Telephone a nurse at your pre-planned delivery hospital...tell her about your discomfort. And read the following if time allows:
Management of Normal Labor (See first source below...)
Labor consists of a series of rhythmic, involuntary, progressive contractions of the uterus that cause effacement (thinning) and dilation of the uterine cervix. The stimulus for labor is unknown, but digitally manipulating or mechanically stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocinSome Trade Names
PITOCIN
SYNTOCINON
Drug Information
by the posterior pituitary gland. Normal labor usually begins within 2 wk (before or after) the estimated delivery date. In a 1st pregnancy, labor usually lasts a maximum of 12 to 14 h; subsequent labors are often shorter, averaging 6 to 8 h.
Stages of labor: There are 3 stages of labor.
The 1st stage—from onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases, latent and active. During the latent phase, irregular contractions become progressively better coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. The latent phase is difficult to time precisely, and duration varies, averaging 8 1⁄2 h in nulliparas and 5 h in multiparas; duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas. During the active phase, the cervix becomes fully dilated, and the presenting part descends well into the midpelvis. On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in multiparas. The cervix should dilate 1.2 cm/h in nulliparas and 1.5 cm/h in multiparas. Pelvic examinations are done every 2 to 3 h to evaluate labor progress. Lack of progress in dilation and descent of the presenting part may indicate dystocia (fetopelvic disproportion). If the membranes have not spontaneously ruptured, amniotomy (artificial rupture of membranes) is typically done during the active phase. As a result, labor may progress more rapidly, and meconium-stained amniotic fluid may be detected earlier. Amniotomy during this stage may be necessary for internal fetal monitoring to confirm fetal well-being. Women may begin to feel the urge to bear down as the presenting part descends into the pelvis. However, they should be discouraged from bearing down until the cervix is fully dilated so that they do not tear the cervix or waste energy.
The 2nd stage is the time from full cervical dilation to delivery of the fetus. On average, it lasts 2 h in nulliparas (median 50 min) and 1 h in multiparas (median 20 min). It may last another hour or more if conduction (epidural) analgesia or intense opioid sedation is used. For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down.
Maternal heart rate and BP and fetal heart rate should be checked continuously by electronic monitoring or by auscultation during the 1st stage of labor (see Normal Pregnancy, Labor, and Delivery: Fetal Monitoring). In the 2nd stage, women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. Uterine contractions may be monitored by palpation or electronically.
The 3rd stage of labor begins after delivery of the infant and ends with delivery of the placenta.
Before admission: Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labor by as much as 72 h. Labor begins with irregular contractions of varying intensity; they apparently soften (ripen) the cervix, which begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency.
Occasionally, the membranes (amniotic and chorionic sac) rupture before labor begins, and amniotic fluid leaks through the cervix and vagina. Rupture of membranes at any stage before the onset of labor is called premature rupture of membranes (PROM—see Abnormalities and Complications of Labor and Delivery: Premature Rupture of Membranes (PROM)). Some women with PROM feel a gush of fluid from the vagina, followed by steady leaking. Further confirmation is not needed if during examination, fluid is seen leaking from the cervix. Confirmation of more subtle cases may require testing. For example, the pH of vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH > 6.5 (pH of amniotic fluid: 7.0 to 7.6); false positives can occur if vaginal fluid contains blood or semen or if certain infections are present. A sample of the secretions from the posterior vaginal fornix or cervix may be obtained, placed on a slide, air dried, and viewed microscopically for ferning. Ferning (crystallization of NaCl in amniotic fluid) usually confirms rupture of membranes. If rupture is still unconfirmed, ultrasonography showing oligohydramnios (deficient amniotic fluid) provides further evidence suggesting rupture. Rarely, amniocentesis with instillation of dye is done to confirm rupture; dye detected in the vagina or on a tampon confirms rupture.
When a woman's membranes rupture, she should contact her physician immediately. About 80 to 90% of women with ruptured membranes at term and about 50% of women with preterm PROM go into labor spontaneously within 24 h; > 90% of women with PROM go into labor within 2 wk. The earlier the membranes rupture before 37 wk, the longer the delay between rupture and labor onset. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection.
Birthing options: Most women prefer hospital delivery, and most practitioners recommend it because unexpected maternal and fetal complications may occur during labor and delivery or postpartum. About 30% of hospital deliveries involve an obstetric complication (eg, laceration, postpartum hemorrhage). Complications include abruptio placentae (premature separation), nonreassuring fetal heart status, shoulder dystocia, need for emergency cesarean delivery, neonatal depression or abnormality, and maternal postpartum hemorrhage. Nonetheless, many women want a more homelike environment for delivery; in response, some hospitals provide birthing facilities with fewer formalities and rigid regulations but with emergency equipment and personnel available. Birthing centers may be freestanding or located in hospitals; care at either site is similar or identical. In some hospitals, certified nurse-midwives provide much of the care for low-risk pregnancies. Midwives work with a physician, who is continuously available for consultation and operative deliveries (eg, by forceps, vacuum extractor, or cesarean section). All birthing options should be discussed.
For many women, presence of the father or another support person during labor is helpful and should be encouraged. Moral support, encouragement, and expressions of affection decrease anxiety and make the process of labor less frightening and unpleasant. Childbirth education classes can prepare parents for a normal or complicated labor and delivery. Sharing the stresses of labor and the sight and sound of their own child tends to create strong bonds between the parents and between parents and child. The parents should be fully informed of any complications.
Admission: Typically, pregnant women are advised to go to the hospital if they believe their membranes have ruptured or if they are experiencing contractions lasting at least 30 sec and occurring regularly at intervals of about ≤ 6 min. Within an hour after presentation at a hospital, whether a woman is in labor can usually be determined based on occurrence of regular and sustained painful uterine contractions, bloody show, membrane rupture, and complete cervical effacement. If these criteria are not met, false labor may be tentatively diagnosed, and the pregnant woman is typically observed for a time and, if labor does not begin within several hours, sent home.
When pregnant women are admitted, their BP, heart and respiratory rates, temperature, and weight are recorded, and presence or absence of edema is noted. A urine specimen is collected for protein and glucose analysis, and blood is drawn for a CBC and blood typing. A physical examination is done. While examining the abdomen, the physician estimates size, position, and presentation of the fetus, using Leopold's maneuvers (see Fig. 1: Normal Pregnancy, Labor, and Delivery: Leopold maneuver.). The physician notes the presence and rate of fetal heart sounds. Preliminary estimates of the strength, frequency, and duration of contractions are also recorded. A helpful mnemonic device for evaluation is the 3 Ps: powers (contraction strength, frequency, and duration), passage (pelvic measurements), and passenger (eg, fetal size, position, heart rate pattern).