January 10, 2008

Whose Schedule Are We On Anyway?!

About a year ago I was attending my friend Valerie’s birth. She labored well, and after a number of hours it was time to push her baby out. When she started to push, her contractions were spaced out to about 8 minutes apart. Most women’s contractions do space out once the cervix is fully dilated and the second phase of labor starts, but 8 minutes is a bit longer then the average (4-5 minutes).

Relatively early in Valerie’s pushing experience, we were informed that the hospital’s policy is to allow the woman to push for a maximum of 3 hours. If the baby is not out at that point, she will give birth by cesarean section. I asked the nurse if there was any room to negotiate that time line, given that Valerie was getting only half the chances to push since her contractions were so far apart. The nurse seemed baffled and responded that we would wait and see. Luckily, Valerie pushed her beautiful baby out right before her ‘deadline’ for a vaginal birth.

Because situations like Valerie’s are not uncommon, I have become fanatical about teaching “The 3 Questions”: Is mom ok? Is baby ok? Can we have more time?

Some of the main issues you may encounter involving a timetable are: How far past the mother’s due date is allowed before induction? When should the mother start to push her baby out? How long can the mother push? How long can the mother labor?

How far past the mother’s due date is allowed before induction?
Six Care Practices that Support Normal Birth that labor begins on its own. There are, of course, medical exceptions to this rule – which does not include, by the way, an estimation of a large baby, unless the mother has gestational diabetes. Generally, it is believed that labor should not be started artificially. Researchers now believe that when a baby is ready for life outside his mother’s uterus, his body releases a tiny amount of a substance, which signals the mother’s hormones, which begins labor.

When should the mother start to push her baby out?
It is not uncommon for a woman to reach full dilation before she has the urge to push. There is no harm in waiting for her to have the urge to push. If she starts pushing before she is ready, not only will she exhaust herself for no reason, but she will start the clock on the time line alloted for the second stage of labor. The mother might be wasting an hour with ineffective pushing while she could be resting and naturally allowing her contractions to continue to help move her baby further down the birth canal. One good sign that a woman is really ready to push is that it feels better to push through the contraction than to simply breathe through it.

With women who are not using pain medication, the urge to push is very apparent. However, those women who opt for an epidural will not get the same hormonal signal telling them to push. So it is a good idea to turn the pain medication down so that she can listen to her body, follow the urge to push, and push more effectively.

How long can the mother push? Some hospitals have a preset amount of time alloted for pushing, as mentioned in the earlier situation with Valerie. However, there is no evidence supporting the use of an arbitrary time restriction if there are signs of progress and neither mother nor baby are showing signs of distress. “The time taken to complete the second stage will vary considerably between mothers; clearly it should not be allowed to continue for many hours. However, in the presence of regular contractions, good maternal and fetal condition and progressive descent, considerable flexibility in duration should be allowed.” (Myles Textbook for Midwives, 13th Ed. 1999 p.452)


How long can the mother labor?
Each caregiver may have his or her own time limit in mind for which they are willing to allow the mother to labor before declaring a cesarean necessary. Often if a woman does not progress within this alloted time, she is labeled as ‘failing to progress’. The danger is that not every labor follows the same equation. There are theories that labor should progress on average a centimeter an hour, but that may not be the case with all mothers. In about 50% of all natural labors (labors that have not been altered by medications to speed them up or slow them down), dilation does not follow a straight line but rather a gentle slope with a plateau, then a sudden cliff at the end. Even though dilation is not increasing during this plateau, the labor is still progressing. It is important to remember that the body is doing more work than just dilating a cervix.

There can be many reasons that labor is slow. If I am attending a birth that is slow, the first thing I consider is the baby’s position. Is the baby in a posterior position? I also check in with the mother to see if she is experiencing fear or anxiety. These emotions can keep the labor at bay. I also try to determine whether or not she is well-hydrated. However I never want to put pressure on the mother, making her think there is something wrong with how her body is working.

Should you be experiencing a slower labor, don’t panic. It might just be the way your body is working. Maybe your body needs time to get the right hormonal levels. Maybe your body needs time to allow your baby to move into the optimal fetal position. But if mom is ok and baby is ok, then whose schedule are we on anyway?

I truly believe in the intelligence of our bodies. As Midwife Ina May Gaskin said, “Our bodies must work pretty well, or there wouldn’t be so many humans on the planet.” With that in mind, allow your body and your baby the time and space needed to work through the journey of labor and birth on your own schedule.

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