I had no illusions that childbirth would be easy, but I at least pictured it starting with gentle contractions that gradually intensified until that final, monumental push. Instead, my labor started with a dose of Pitocin because my contractions were next to nil and ended with a snip of the doctor's big scissors for an episiotomy. In short, my experience was bracketed with medical interventions I hadn't expected.
The reality is, medical interventions are sometimes necessary to ease your baby's entry into the world. About 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. 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, MD, 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."
You're Your Own Advocate
Be prepared to introduce the topic yourself. "Most doctors are not likely to bring up the issue spontaneously," says Katherine Hartmann, MD, assistant professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill. For example, the first time Jen Loya heard about a vacuum delivery from her obstetrician was in the delivery room, when he announced he was going to use one. "My doctor and I had discussed pain medications ahead of time, but not the different interventions," says Loya, a mom of two from Fairfield, Connecticut. Fortunately, she'd been briefed in her childbirth class months beforehand.
"Only half of first-time parents take a childbirth class, so many women go into labor not knowing what the interventions are and what variables are involved," says Jane Hanrahan, president of the International Childbirth Education Association. (All ICEA-certified classes cover the interventions; to find a class in your area, go to icea.org.) You may not be keen on hearing how labor can require specific equipment, but the knowledge is empowering, she says. Here's a rundown of the birth interventions that you're most likely to face.
Pitocin & Episiotomies
Induction: Kick-Starting Contractions
What it is: Intravenous Pitocin (oxytocin) is a synthetic hormone that a doctor or a certified nurse-midwife administers to stimulate contractions.
Why it's done: Pregnancy lingers two weeks or more past the due date; labor stalls -- or doesn't start after membranes rupture. The longer the baby remains inside the womb, the greater the risk of uterine infection in the mother.
Possible problems: Contractions come on fast and hard and sometimes are unrelenting. "Fortunately, Pitocin clears from the system within moments when we stop the IV," says Jeffrey Goldberg, MD, clinical assistant professor of obstetrics and gynecology at Jefferson Medical College of Thomas Jefferson University, in Philadelphia.
If you're intent on an all-natural birth, realize that being induced usually means staying flat on your back, says Patricia Crane, certified nurse-midwife and director of Nurse Midwifery Services at the University of Michigan, Ann Arbor.
Episiotomy: A Cut Below
What it is: A cut in the perineum, between the vagina and rectum. Unless an epidural is in effect, the doctor or nurse-midwife applies local anesthetic before using surgical scissors.
Why it's done: A wider opening may speed delivery if the baby's in a difficult position.
Possible problems: While some providers routinely do episiotomies, the latest research shows no benefit -- and even potential harm. "Twenty years of data show there's no evidence for what were believed to be benefits: less pain, faster healing, and sexual functioning," says Dr. Hartmann, lead author of a review of 986 related studies on episiotomies.
In addition, all episiotomies require stitches, compared with just one out of three uncut deliveries, and they may even cause further tearing, says Dr. Hartmann. In fact, Dr. Goldberg and his colleagues found a 16 percent risk of severe tearing with episiotomy -- four times the risk without incision. In addition, he says, episiotomy makes injury to the anal sphincter (which can lead to bowel incontinence) four to 10 times more likely. More common, less serious side effects include bleeding, bruising, and pain for two or three days.
Postnatal pointers: Apply ice for the first 12 hours to reduce pain and swelling, use a squirt bottle for post-toilet cleansing, and keep the area dry. "Use a hair dryer on a low setting after showering, and skip underwear if you feel comfortable with that," suggests ACOG spokesperson Iffath Hoskins, MD, chair of the department of obstetrics and gynecology at Lutheran Medical Center, in Brooklyn. "Warm compresses are also soothing and increase blood flow to speed healing." Call your doctor if discomfort persists for more than a week, which could signal an internal blood clot or infection.
Forceps, Vacuums, C-Sections
Operative Vaginal Delivery: Push Comes to Pull
What it is: 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 it's done: "The baby isn't descending, or is having breathing difficulties and should be delivered quickly," says Dr. Hoskins, "or the mother can no longer push effectively because she's fatigued or contractions have slowed."
Slowed contractions can be an issue for many women. "My water had broken 15 hours earlier, and the doctor felt that labor was taking too long, so he went in with the vacuum," says Loya. "I'd had an epidural earlier but also got a local anesthetic; still, I was surprised by how much it hurt."
So is this type of pain par for the course? Unfortunately, yes. "You can't get the high level of anesthesia that you'd be able to for a c-section because we need you to push," says Dr. Flamm.
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).
Postnatal pointers: Do Kegel exercises to help tighten the vaginal muscles stretched by the instrument, suggests Dr. Hoskins. A specially designed donut-shaped cushion can also reduce pressure on the area when you're sitting.
C-Section: The Last Call
What it is: After topping off an existing epidural or numbing the region with a spinal block, a doctor cuts through the abdomen to reach the uterus, makes an incision, suctions out the amniotic fluid, and removes the baby. "The baby's usually out within five minutes, though sewing up can take up to an hour," says Dr. Flamm.
Why it's done: The top reason is stalled labor, but fetal stress may also call for c-section. "Sometimes a cesarean is the only option left, particularly when there has been no progress with forceps or vacuum," says Dr. Hartmann. Nurse-midwives have doctors on standby to do the surgery if needed.
Possible problems: About 5 percent of women have complications including wound infection, internal bleeding, or blood clots. Adhesions, also known as scar tissue, usually pose no problems; but repeated cesareans raise the risk that this scarring could affect nearby organs, such as the bowel and bladder, causing chronic pain, says Dr. Goldberg.
Postnatal pointers: The incision makes it difficult to lift, bend, and even breastfeed, so enlist as many helpful arms as you can, advises Dr. Flamm. Surgery also dulls reaction time, so don't drive for two weeks. Sometimes c-sections also have emotional repercussions. "Some moms feel they did something wrong because they didn't deliver vaginally, but that is not a failure," says Dr. Flamm. "Every childbirth is different, just as every baby is different."
So be sure you understand the interventions, express your opinion about options -- and accept that safety issues may trump personal preference. "I find that many mothers lack confidence in their bodies and in their ability to make good decisions," says Hanrahan. "The more informed you are, the better your birth experience will be because you'll understand everything that happened and why. After all, the ultimate goal is a healthy mom and a healthy baby."
Rachelle Vander Schaaf is a writer in Macungie, Pennsylvania.
Originally published in American Baby magazine, January 2006.
All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.