Common Interventions During Labor and Delivery
You may be planning a natural birth, but there are times when your healthcare provider must intervene for health and safety reasons. In fact, 20 percent of deliveries are nudged along with Pitocin, more than 35 percent involve episiotomies, up to 15 percent enlist forceps or a vacuum, and more than 25 percent end as cesareans.
When a medical intervention is suggested or presented as routine procedure, ask about the benefits, risks, alternatives, and whether you can do the procedure later – or not at all. Research shows that many times interventions are done more for convenience sake than for medical reasons. Most important, trust your intuition. Everyone, including you, should stop and think before an intervention is suggested.
While health concerns often dictate what's ultimately done, briefing your provider on how you feel about each intervention could offer clarity in gray areas. "If I know a mom wants to avoid a C-section, I may be willing to give a slow labor more time if the baby's not in danger," says Bruce Flamm, M.D., professor of obstetrics and gynecology at the University of California, Irvine, and spokesperson for the American College of Obstetricians and Gynecologists (ACOG). "The key is to express your wishes in advance because it can be hard for some moms to think clearly in the midst of labor."
Here’s what you need to know about common birth interventions: electronic fetal monitoring, induction, directed pushing/ breath holding, episiotomy, forceps and vacuum, and Caesarean birth.
Electronic Fetal Monitoring
What is electronic fetal monitoring? Electronic fetal monitoring (EFM) is used to evaluate uterine contractions and the baby’s response to them. There are three types of monitors. External monitors have two belts that use ultrasound and a pressure transducer. Telemetry units allow the woman more movement, so she’s not “tethered” close to the machine. If there is some reason that the above are not taking accurate measurements, internal monitors can also be used.
Why use electronic fetal monitoring? For a long time, listening to a baby’s heartbeat has been used to assess how the baby is tolerating labor. Low-risk women can be monitored intermittently, while high- risk women may be monitored nonstop. Continuous monitoring has not improved outcomes for healthy women having normal labors; instead, it has proven to increase the rate of cesarean. And it has affected women’s ability to move and change positions as needed. There are times when continuous monitoring is necessary in low-risk women, for example, if your labor is induced or augmented with Pitocin, or if you have an epidural. If your baby’s heart rate changes, or you or your baby have a health problem, you also may be monitored continuously.
Lower your risk: The American College of Obstetricians and Gynecologists (ACOG) supports periodic monitoring (once every 30 minutes in active labor) via EFM or auscultation, which is “listening” to what’s going on with the baby and the contractions using ultrasound. If that’s not an option in your hospital or birth center, talk with your nurse about being upright (such as in a rocking chair or on a birth ball) when being monitored, as opposed to laboring in bed. Or, ask for a mobile monitoring unit so that you may continue to walk, go to the bathroom, stretch, or slow dance. Try not to labor in bed for long periods. Don’t be distracted by the monitor – turn it away and lower the sound. Remind your support team to focus on you, not on the machine.
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What is induction? An artificial way to start labor using one of the following induction methods:
- Membrane stripping or sweeping via your health-care provider’s finger to separate your cervix from the tissue around your baby’s head.
- Rupture of membranes using a sterile hooked instrument.
- Cervical ripening with the insertion of either a prostaglandin gel or a balloon-like catheter.
- Pitocin, a synthetic hormone given through an IV drip in steadily increasing amounts to stimulate contractions.
In addition, some non-medical induction methods may be suggested, including acupuncture, homeopathy and/or herbs, sexual intercourse, and nipple stimulation. Discuss the pros and cons with your health-care provider. If you do try one of the above, keep him or her updated on your progress.
Why should you be induced? ACOG recognizes various medical reasons for inducing labor. For example, if the pregnancy lingers two weeks or more past the due date, there’s a greater risk of uterine infection in the mother.
However, the number of inductions in the United States is on the rise, due to a recent trend of inducing for non-medical reasons. These include the mother’s desire to plan the baby’s birth date, to minimize end-of-pregnancy discomfort, or to have a favorite health-care provider attend the birth. In addition, many women are induced because their health-care provider suspects the baby is large. According to ACOG, this is not a medical reason for induction. Studies show that the birth of a big baby is not affected by inducing labor versus letting labor begin on its own.
Lower your risk: Unless there is a clear medical reason for induction, it is far less complicated and far more healthy for you and your baby to let labor start on its own. Going into labor naturally is the best way to know that your baby is ready to be born and your body is ready for labor. If a medical concern does arise, spend as much time as possible with your health-care provider weighing the benefits and risks of each labor-induction method.
Directed Pushing - Breath Holding
What is directed pushing? Women are instructed to take a deep breath in and hold it for 10 counts, then push throughout the contraction – regardless of her natural urge to do so. Often, women are put in a semi-recumbent position, with legs up and chin tucked in a C-position.
Why use directed pushing? Directed pushing during childbirth became the standard half a century ago when women were heavily medicated during labor and birth. It’s still a common practice in labor rooms, but evidence shows that this technique should be avoided. Instead, women should be encouraged to follow their bodies, pushing only when they feel an urge.
Lower your risk: Ask your labor support team to follow your lead when it comes to pushing. Change positions often during this stage. Remember, there is often a “rest and be thankful” stage between urges. Try moaning or exhaling while you push. Ninety percent of the work is done by your uterus. You can focus on relaxing your perineum and pushing with your body cues. Visualize your baby rotating and descending.
If you have an epidural, remember that your pushing can be impeded by the numbness. Talk with your support team about the practice of “laboring down.” This means allowing the uterus to move the baby down without your active pushing, until the baby is low enough in the pelvis and triggers the receptors that will give you the urge to push. Patiently allowing time for the baby to descend naturally reduces the chance of requiring an instrument delivery or a cesarean
What is an episiotomy? A surgical cut to the perineum and the muscle beneath it, between the vagina and the anus, during the pushing stage.
Why get an episiotomy? If there is fetal distress, an episiotomy may shorten the pushing stage by 5 to 15 minutes so the baby can be born faster. It is often required if the baby needs to be assisted, rotated with forceps or a vacuum extractor, or if her shoulders aren’t able to rotate and pass through the pelvis. Episiotomy should not be done routinely; it is largely unnecessary and carries risks to the mother, such as pain, infection, and blood loss.
Lower your risk: Recent studies have shown that the routine use of episiotomy does not benefit the mother or newborn. Also, not only does it increase postpartum pain but it weakens the pelvic floor, contributing to long-term problems. Make it known before labor begins that you’d like to avoid having an episiotomy unless absolutely necessary.
During late pregnancy, continue Kegel exercises to strengthen and elasticize your pelvic floor. This will decrease your need for an episiotomy and lessen the chance of tearing naturally. Choose labor positions, like squatting, that help speed the process. Try not to hold your breath for extended periods. And follow your body’s cues, pushing when you feel the urge. Warm compresses or oil on your perineum may help ease pain.
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Forceps and Vacuum
What is forceps and vacuum delivery? A procedure in which a doctor uses forceps (a tong-like steel instrument) or a vacuum (a suction cup) to gently pull the baby out by the head during a contraction. Between the two, doctors tend to opt for the technique they're most comfortable with and best matches the situation – for example, forceps better rotate a baby or fit a preemie's head. The recent trend, though, is toward using vacuums, which are easier to maneuver and result in fewer injuries. A specially trained nurse-midwife may use a vacuum, but only doctors work with forceps.
Why is forceps and vacuum delivery done? "The baby isn't descending, or is having breathing difficulties and should be delivered quickly," says ACOG spokesperson Iffath Hoskins, M.D., chair of the department of obstetrics and gynecology at Lutheran Medical Center, in Brooklyn. "Or the mother can no longer push effectively because she's fatigued or contractions have slowed."
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Possible problems: The device could injure the baby's head or face or fracture the skull, although serious injuries occur in less than 1 percent of cases, says Dr. Hoskins. Risk increases with repeated attempts, so three or four unsuccessful tugs mean a C-section. (As a safety measure, the vacuum pops off to prevent pulling too hard.) The mother's risks include vaginal tearing – more common with forceps, which encircle the baby's head and are more likely to touch the mother (as opposed to the vacuum placed atop the baby's head).
What is a C-section? Major surgery that allows the baby to be removed via incisions into the abdomen and uterus.
Why do women get C-sections? When there is an urgent threat to the life of the mother or the baby, a cesarean can be a life-saving intervention. Examples include a mother hemorrhaging or a baby not getting enough oxygen. But most cesareans are not emergencies. Some non-emergency reasons are prolonged labor (“failure to progress”), a baby in a breech or transverse position, and changes in the baby’s heart rate.
Lower your risk: Cesarean rates in the United States have reached an all-time high of almost 32 percent, and the World Health Organization is urging health-care providers to decrease that number. Lower your risk by choosing a health-care provider and place of birth with a low cesarean rate. Skilled, continuous labor support is also vital. Research has shown that the presence of a doula can lower the chance of having a cesarean. Finally, be actively involved in all decision making before and during labor, and ask if each medical intervention or pain-relief option increases the risk of cesarean birth.
Some hospitals or health-care providers will not allow a woman to have a vaginal birth after she has had a cesarean (VBAC). But the American Academy of Family Physicians has a policy to expand VBACs, so research your options.