13 Apr Long Labors
The other night, my husband (Joey) and I were discussing our close friend’s labor. For the last few days things have been slowly progressing. However, mom and baby seem to be doing well, so there has not been any intervention given. Joey asked me why some labors take longer then others. That is certainly a question that is asked frequently. There is a general idea that for first time moms, an average labor is anywhere from 12-18 hours (although this can vary tremendously) and during this time the care provider is able to see a pattern of uterine contractions that result in progressive dilation and effacement of the cervix.
What is the definition of labor dystocia aka “long labor?”
Considering that “normal” labor shows a steady pattern of progress, a “long labor” or “labor dystocia” therefore would be the absence or stalling of cervical dilation and effacement.
What could cause labor dystocia?
There are several factors that could cause a prolonged labor.
Malposition of the fetus
As a doula, this is the first issue I consider when a labor has not taken on a steady pattern. If the labor pattern is all over the place (meaning the contractions could be 3 minutes apart then space out to 8 minutes) but the mother is showing signs of very painful contractions, I wonder if the baby is in an unoptimal fetal position. This could mean that the baby is entering the pelvis either asyncliticly or in the Occiput Posterior (OP) position (The baby’s occiput- back of the head- is facing the mothers back), which will not put adequate pressure on the cervix resulting in arrested dilation. Luckily, there are ways to resolve this issue which are discussed in the section below:
“How to handle a long labor”
Years ago, I attended what was to be the longest birth of my doula career- close to 40 hours. I was a relatively new doula at that the time and was still learning the subtleties of birth. I had applied all the pain management techniques that I knew, and eventually called in my mentor for advice. A year after the birth, the mother called me and asked if I would come over to discuss her birth. Within that year she had spent a lot of time processing her birth experience, and she explained that she was so paralyzed with the fear and responsibility of becoming a mother that she was literally holding her baby in to avoid passing through the threshold to motherhood. I thanked her for sharing her journey. This revelation enlightened and inspired the way I approach birth today. Now, I open a discussion with the mother prior to labor if she has any fears or issues she would like to discuss. I will also ask questions during labor like, “what was going through your head during the contraction?” to see if there is anything that the mother needs to get off her chest.
The mind/body connection can be very strong, and our emotions play a great deal in the way our body functions. Here is a short list (and by no means complete) of some emotional issues that may be preventing the mother from letting go and opening up during her labor:
-Someone present in the room is making the mother uncomfortable
-Unresolved issues lingering in the back of the mother’s mind
-Fear of pushing the baby out
-Fear of defecating, tearing while pushing
-Fear of what her partner may think of watching her in this vulnerable, primal state
Inadequate uterine contractions
Another cause of labor dystocia could be from inadequate uterine contractions caused by dehydration. It is interesting that dehydration can cause pre-term labor, but in the actual labor itself, dehydration can have a very negative result. In the book, Labor and Delviery Nursing by Michelle L Murray and Gayle M Huelsmann, they state “Hydration affects the duration of labor. A well-hydrated woman should have a shorter labor than a dehydrated woman. Dehydration is not just too little body fluids: it also includes an electrolyte deficiency. Dehydration is related to maternal fatigue, which may have an impact on her pain tolerance and ability to push her baby out. During labor, it is suspected that a dehydrated uterus will not contract well, and may even result in poor labor progress” (pg 35).
As discussed above, the emotional state one experiences during labor can have a physiological effect on uterine contractions. If a woman is feeling unsafe or anxious her body will go into the “fight or flight response.” When this happens, the body is shifted into the sympathetic nervous system and adrenaline is released into the blood stream. The presence of adrenaline will interfere with the productivity of oxytocin – the hormone responsible for contracting the uterus. A lack of oxytocin slows the contractions down, or even possibly stop them all together.
The position one is laboring in could also influence the strength and frequency of uterine contractions. According to the Lamaze Institute for Normal Birth Care Practice Papers, “When you walk or move around in labor, your uterus, a muscle, works more efficiently.” This can explain why many women feel find their labor rhythm more easily and effective when having the freedom to move about as oppose to lying in one position.
Cephalopelvic Disorder (CPD) refers the baby’s head being too large to fit through the pelvis. True CPD is rare (occurs in 1 out of 250 pregnancies) and can often be remedied by changing the position of the mother which can encourage a malpositioned baby to shift it’s incoming angle into the pelvis that allows for a more spacious fit and optimal birthing position or allowing more time for the baby’s head to mold. Also, if the baby is large and the pelvis is small, there are certain laboring positions, like reclining, that decrease the space in the pelvis, increasing the likelihood of a “bad fit”.
Sometimes CPD is caused by a small pelvis (this is not to be judged from the external dimensions of the pelvis- a small hipped woman could have a deceivingly roomy pelvis and visa versa), trauma to the pelvis, or malnutrition.
There is much evidence that the use of epidural anesthesia can weaken contractions, slowing down labor progress.
A very interesting article called, Pros and Cons of Epidural Analgesia During Labor: Recent Research, conducted a lengthy comparison of several studies about the risks versus the benefits of epidural usage and came to the conclusion:
In general, the studies/reviews analyzed indicate epidural analgesia as an effective means of pain relief during childbirth. The undisputed risks seem to be a longer labor, greater cost and higher chance of instrumented vaginal delivery, while the undisputed benefit found is effective pain relief.
If Labor is long, but would like to avoid medical intervention
Here are 3 questions to ask your care provider if your labor is starting to present itself as “long” but you would like to avoid medical intervention (These questions could be used for any situation where the mother is feeling the crunch time of a schedule).
1. Is mother ok?
2. Is baby ok?
3. Can we have more time?
If either of the first two answers is no- then medical intervention is best. Otherwise, the mother can continue to find pain management techniques that support her as she allows her body to open.
How to handle a long labor
If your labor is going longer than anticipated, it is essential to find coping strategies and support. Here are some ideas of how to move through the long haul.
Keep well hydrated and nourished
As discussed in the section above, dehydration can have a very negative affect on labor, so it is important to keep the body well hydrated and the electrolyte levels up. Noshing on light food will also help balance blood sugar and help the laboring mother with her stamina level.
(Here is the link to a past blog Eating During Labor. There are some suggestions of “labor friendly” snacks.)
Find pain management techniques that help
Again, I am referring back to a past blog, “7 Tricks of the Trade”
I want to take a moment to highlight a few of the 7 Tricks I refer to in the blog.
Change Positions Often!!
Changing position every 20-30 minutes may help reduce the woman’s pain significantly as well as help resolve labor dystocia. There are several common positions for women to use during labor; side lying, semi seated positions, upright seated, standing and leaning forward, kneeling and leaning forward, all fours (hands and knees), child’s pose, cat/cow, body circles, slow dancing, rocking on a birth ball, asymmetrical lunge in the upright position and squatting.
How change of position helps? Changing positions often gives the woman a chance to experiment and discover what positions seem comfortable and effective, but also allows the baby to move around in the pelvis, encouraging fetal descent and moving into an ideal birthing position. This is especially important in arrested labors where there is malposition (deflexed head, OP or the head slightly asynclitic) presentation of the baby or there is CPD suspected. For those experiencing “back labor” from a baby in the OP position, it is best to find laboring positions where the mother’s belly is facing downward, like cat/cow, all fours, and child’s pose. This will take the pressure off the back, alleviating some of the pain, but also allow gravity to rotate the baby towards the mother’s front into the anterior position.
Also, if the labor is slowing down, changing positions may help the mom get back into a rhythm that is comforting and calming while shifting the baby into the most advantageous position for passage through the pelvis. Once the baby is in an ideal fetal position, with adequate contractions, the baby’s head applies pressure to the cervix and this is what causes dilation.
Shower or Bath
The feeling of warm water on your belly and back during labor can be a life saver! You may find that the water helps alleviate the pain and distracts you from such intense sensation. This would be especially good if you are having back labor. If the laboring woman is too tired to stand in the shower, place a stool or the birth ball in the shower or tub. Again, it is important for the partner or doula to monitor the temperature of the water and make sure it is not too hot. Because the bath or shower is so relaxing, I typically do not use this method of pain relief until the mother appears to be in active labor because it can slow labor down. However, if the early stage of labor is rather drawn out and the mother needs to relax, a bath or shower could be the perfect solution.
How the shower or bath helps? The warmth of the water on the mother’s body can be mentally and physically relaxing. The water pressure can help alleviate muscle tension and back pain. The effects of immersion in water may be summarized as the following: bathing provides buoyancy and warmth, both of which often bring immediate pain relief, relaxation, lowering of catecholamines, increases oxytocin, and more rapid active labor progress. (The Labor Progress Handbook by Penny Simkins and Ruth Ancheta)
The Birth Ball is a large physiotherapy ball- typically 65 cm is appropriate for the average size woman. It can be used prior to labor to help alleviate back pain and promote an ideal fetal position. Many women are surprised by my advice to bring it to the hospital with them.
How the Birth Ball helps? During labor, it is particularly useful to sit on the ball which promotes a natural swaying and rocking of the pelvis. This motion can encourage fetal descent and help alleviate lower back tension, as well as provide gentle support for the perineum. As an alternative to being on all fours, lean over the birth ball. This position encourages an anterior position of the baby and takes pressure off the mother’s back. You can also place the ball on the bed, table or couch and lean over it while standing and swaying your hips. This helps the laboring mother to take advantage of gravity and again encourages fetal descent.
I have met very few laboring women that do not appreciate a reassuring and relaxing massage. You do not need to be a professional massage therapist to give someone you love a little helpful massage. All you have to do is move into the massage with the intention of helping to release tight muscles and alleviate pain and most importantly, watch for the woman’s response. She may not verbally tell you if you are doing it right, so watch for her facial expressions and sounds.
How massage helps? Massage has been credited with helping to reduce pain, anxiety and fear by increasing endorphin levels in the body. Several of the common areas that the laboring mom may enjoy to have massaged are the lower back, neck, shoulders, hands and feet. Also keep in mind, the more relaxed you are, the less painful the contraction will seem. The more stressed you are, the more painful the contractions will seem. Final tip- be prepared with lotions or oils that smell good to you. Just the smell of the products may help relax you.
Continue to get the support of your entourage
It is so important to have the full support from those attending your birth. Even when a long labor may feel discouraging and tiring to your entourage, they should never show this to the laboring mother. This is one reason I think it is so important to have more than one person as a support team. If the labor is long, the support people can trade off in giving undivided attention, encouragement, hands-on support (like counterpressure or massage), inquire if there is anything emotional that is distracting and suggestions for pain management techniques to the laboring mother.
This is a prime example of “easier said than done!” But if everyone involved can have patience and allow the mother time for her body to open and time for the baby to get into an optimal birthing position, less stress and pressure will be felt and the labor may progress more quickly.
For more specific laboring positions and in depth explanation of labor dystocia, I highly recommend reading The Labor Progress Handbook by Penny Simkins. It is a must have for any professional in the childbirthing community!