Labor and delivery are the final phases of a pregnancy, which end with the birth of the baby. Labor begins with physiological changes in the mother’s body that indicate the imminent birth of the child. These changes include:

• Dilation (widening) and effacement (thinning) of the cervix
  
  
• Rhythmic contractions of the uterus that become more frequent and intense as delivery nears

Once a woman has gone into labor, a prolonged, three-stage process begins in which the baby moves down into the pelvis in preparation for birth. Labor often lasts between 12 and 14 hours – or longer – for first-time mothers, but is usually shorter in subsequent births.

In most cases, labor and delivery occur between the 37^th and 42^nd weeks of a pregnancy. The typical U.S. pregnancy is about 39 weeks, according to new analysis by the March of Dimes. In other situations, labor may begin before the 37^th week of pregnancy, a condition known as preterm labor that is potentially dangerous to the health of the fetus. In still other cases, natural labor may be delayed or is not strong enough to produce adequate contractions. In such instances, a physician may need to induce or augment labor to help the birth process advance.

Labor and delivery are the stages of pregnancy that result in the birth of the baby. During labor, a pregnant woman experiences various signs and symptoms as the baby moves lower into the pelvis in preparation for the birthing process. Labor unfolds in three stages, with the final stage ending with the delivery of the baby and the placenta from the woman’s body.

Babies are delivered in one of two ways:

• Vaginal birth. The baby is delivered through the vagina. As the baby’s head appears at the vaginal opening, the tissue of the vagina thins and becomes tightly stretched. In some cases, it may be difficult for the baby’s head to fit through the vagina without severely tearing the mother’s skin and muscles. To prevent this – and to ease pressure on the baby’s head – the physician may perform an episiotomy, in which a small cut is made in the vaginal tissue.
  
  Controversy has arisen about whether episiotomies are always medically necessary, and in some cases they can cause prolonged postpartum discomfort including pain during sexual intercourse (dyspareunia) or rectal problems (e.g., bowel incontinence).
  
  The American College of Obstetricians and Gynecologists (ACOG) recommends the procedure only in cases where it is absolutely necessary, such as to avoid severe maternal lacerations or facilitate and speed up difficult deliveries. Some studies also have shown that women who do not have episiotomies suffer only a small tear to their vaginal tissue that easily heals. Episiotomy can sometimes be avoided through the use of lubricants and perineal massage during labor.
  

  

• Caesarean delivery. In some cases, the baby cannot be delivered through the vagina. Instead, an incision is made in the abdomen and uterus, and the baby is delivered through the opening. This procedure is known as a Caesarean or C-section.
  
  A physician may suggest a C-section prior to labor. Situations that might indicate the need for this procedure include:
  
  
• Position of the fetus in the uterus makes a vaginal delivery difficult.
  
  
• Mother has a medical condition that makes a vaginal birth risky (e.g., hypertension, certain sexually transmitted diseases).
  
  
In other circumstances, a C-section becomes necessary because of an unexpected difficulty during labor. Examples of such developments include:


• The baby is discovered to be too large to fit through the vaginal opening
  
  
• The dilation of the cervix is slow or incomplete
  
  
• The baby struggles to cope with the stress of labor
  
  
• The baby’s heart rate drops or slows for an extended period
  
  
• The mother experiences a health threat, such as severe bleeding

Women who take the necessary preparatory steps can make the sometimes difficult labor and delivery process a bit easier. After the baby is born, the mother and child may spend a short period of time in the hospital as the mother recovers from the demands of labor.

During her pregnancy, a woman (and, ideally, her spouse or partner) may want to attend a childbirth education class, which will help her know what to expect before, during and after delivery. It is a good idea to take these classes during the 6^th to 7^th month of pregnancy.

The obstetrician (OB) is also an invaluable aid in understanding labor and delivery, and women should try to have all their questions answered during their prenatal visits.

Expectant mothers and their partners should establish a birth plan prior to delivery. During this process, a woman can develop a written plan of her labor and delivery preferences. The plan should be flexible, because labor and delivery is often unpredictable.

Preparation steps that can be taken include planning the hospital route, properly installing a baby seat in the car and planning for childcare, if necessary.

Prior to labor, pregnant women should decide whether they want to relieve pain through use of medication, or whether they prefer natural methods of pain relief. Pain relief through medication includes analgesia (which masks pain) and anesthesia (which eliminates pain).

The type of pain relief chosen depends on a number of factors, including the stage of labor or delivery. It is important that women try to get to the hospital promptly after labor begins, as pain medications may no longer be an option if labor moves too far along.

Methods of administering pain medication include the following:

• Epidural block. Delivery of regional anesthesia (through needle or catheter) into the epidural space around the spinal cord that partially or fully numbs the lower body. This method allows a physician to administer additional anesthesia as needed throughout labor. A lighter epidural allows the mother to feel enough that she is still able to push, which reduces the risk of stalled labor. It may also be used during Caesarean section (C-section) or post-birth procedures (such as tubal ligation).
  
  
• Spinal block. Also called spinal block, a method of pain relief that can be given to a woman during childbirth by injection into the spinal fluid. It provides immediate pain relief, but its effects last only up to a couple of hours. Longer deliveries may require additional injections. Although not as commonly used as epidurals, spinal blocks are sometimes used for C-sections and during difficult deliveries in which forceps are required.
  
  
• Combined spinal-epidural block (CSE). Also referred as a “walking” epidural, this method has the advantages of both epidural and spinal anesthesia. This type of pain relief is injected into the spinal fluid and into the space below the spinal cord. A CSE provides instant pain relief and additional medication can be administered – via a catheter – as needed throughout labor. The advantage of this procedure that has recently become more popular is that because it only numbs a woman’s abdominal nerves, it allows her to move around without discomfort for an extended period prior to delivery. Due to the combined technique in CSE there is rapid pain relief provided by the spinal part in addition to long-lasting, continuous relief through the epidural portion. However, a woman should assume that if she is going to get an epidural, she will not be able to ambulate until after the delivery, when the epidural is discontinued. In addition, a CSE requires a special technique and may not be available at all birthing centers or hospitals.
  
  
• Pudendal blocks. These drugs block pain between the vagina and anus (perineum) in cases when delivery of the baby needs to be assisted by vacuum extraction or the use of forceps. In this treatment, a local anesthetic (e.g., lidocaine) is injected into the pudendal nerve, through the vaginal wall shortly before delivery. Pudendal blocks can be used to relieve pain experienced after an episiotomy or a tear during delivery. Pain relief is localized and usually lasts for several minutes up to an hour. Pudendal blocks do not provide pain relief from contractions and they may slightly decrease a woman’s urge to push.
  
  
• Intravenous pain medication. Pain medication can be administered into the mother’s bloodstream through an intravenous catheter. This method is frequently used to relieve pain in early labor since the medication does get into the baby’s bloodstream and, ideally, it is out of the baby’s system before delivery. 

Some women may choose non-medicinal pain-relief techniques, which include acupuncture, hypnosis, relaxation and positive visualization techniques. It is important to discuss all these options with an OB. In addition, a woman will meet with an anesthesiologist after she is admitted to the hospital.

Prior to normal labor, a woman’s body usually will offer several cues that the process is about to begin. These differ from woman to woman, and may be more subtle for some women than for others.

Changes that may signal impending labor include:

• Lightening. As a woman’s pregnancy enters its final stage, the baby may begin to settle deeper into the pelvis. This process is known as lightening. During lightening, a woman may notice a change in the shape of her abdomen and a feeling that the baby has become less heavy. The baby’s new, lower position often makes it easier for the mother to breathe as there is less pressure on the diaphragm. However, this benefit to the lungs is somewhat offset by the fact that the baby is now exerting increased pressure on the bladder, which can make the mother need to urinate more frequently
  
  In an initial pregnancy, lightening usually takes place weeks or days before labor begins. In subsequent pregnancies, it may not occur much in advance of actual labor.
  
  
• Effacement. Prior to birth, the cervix begins to soften and thin, a process known as effacement. The only way to detect effacement is for a physician to examine the cervix during a vaginal exam. The degree of effacement is expressed as a percentage from 0 to 100, and the cervix must be completely thinned out prior to vaginal delivery.
  
  
• Dilation. The closer a woman gets to delivery, the more her cervix opens, a process known as dilation. A physician measures the degree of dilation in centimeters from 0 to 10. Many women dilate very slowly until labor begins, when dilation quickly increases.
  
  
• Bloody show. Throughout a woman’s pregnancy, a thick plug of mucus develops that walls off the cervical opening from the outside. This helps prevent bacteria from entering the uterus. As the cervix thins during effacement, the plug is sometimes lost. A woman may notice this as stringy mucus or a thick, brownish mucus that sometimes contains blood. The loss of the mucus plug is often – although not always – a sign of impending labor.
  
  
• Nesting. Women sometimes feel a burst of energy to make preparations for their new baby, such as cleaning or arranging baby clothes. This feeling is often strongest just prior to labor.
  
  
• Contractions. Initially, a woman may experience irregular bouts of rhythmic tightening and relaxation of the uterus. These are known as Braxton Hicks contractions and they do not indicate impending labor.
  
  However, eventually a woman will experience contractions that do indicate labor is about to begin. There are several characteristics to contractions that signal impending labor:

Once a woman experiences these types of contractions, she should call her physician. Ultimately, the only way to determine whether or not contractions indicate true labor is to check for the telltale signs of cervical dilation and effacement.

Some pregnant women may go into labor early. This condition is known as preterm labor, and it occurs when labor starts anytime before the 37^th week of pregnancy. Symptoms associated with preterm labor include:

• Vaginal discharge, including change in amount and type (watery, bloody or containing mucus) of discharge
• Pelvic or lower abdominal pressure
• Low, dull backache
• Abdominal cramps, with or without diarrhea
• Regular contractions or uterine tightening

When possible, attempts will be made to prevent the woman from going into labor, as the fetus’ odds of surviving are much higher if it remains in the womb. Methods to relax the uterine muscle will be employed, and may include:

• Bed rest
• Intravenous fluids
• Medications

Such treatments are more likely to be successful if they are started early. However, attempts to prevent preterm labor sometimes fail. Children who are born prematurely are more likely to have low birth weights (less than 2,500 grams, or 5 pounds, 8 ounces), breathing problems and underdeveloped organs and organ systems. In many cases, these babies require an extended hospital stay until their health is stable.

Premature babies are also at higher risk for lifelong health risks such as cerebral palsy, blindness, lung diseases, learning disabilities and developmental disabilities. However, with the proper medical care, many premature babies can go on to lead healthy, normal lives.

In some cases, a woman may need to have her labor induced. This may be recommended for either fetal or maternal indications. Induction can be performed using several methods. These include:

• Cervical dilators. A mechanical method of dilating the cervix, which is among the oldest inducement techniques. A number of methods may be used, including the rupturing of membranes surrounding the fetus (amniotomy) and the insertion of a balloon catheter (which is then inflated to dilate the cervix).  
  
  
• Prostaglandin E suppositories or gel. These medications help make the cervix more favorable to induction. In many cases, administration of the suppository or gel will cause labor and delivery to follow within 24 hours. In other cases, another method of induction is necessary to finish the process.
  
  
• Oxytocin. Medication used to induce the uterus to contract. The drug is given to the expectant mother through an intravenous (I.V.) drip. This allows the physician to closely control the amount of medication given based on the mother’s strength of contractions and the baby’s response to the contractions.
  
  
• Misoprostol. Tablets that are placed high in the vagina that help make the cervix more favorable to induction. To date, this method is considered experimental.

Circumstances that may require induction for medical reasons include:

• Placental insufficiency. This occurs when the placenta is not getting enough nutrients and oxygen.
  
  
• Chorioamnionitis. Infection of the placental tissues.
  
  
• Post-term pregnancy. Induction may be performed when a pregnancy has extended to 42 weeks or more.
  
  
• Danger to the fetus. Occurs when the fetus is no longer thriving in the uterus due to poor placental function, maternal disease or other conditions.
  
  
• Poor result from stress test or nonstress test. These tests measure whether or not the placenta is still functioning properly. If not, induction may be necessary for the health of the fetus.
  
  
• Delay in labor after membranes rupture. If membranes have ruptured but labor has not started spontaneously within 12 to 24 hours, labor may be induced.
  
  
• Serious maternal medical condition. Women who develop preeclampsia or another serious medical condition that cannot be controlled by medication may need to be induced.

In some cases, a physician may induce labor for reasons that are not strictly medically necessary. These include lack of access to nearby hospital or specialist, family circumstances or other reasons.

Inductions are not always successful in bringing about the baby’s birth. In such situations, a second induction or a Caesarean section may be necessary. Women should discuss the pros and cons of an induction with their physician before deciding to undergo the procedure.

In addition, natural labor is not always strong enough to produce adequate contractions. In this case, labor can be augmented using medications that make contractions stronger.

Induction of labor using drugs carries a small risk of amniotic-fluid embolism (tearing of the amniotic sac resulting in leakage of amniotic fluid into the mother’s blood), according to a new study. Although this is an extremely rare occurrence, it can be life-threatening for the mother.

Most women will have their baby in the hospital, although some women opt to have the baby delivered at home. As a woman’s due date approaches, she should contact her obstetrician (OB) and/or go to the hospital if any of the following occur:

• The amniotic sac (which holds the fluid that surrounds and protects the fetus) ruptures. More commonly referred to as a woman’s water “breaking,” this occurs when there is a leak or break in the sac holding the amniotic fluid that surrounds the baby. Women may notice a leakage of fluid that can range from a trickle to a gush. When a woman’s water breaks, she should call the hospital or a physician immediately. A broken amniotic sac is vulnerable to infection.
  
  
• Bleeding from the vagina. Bleeding that is more substantial than mere spotting may be a sign that labor is beginning.
  
  
• Contractions arrive five minutes apart or less for at least one hour.
  
  
• Constant, severe pain ensues.
  
  
• There is a marked decrease in fetal movement.

After the woman is admitted to the hospital, she will be given an initial physical evaluation, which will include measuring her blood pressure, heart and respiratory rates, temperature and weight. The physician will also review the patient’s prenatal records. This is done to look for signs of potential complications and to review other valuable information. The physician also will monitor the fetus’ heart rate and may palpate (examine through touch) the fetus through the abdomen using a technique known as Leopold maneuvers. This can help the physician determine whether or not the fetus is lying in the proper position for safe delivery, with the head emerging before the rest of the body.

Once labor actually begins, it often lasts between 12 and 14 hours – or longer – for first-time mothers. Labor is usually shorter in subsequent births. Throughout labor, the heart rate of the fetus will be monitored either through listening (auscultation) or an ultrasound device. The heart rate is usually checked after each contraction.

In addition, women may receive various medications to numb discomfort during labor, or may use natural techniques to help block pain. Relaxation techniques such as breathing exercises also may help reduce discomfort.

Labor is divided into three distinct stages. Each stage has different phases:

• Stage one. Begins after the cervix dilates and effaces (thins out), and ends when the uterus is fully dilated. It is the longest stage of labor, and is divided into three separate phases:
  
  
• • Early labor. The cervix dilates from 0 centimeters to 3 centimeters, and mild to moderately strong contractions last 30 to 60 seconds, arriving every five to 20 minutes. If a woman has not previously experienced bloody show (blood that appears as the cervix dilates and capillaries rupture), it is likely to occur at this point. Many women also report symptoms such as backache, upset stomach, warmth in the abdomen and diarrhea.
    
    Early labor can last from several hours to several days. It is likely to be longer for first-time mothers.
    
    
  • Active labor. The cervix dilates to nearly 7 centimeters, and contractions become stronger and longer, lasting as long as 45 seconds to a minute or longer. Contractions are often two to four minutes apart. Many women report increasing pressure in their back during active labor. If a woman has not reported to the hospital by this point, she should now do so.
    
    Active labor usually lasts between three and eight hours, but may be shorter for women who have had a previous delivery.
    
    
  • Transition. The cervix dilates from 7 centimeters to 10 centimeters. This is usually the shortest stage of labor, but is often the most unpleasant. Contractions increase in strength and frequency, with time for only hurried breaths between contractions. Contractions quickly reach peak intensity and last up to 90 seconds.
    
    Many women feel increased pressure in the lower back and rectum, and may feel hot and sweaty for a minute, then cold and chilled. Transition can last between 15 minutes and three hours. Women who have had a previous vaginal delivery are likely to experience shorter transitions.
    
    
• Stage two. This is the phase in which the baby is actually born. Once the cervix is fully dilated, the baby must move down into the vagina. To facilitate this process, women are encouraged to push each time they have a contraction. Some women may find this to be more comfortable from a lying position, while others prefer squatting, sitting or getting on their hands and knees (or kneeling).
  
  As the baby moves deeper into the pelvis, the body and head will turn to make delivery as easy as possible. It can take from a few minutes up to several hours or more until the baby is born. Generally, it takes longer for first-time mothers and women who have received an epidural, an injection of anesthesia into the epidural space of the spine.
  

  

  In some cases, the physician may need to help the baby’s delivery. There are two ways to achieve this:
  
  
• • Forceps. An instrument that resembles two large spoons. These are gently placed on either side of the baby’s head, and the baby is pulled out of the womb.
    
    
  • Vacuum cups. A plastic cup is attached to the baby’s head using a vacuum pump, and the baby is gently delivered.
    
    
  Once the baby’s head has been delivered, the baby’s airway will be cleared. The physician or other healthcare provider will make sure the umbilical cord is free, and the rest of the baby’s body will follow.
  
  Infant nutrition experts recommend that physicians wait at least two minutes before clamping a newborn’s umbilical cord. Delaying cord clamping can boost iron reserves and prevent anemia for several months in babies, according to a new study. The umbilical-cord clamping procedure stops blood flow from the placenta to the baby in preparation for cutting the umbilical cord. Typically, the procedure is done within 10 seconds after a baby’s shoulders are delivered.
  
  After the baby is finally delivered, the umbilical cord is cut and the baby is washed off, weighed and measured. The physician also performs an APGAR test. This includes several measures that are taken at one minute and again at five minutes after birth. A score of 7 to 10 is considered normal, while a score of 4 to 7 might require resuscitative measures. Measures below 3 require immediate resuscitation. APGAR measures include:

• Stage three. After the baby is delivered, the uterus continues to contract. The placenta is typically delivered about five to 10 minutes after the baby has been delivered. In some cases, it may take up to 30 minutes. When the placenta is expelled, it usually comes out in a small gush of blood. If necessary, medications to help contract the uterus and decrease the amount of bleeding may be administered at this time. Mild contractions may continue for a while after the placenta has been delivered.
  
  The placenta will be examined to make sure it is intact and that there are no remaining fragments in the uterus that could cause bleeding and infection. The mother will also be examined to see if there is any need for stitches or other repair work. If stitches are required, a local anesthetic may be injected into the area.

Perineal pads are applied to soak up excess blood from the genital area. The physician will measure the amount of blood on these pads and will monitor blood pressure for several hours to ensure that the mother is not losing excessive amounts of blood.

The first hour after delivery is the time of greatest risk for postpartum complications. Postpartum uterine hemorrhage occurs in 1 percent of patients, and is more likely to occur after rapid or protracted labor, or uterine enlargement. It is a potentially life-threatening condition.

Shortly after birth, babies may look a bit odd. Babies who are delivered vaginally may have a molded or cone-like shape to their heads. This shape may last for up to two weeks. Some babies whose heads were pushed against the cervix may have a lump known as a caput succedaneum. This usually disappears in a day or two.

Other features of a newborn include hair that may (or may not) fall out before being replaced; vernix caseosa coating (a protective coating that covers the baby’s skin prior to birth); lanugo (fine, downy hair on a newborn baby’s shoulders, back, forehead and temples).

Barring medical problems, the mother will be allowed to hold the baby and may be allowed to breastfeed for the first time.

New mothers and their infants usually spend a day or two in the hospital following a vaginal birth. Caesarean birth or a birth complicated by other issues may require a longer hospital stay. It is not unusual for mothers to experience some discomfort following delivery. This is often related to afterbirth pains caused by the uterus as it contracts and relaxes before returning to normal. Contractions usually last a few days and tend to be more mild after initial births and stronger after subsequent births. To reduce such symptoms when they occur, mothers should:

• Change their position
• Lie with a pillow under their abdomen
• Empty their bladder frequently
• Take any medications prescribed by a physician

During the hospital stay, the baby may receive initial vaccinations against diseases such as rubella and hepatitis. In addition, the mother may learn how to feed, bathe and change the baby.

Premature infants often spend some time after birth in a neonatal intensive care unit. This is an area of the hospital specially designed to provide appropriate warmth, nutrition and protection for preterm babies to ensure proper growth and development.

When parents are ready to bring their baby home, they will be required by law to strap the child into a special car safety seat. These seats should be purchased prior to labor and should be approved for use by newborns.

After delivery, the new mother eventually will settle in to her day-to-day routine. During this time, she also may continue to experience symptoms related to the end of her pregnancy. These include:  

• Breast swelling. The mother’s breasts may be full and hurt for several days after delivery. A support bra can help relieve these symptoms. Women who are not breastfeeding may use ice packs to relieve discomfort. Stimulating or pumping the breasts will only make the situation worse.
  
  
• Pain from an episiotomy (small incision in the vaginal tissue made to facilitate delivery) or vaginal tear. Women who have an episiotomy may use cold packs right after delivery to relieve discomfort. Later on, heat – via a heat lamp or warm baths – may be more appropriate and may help speed the healing process.
  
  
• Hemorrhoids. During pregnancy, labor and delivery, hemorrhoids may flare up and swell. Sprays, creams, and dry or wet heat can provide relief.
  
  
• Constipation. Some new mothers experience constipation, and those who have had an episiotomy or who have hemorrhoids may find bowel movements to be painful (dyschezia). Diets high in fiber and drinking plenty of water, milk and juices (such as prune juice) can help.
  
  
• Emotional changes. Around one week after delivery, many women begin to notice mood changes. These include being tired and feeling overwhelmed or depressed, and may be a sign of postpartum depression or “baby blues.” In most cases, these feelings disappear after a few weeks. However, if these symptoms do not dissipate, a physician and/or mental health professional should be consulted.

A new mother’s body will also begin to return to normal and reverse many of the changes that have taken place over the 40 weeks of pregnancy. These changes include:

• Abdomen. Within one week of delivery, the opening of the cervix will shrink back to the size of a dime. Within two weeks of delivery, the weight of the uterus will decrease from 2.5 pounds to only two ounces. It also will recede away from its post-delivery position of pushing against the navel. It will take time before stretched abdomen muscles become tight again.
  
  
• Hair loss. It is not unusual to lose large amounts of hair a few weeks after delivery. The normal growth cycle will resume shortly thereafter.
  
  
• Lochia. This is a form of vaginal discharge made up mostly of blood and what remains of the uterine lining following pregnancy. Discharge is bright red initially, but becomes pink and decreases in volume over time. Within 10 days, the discharge becomes white or yellow. Tampons should not be used while the flow is heavy.
  
  
• Menstrual periods. Menstruation usually returns seven to nine weeks after delivery. Periods initially may be shorter or longer than previously, but will gradually return to normal. Some women who are breastfeeding will not experience a return to normal menstruation for months. However, it should be noted that despite not having periods, women can still become pregnant.

Recommendations on resuming sexual intercourse vary. Some physicians will suggest that women return to sex as soon as they feel comfortable. Others suggest that women refrain from intercourse until after their six-week checkup.

Women should call their physician if they experience certain changes in health, including:

• Fever over 100 degrees Fahrenheit (38 degrees Celsius)
  
  
• Nausea and vomiting
  
  
• Painful urination, burning or a strong and sudden need to urinate (dysuria)
  
  
• Heavy bleeding
  
  
• Pain, swelling and tenderness in the legs
  
  
• Chest pain and cough
  
  
• Hot, tender breasts
  
  
• Pain between the vagina and the rectum that gets worse over time

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about labor and delivery:

1. Should I call you first or should I go directly to the hospital if I think I’m in labor?
   
   
2. What signs or symptoms tell me I should go directly to the hospital?
   
   
3. Will you be able to deliver the baby on or around my due date, or will another doctor be on call?
   
   
4. Will I be allowed to drink water and other beverages (e.g., juice, soda) after I’ve been admitted to the hospital?
   
   
5. Will you allow me to go beyond my due date or will you induce labor?
   
   
6. What pain relief options do you recommend during labor and delivery?
   
   
7. Who can join me in the delivery room? Who can be in the operating room if a Caesarean section is required?
   
   
8. Are cameras permitted?
   
   
9. What is the visitation policy for family? Is there some place for my spouse/partner to sleep in my hospital room?
   
   
10. How long do I stay in the hospital for vaginal or Caesarean delivery? May I leave earlier if I wish?
    
    
11. How soon after delivery will my baby need to be fed?