the muscle below the vagina (perineum). This allows hands and implements such as forceps or vacuum extractors (suction cups) to be inserted into the mother and attached to the baby. Traction is then applied to the baby, which is to say, they pull on the baby (usually the baby's head). The baby may have stopped and tried to wiggle into a better orientation. The implements are often used to forcibly reposition the baby, and then to pull it out. If any slight error is made in understanding the baby's position and it is still stuck, the effect of pulling will be to damage the baby (usually its head, but often its shoulders and potentially all of the nerves on one side) and injure the mother. The baby is, after all, connected to the mother. Pulling on a stuck baby pulls on mom's uterus, loosening its connections internally in the body and increasing the likelihood of future problems (like uterine prolapse). All of this activity tends to result in the original cut (episiotomy) extending, sometimes into the rectum, which will be difficult to repair and impossible to keep clean. Infections that result from serious tears (almost always the result of episiotomies that extended) are a major source of maternal morbidity (mom getting an infection) and mortality (dying).
When forceps and vacuum extraction are not performed, but cervical examinations are telling a story that medical professionals don't like to hear, another option is the C-section. One reason given for a C-section is that the waters have been broken and infection will set in after 24 hours. This is not true. As long as no more than one cervical examination is done, infection is not particularly likely. It is not unsafe to send such a woman home to rest for one, two, three days or even longer in some circumstances. Another reason given for a C-section is that the fetus is in distress, here, just look at these tracings. Increasing C-sections have not improved outcomes. The same tracing will generally be read differently by different professionals and even the same professional on different days. Another reason is cephalo-pelvic disproportion (CPD or, head is too big for your hips, lady). Lying flat on the back, or semi-sitting, compresses the pelvis by 30%, and put the tailbone in a particularly inconvenient place from the baby's perspective trying to wiggle its way out. CPD is diagnosed by a woman trying to have a baby, and not succeeding. Rarely, in these circumstances, is she allowed, much less encouraged, to increase her P (pelvis) by changing her position. Standing and squatting both improve the size of the pelvis and assist in labor by adding gravity. Hands-and-knees, while gravity neutral, does improve the size of the pelvis. Many professionals will not permit the woman to attempt birth in these positions, because they're not sure what to do themselves, and they consider their work more important than mom's work.
C-sections are performed for many other reasons. If the baby is not head down (vertex), C-section is almost always suggested, even though this has not improved outcomes for these babies. If the mother has herpes, C-section may be suggested (even though maternal infection is virtually never transmitted to the infant, even in the presence of active lesions).
Giving birth is profoundly moving, an incredible experience, a miracle. The result is almost always a healthy baby and a healthy mother (or a baby and mother that will recover in days, weeks or months). It would be very difficult to make childbirth so negative an experience it would counteract those amazing outcomes. Current obstetrical management in the US has not yet done that. It is quite easy to demonstrate that at various points in the past, things were worse. However, they are not particularly rational or evidence-based, and they create unnecessary stress and pain for many women and their babies. Why?
Birth as an American Rite of Passage by Robbie Davis-Floyd supplies a wonderful analysis in answer to this question based largely on anthropology. Henci Goer's books document in excruciating detail the irrationality of current practice. I think the simplest, not entirely false answer is that this interventionist approach to managing birth makes the participants feel better.
Birth attendants who attend a lot of births will inevitably see that pregnancy and childbirth is a difficult process that can go badly wrong. Babies can be born who cannot live. Mothers can have hearts attacks, seizures, infections or respiratory problems of their own. It is difficult to accept that this process that so often works so beautifully on its own, sometimes goes horribly awry on its own, and probably impossible for a medical professional to do nothing in the wake of that awareness. In an ideal world, medical professionals would be highly motivated to do the studies necessary to find the best thing to do in all possible circumstances. Unfortunately, in practice, all they really need is to do something, anything, to resolve the terrible anxiety that comes from doing nothing. Unluckily for mothers, birth attendants who do nothing but support the mother in her efforts are doing exactly the right thing almost every time. As long as our birth attendants are human, some of them, some of the time, will succumb to unneeded, harmful intervention because their task is so very difficult to do with equanimity and compassion.
You have a lot of choices, many of which are constrained by what kind of pain medication you want access to, your choice of birth attendant, and your relationship with that person (or, more likely, those people). One way around this particular piece of pain is to just schedule the C-section right from the start and dodge the whole, evil path. Unfortunately for you, the data is currently suggesting that scheduling a C-section before labor begins is not so good. Any error in dates risks a premature baby caused by the C-section. Also, babies that went through some of the labor process tend to do a lot better than babies that didn't.
Avoiding obstetricians slows the process down, which is why I emphasize trying to find a family practice MD who attends births. Midwives, whether at home or in a birthing center, tend not to get trapped in the cascade; they have a lot of less dangerous things they can do when they are feeling anxious, like making you a cup of tea or rubbing your back. But most women probably would rather have a specialist and give birth in the hospital. Those two factors help them overcome a lot of their fears, and access to epidurals and other forms of pain medication are important to many women as well. So my other piece of advice is very simple. Labor at home, or in another, non-hospital setting, as long as you can before transferring to the hospital. The clock starts for the professionals when you walk in the door, not when you tell them you went into labor. Given that the first part of the process can drag on for days or weeks, it seems straightforward to do as much of that as possible where it won't increase the anxiety of busy people who have horrific memories of Things Going Wrong.
The first bit literally can go on for weeks. People will tend to call a lot of that false, early, preterm labor, Braxton-Hicks, practice contractions, etc. You can tell what is happening to you; you can't predict what will happen next. Since "real" labor is defined by pattern, predictions are difficult. That said, in general first time mothers take a lot longer about things than mothers who have done this before. Precipitous labor is defined as less than three hours. Prolonged is defined as more than 20. But these numbers basically start from when you check in with a professional, usually at a hospital, and only you know how long things went on beforehand. While I strongly recommend delaying going to a hospital (if you have chosen a hospital), there is a slight risk that once you get to the second bit, where you feel a strong or overwhelming urge to push, things will develop so quickly you will not be able to transfer as planned. If your hospital is a long ways from your home, there is bad traffic between you and the hospital, or you must await transportation that is slow in arriving, this likelihood is increased. First, realize that if things are going quickly, it's usually because things are going well. Second, if you think you will give birth before arriving, you might want to stay put and make phone calls instead, and have people (paramedics, your midwife, etc.) come to you. If you are having your second baby, and your first baby came in less than 8 or so hours, your likely-to-be-faster second baby may surprise you. In the event you give birth to a baby on your own, or without the assistance of a health care professional, you can do a number of things to improve the odds that you and your baby will be just fine.
As noted in an earlier chapter, there are wide variations in normal length of pregnancy. Knowing the date of conception is uncertain as well. The combination means that only a small percentage of babies are born on their due date. Natural labor in women is understood to be started by hormone changes in the baby, communicated through the placenta and, in turn, the mother's hormones. As one's due date arrives and recedes into the past, it is easy to become uncomfortable and impatient. There are some things that can be done to try to hurry things along. At some point, you may think you are in labor, be told that you are not and be offered the option of induction. Or, alternately, you and your attendant think you are in labor, but it stops, and the option of attempting to restart is offered. This is a complicated area with a lot of tradeoffs.
Because the ripening of the cervix (softening and opening up) is mediated by prostaglandins, having sex may speed this part of the process. Stimulating the nipples seems to help. Prostaglandins were initially discovered in semen. They are produced in a woman when she has an orgasm along with uterine contractions. As long as the bag of waters has not broken, there is no unusual risk in having sex at this time. If sex results in contact with the cervix, this may also tend to start labor. Doctors and other health care practitioners can get a similar effect by placing prostaglandins in gel form directly on your cervix.
A wide variety of herbs, drugs and foods may increase uterine contractions. Health care practitioners of various kinds might give you some of these in order to start labor. The usual delivery systems are orally (eating or drinking), as an enema, or by injection, but some are put on the cervix as with the prostaglandin gel. Certain fatty acids are worth considering.
No intervention is risk free. Some very effective methods of inducing labor (misoprostol, or cytotec) are, in addition to being cheap, potentially very dangerous.
Breaking the bag of waters is sometimes used to start labor, but as noted earlier, may only begin the cascade. Stripping the membranes in a digital manipulation of the cervix intended to get the cervix to ripen completely. In addition to being uncomfortable to painful, as with any digital intrusion, includes a risk of introduced infection.
All the above and many more can be found discussed in some detail in online forums where birth attendants hang out.
The indicator that birth attendants find most useful is the pelvic exam, digitally examining the condition of the cervix. If you are sufficiently agile, and your fingers are long enough, you could certainly monitor your cervix yourself. Our Bodies, Ourselves, published by the Boston Women's Health Book Collective, includes detailed descriptions and pictures to help you understand and interpret what you feel and see, and includes both how to digitally examine your cervix, and how to visually examine your cervix. If you have a partner, they could certainly help you do this, or do this for you. It is possible for an exam to move bacteria from the lower vagina up higher, and if the bag of waters has already broken, you risk infecting your uterus and/or baby, even if you have perfectly sterile technique including gloves. Without gloves, you also risk introducing bacteria from your hand (or your partners). That said, if you are having unprotected sex with each other, and the bag of waters has not broken, it is unlikely you will introduce anything that you haven't already been exposed to, and the germs you have on and around you in your home are ones you are already adapted to.
As noted above, in order for the baby to be born vaginally, the end of the cervix must soften, and it must open up. These two processes may overlap. Health care professionals assume that a cervix is completely opened up when the opening is about 10 cm across. Softening (or effacement) can take weeks. The first third to a half of opening up often takes days, especially in a first time mom. The second half and last third of opening up can go much more quickly, but generally takes many hours, especially in first time moms, and this is often experienced as pain. Research suggests that administering drugs to the mom before the cervix is half way open can stop or slow the process. Because mom's participation in pushing the baby out once the cervix is fully opened is so important, most professionals are reluctant to administer drugs after the cervix has opened fully (or is almost fully opened). Rather than relying purely on intensity and timing of contractions, one could use the information gathered through examining the cervix to delay going to the hospital until at least 5 cm dilated, and thus reduce the risk that the people helping you with your pregnancy become concerned it is taking too long and become anxious to speed things along. Also, if you knew your cervix was not soft at all, and decided to accept an induction, you would know to insist on ripening (softening and effacing) the cervix successfully before using agents that primarily stimulate uterine contractions.
Talking to your health care provider and understanding the status of your cervix can help you to decide which interventions to accept (and in which order), to minimize risks and maximize the likelihood of the intervention doing what it is supposed to do. I highly recommend Guide to Effective Care in Pregnancy and Childbirth for information to help you understand what you are being told and to make informed decisions based on the best current research.
Copyright 2005 by Rebecca Allen
Created May 20, 2005 Updated March 8, 2006