The Penn Medicine Labor Podcast

Today, we are joined by Dr. Lisa Levine, a Maternal Fetal Medicine specialist, who talks to us about induction of labor. 

We answer the following questions: 

1. What is an induction of labor?

• So first, of all, remember: labor is when a pregnant person has contractions of their uterus, or womb, and their cervix starts to open. If everything goes well, at the very end, the person is able to push and deliver their baby (or babies) vaginally. Labor induction, is very simply put, getting someone into labor who is not yet in labor. I often say it is like “jump-starting” labor. And the goal is for that person to give birth vaginally.

We absolutely would love if every pregnant person could go into labor on their own. That would make our jobs easier! However, there are some people who, because of medical problems they had before pregnancy, or medical problems they develop during pregnancy, need to be delivered earlier so that they and their babies can stay healthy. After a certain point, staying pregnant may not be the healthiest option for that person or for their baby. Some people may also choose induction after a certain point for their own reasons, such as help with childcare or needing to go back to work, but that does not usually happen before 39 weeks. There are many reasons to be induced, and you should talk to your doctor about when it is safest for both you and your baby to undergo an induction.

We call a “term” pregnancy, meaning a fully developed pregnancy, anywhere between 37 and 42 weeks. And usually, that is when pregnant people will go into labor. So, most people are not considered “early” or “preterm” if they go into labor, say… when they are 38 weeks and 2 days-which is just 12 days before their due date. And for most people who don’t have medical problems before or during pregnancy, it is totally fine for them to go into labor sometime between 37 and 42 weeks.

That depends on the patient’s medical condition, how the baby is doing inside, and a lot of other factors. This would have to be a discussion with your doctor. Most of the time, that date will be in the 39-40 week range, but if you develop high blood pressure of pregnancy, have a more serious medical condition or we think that baby is not doing well, we may recommend earlier.

Also, for patients and babies that are healthy overall, if they go past their due date, we would also monitor them and their babies very closely because of that tiny increased risk of stillbirth. Therefore, your doctor may talk to you about induction of labor at 41 weeks or bring you in for monitoring of the baby if you are past 41 weeks and want to try to go into labor on your own. We usually do not recommend going past 42 weeks, because of that increasing stillbirth risk.

The first thing to expect is that we have to do a lot of stuff upfront to make sure that we are giving you the correct medicine to put you into labor and caring for you in a safe way. This will include bloodwork to see what your blood counts are and what blood type you have, testing you for some sexually transmitted infections, like HIV and syphilis, as well as an ultrasound to determine that the baby is head down. We don’t recommend induction if the baby is in any other position. We will also put in an IV so that we can give you medicines through it to help with your induction.

If your cervix is not very dilated or not thin (we mean anything under 3 or 4 centimeters), we would recommend first starting with some medicine that you take by mouth or that we place in the vagina. This medicine is called misoprostol, which is a medicine that can help soften and thin the cervix and get it to open up a little bit more. The second thing we may recommend is something called a “Foley” balloon, which is a thin tube that has a small, inflatable balloon at the very tip. Your doctor will place the foley balloon into the cervix through the vagina, and then inflate the balloon with some water. That balloon pushes on your cervix and allows the cervix to release natural hormones that thin the cervix and get it ready for labor. Typically, the Foley balloon stays in place for 6-12 hours. When it comes out, your cervix will be open 3 or 4 cm. Misoprostol can be used separately or at the same time as the Foley balloon.

This whole process is called “ripening” of the cervix and we recommend doing this if your cervix is not very dilated or is not thinned out because there are studies that show that we are more likely to achieve a vaginal delivery if we first get your cervix to open up and thin out a little before we start IV medication.

if the patient wants some kind of pain medication, they can receive it. These include IV pain medication or an epidural. But I understand that you have an anesthesia podcast already dedicated to this topic, so I won’t go into that as much.

Then, after the patient’s cervix is 3-4 cm dilated, as long as the patient and the baby are still doing well, we will start with some medication that goes through the IV. A lot of people will have likely heard of it: it’s called Pitocin. Pitocin is just the brand name for the hormone that your own body makes called oxytocin. Oxytocin is something that a pregnant person makes during labor, and it helps to create contractions and continue the labor process. Essentially, we are just giving you a synthetic hormone your own body makes to put you into labor. Another method is doing nipple stimulation with our labor floor protocol, because stimulating the nipples can also release natural oxytocin, achieving the same effect. Another method would be breaking the bag of water around the baby, because that can also release hormones that speed up labor.

we always have the two monitors. One is to check on the baby’s heart rate through something called a “doppler,” which is like an ultrasound, and the other is a pressure sensor to monitor contractions. Usually, both of the monitors go on the pregnant person’s belly.

Sometimes, it may be hard to keep the baby’s heart rate on the monitor if the baby is moving around, if the baby is small, or if the baby is very low in the pelvis. It may also be hard to monitor contractions from the outside, especially if the pregnant person is moving around during labor or if there is more soft tissue between the monitor and the uterus. When this happens, we may suggest placing monitors that actually go inside the uterus, and this can only be done once the bag of water around that baby is broken.

One is a pressure catheter that can more easily measure the contraction timing and strength. This is called an intrauterine pressure catheter, or we often refer to it as an IUPC. This is a very thin, plastic tube that goes into the uterus and stays in until the baby comes out. This does not harm you or the baby in any way.

Another is something called a fetal scalp electrode, which is like a little clip that goes on the baby’s head. This clip can be a better way to track the baby’s heart rate on the monitor if we are having trouble getting it from the outside monitors that go over the pregnant person’s belly. This also gets taken off once the baby’s head is coming out or crowning. Again, this does not harm you or the baby in any way. Both of these things are tools that we have to better monitor the pregnant person and baby so that we have more information on how to best guide our patient’s labor.

We then slowly increase the Pitocin until we achieve a good contraction pattern that is changing the cervix every few hours, but is not so much so that the baby is not able to tolerate it.

I’d like for people to imagine that labor is like running a marathon. For some people, labor can certainly take many hours, or even days! So just like how labor can put stress on your body, it can do the same thing for babies and placentas. We never want to cause stress to the baby, which is why we monitor and try to prevent it.

You can become very tired from labor, but your baby, can tire out much faster. This stress on the baby and the placenta can mean decreased oxygen going from the placenta to the baby, and we can see signs of that on baby’s heart rate monitor. Now, the heart rate monitor is not perfect, but signs that babies are not getting enough oxygen could be the heart rate dropping after contractions. Another way is if we see that the nice squiggly pattern of the heart beat is looking more like a flat line. We call that “variability.” A nice squiggly pattern means good “variability” which is a sign that the baby is getting good oxygenation. Once that “variability” goes away, we can’t be sure of that anymore. We don’t really mind if that squiggly patter goes away here and there but when it goes away for a while, that makes us more concerned.

If that happens, that’s a sign that we need to give the baby a break and slow down on the medication or stop it altogether to decrease the contractions. If that still doesn’t help the baby recover from this stress, then that may be a sign that we need to do a C-section because we don’t want the baby to be deprived of oxygen for a long period of time -- that could mean bad things for the baby, like brain damage. It is often the contractions that are causing the stress and, unfortunately, you can’t have labor without contractions! So even if we stop the medication that is giving you contractions, we will need to at least try to restart it to see if we can get you into labor.

No. We have good studies that show that the act of inducing labor itself does not increase the rate of C-section. Patients who are induced do have a longer labor than patients that come in in labor but inducing labor itself does not increase the risk of a C-section. However, many people who require an induction of labor often have medical conditions or their babies may have medical conditions that make it more likely for them to need a C-section.

So, for example, one reason that we may recommend an induction of labor at 37-39 weeks is for something called fetal growth restriction, or when babies are very small and not growing well on the inside. A very small baby could be a sign that the placenta isn’t working very well to get the baby the oxygen and nutrients that it needs. In this instance, we would recommend an induction of labor between 37-39 weeks depending on how small the baby is and some other factors because we believe that it is safer for the baby to be fed and supported on the outside rather than on the inside.

Now, you can imagine that if the placenta isn’t working well already, that labor can put even more stress on the placenta and the baby, and that baby may not do well during labor. That baby is more likely to need a C-section. It’s definitely not a hard and fast rule, and we absolutely still encourage certain patients with small babies to try for a vaginal delivery, because most of the time, small babies can tolerate labor very well. However, we know that there is a higher risk of needing a C-section.

The reason we recommend an induction of labor is because we think that for the health of the pregnant person or baby, we should have the baby sooner rather than later. Usually, we do this because the pregnancy is making a medical condition that the person had prior to pregnancy worse, or the pregnancy itself is causing a health problem. Sometimes, like we mentioned before, it could also be because the baby is not doing as well on the inside, and we think that the baby would be better supported in the outside world, and what we can offer in the NICU.

Because of this, we want to try and make the labor process as quick as possible without harming the pregnant person or baby. Again, we do this because we think staying pregnant longer can make the health of the pregnant person or baby worse. So our patients may hear from their doctors different methods of trying to make labor go a little faster.

We understand that labor and birth is a very special time for parents, and we certainly will try to do everything that we can to make that experience as individual for each person as possible. However, we also want to make sure that both the parent and the baby are safe and healthy, and sometimes, that may mean speeding up the labor process.

I wish I could give you an absolute number for that but an induction can take anywhere from 12 hours, all the way up to 48 hours from start to finish! We know labor is a bit longer in first time parents. About 70-80% of first time parents are delivered within 24 hours of having their induction started. But that means that 20-30% will still be pregnancy after 24 hours. So it is a long process and it is important to be prepared for that. The process is a bit quicker for patients that have had a baby before. For them, about 90-95% are delivered within 24 hours and more than half are delivered within 12 hours. These percentages are somewhat based on which methods we use to start the induction and also how open and thing your cervix is as we talked about before. But that is about as much information as we know!

Today, we are joined by Dr. Dacarla Albright, an Ob/Gyn, who talks to us about recovery postpartum. 

We answer the following questions: 

1. I’ve had my baby… now what?

What I will tell our patients is that the postpartum period lasts for six weeks. So basically, that means that it takes your body six weeks to go back to working like it did before pregnancy. And there are some things that may change forever.

They should rest and recover from their delivery. And while that is easy to say, it is hard to do with a newborn. Most people will start to feel like they are back to normal usually a couple of weeks after they deliver, and this can vary depending on if you have a vaginal or cesarean delivery. But your life is changed forever, and people are especially vulnerable during this time. You likely will not get as much sleep as you did before. You probably will have many more responsibilities because of your new baby. You’re going to be tired. That is why it is very important for new parents to pay attention to their mood.

Especially people who have a history of anxiety, depression, or other mental illness, are at higher risk for postpartum depression. But postpartum blues or depression can happen to anyone. If you do feel like you are becoming irritable, you are feeling down, you’re crying all the time, or thinking about hurting yourself, hurting your baby, or other people, please reach out and call your provider’s office. We have resources to help you. We know that postpartum depression is very common.

Let’s first talk about immediately what happens when the baby and the afterbirth comes out. One of the things that we want to prevent is heavy bleeding, which can put a person’s life in danger. So, we usually will give a medicine through the IV, called Pitocin. If you don’t have an IV, we can give the same medication through a shot that goes in your leg.

Your provider will also check to make sure that your uterus is contracting down. They need to do that every fifteen minutes for the first hour after you give birth, and will continue to need to check at different times while you’re in the hospital. I know that it is not very comfortable, but please understand that it is very important to make sure that you aren’t bleeding too heavily.

Now, of course it is normal to bleed after birth. The bleeding after giving birth is called “lochia,” and may be bright red, dark red, and later on, will become brown. For most people it can start like a heavy period, but it should start to get lighter every day. It is normal to have some clots, especially after you have been sitting or laying down for a while.

However, if you are bleeding more than two pads an hour for more than two hours, that would be a reason to alert your nurse. Or, if you are at home, to call your provider’s office or come into the emergency room.

It is very common for people to have some tearing of the skin or muscle around the vagina. The area between the vagina and the anus is called “the perineum,” and this is the most common place to have tearing when the baby’s head comes out. Depending on how much you tear after delivery, that could determine how sore you are. Your doctor or midwife will repair these tears with stitches that dissolve on their own after a few weeks. Most people do well with just Tylenol and Ibuprofen.

Your nurse will usually give you ice to put on your bottom to help with the discomfort. You will also be given some numbing spray or pads and a spray bottle that you can fill with water to help clean down below, because it might be too uncomfortable to use toilet paper.  It is also common to have burning with peeing. Usually, the first or second day after delivery is when you will be the most uncomfortable because that is when swelling occurs and also when you start moving around more and doing more for yourself. Also, you won’t have your epidural.

It is also important to make sure that you are on a good regimen to help you go poop. Usually, your doctors in the hospital will prescribe you a stool softener, but sometimes, women will not poop until they go home. You should try to not become constipated, because pushing hard to go can be very uncomfortable, and in some cases, may open the stitches.

If you do become constipated, please let your providers know so that they can give you other medications to help with bowel movements.

Sometimes, there can be bigger tears. If you have a larger tear that involves the anal muscles or the rectum, your providers will tell you more about what to expect. We do know that women with bigger tears will have more discomfort, and may require stronger pain medications. It is even more important that you are on a good regimen to go poop, and sometimes, your doctors may put you on multiple medicines to ensure that you don’t become constipated. And your doctors will ask you to follow up sooner after discharge to make sure everything is healing.

So, in some ways, recovery is similar because you will have just had a baby, and the same things about checking in on your mood applies. However, remember that a C-section is major abdominal surgery! So it may take more time than after a vaginal delivery before you feel back to normal.

Most people will feel pain, discomfort, and soreness in their belly, particularly around the site of their incision, but it is normal to have pain in the whole belly too. Again, the first or second day after may be worse than the actual day of your C-section because all of your numbing medicine from your spinal or epidural has worn off, and you are now starting to do more for yourself. Some people even describe a pain that goes to their shoulder. This is because during the C-section, there is always some amniotic fluid and blood that we can’t remove from the belly. This fluid can irritate the lining of the inside of your belly, and even the lining right under your lungs since you were lying flat for surgery. That pain can actually translate to shoulder pain because of the nerves in your belly under your lungs!

It is important that you take the pain medications that your nurses and doctors offer you. While most of the time, Tylenol and Ibuprofen are enough, most people may need to take a stronger pain medication, like oxycodone. It is important that you take the pain medication you need in order for you to get up and move around. This is important for recovery, but also so that you don’t develop dangerous blood clots from not moving around.

That being said, most people only need oxycodone for a few days to a week after surgery. Oxycodone is a narcotic medication, so there are side effects like dizziness, nausea, sleepiness, and at very high doses, it can decrease your breathing rate. It’s why you always have to ask for it, and your nurses won’t bring it to you automatically without you asking. Like all narcotics, it can become addicting, which is why when you go home after a C-section, you are only prescribed a small amount. While we want you to be able to get up and move around and take care of your baby, we want to make sure that you first try the Tylenol and Ibuprofen if you can before you take oxycodone. 

It is also normal to have more burning or pain on one side of your incision compared to the other. This may be because that was the area that your doctor was working more on when doing your C-section, or that may be where the knots are tied on the inside.

Also, after the first few days, you may start to notice that the skin around the incision can start to burn or even itch. That is also a normal part of healing.

Things that are never normal after delivery is a fever, where your temperature is greater than 100.4 F, especially if the fever stays after you take Tylenol or Ibuprofen. Shaking chills are also not normal. This may be a sign that you have an infection, and you should call your doctor or go to the emergency room to be evaluated.

Other reasons to call or come in would be if you have 1) nausea and vomiting where you can’t keep anything down for 12-24 hours, 2) your bleeding is all of a sudden getting heavier and you’re soaking through two pads an hour for two hours, 3) your pain in your belly or on your perineum is getting worse even though you continue to take your pain medications, or 4) if you see redness and swelling around your incision site. Finally, if your doctors have asked you to check your blood pressures after giving birth, if your blood pressure is >160/110, you should also call or come in. Also, if you have bad headaches that don’t go away, changes to your vision, or pain on the upper right side of the belly, you need to call or come in as well.

Most of the time, things that we get concerned about are infection or pieces of placenta that did not come out immediately after delivery. So when you come in, your doctors will likely need to do a pelvic exam or look at your incision, as well as blood work. They may also do a breast exam, because another cause of infection is mastitis, or an infection of the breast.

Sometimes, your doctors may get imaging as well. If they do think that you have an infection or there are pieces of the placenta that are stuck inside, you may need to stay in the hospital for a few days to get antibiotics or a procedure to remove the pieces that are stuck inside. Of course, there are other things that can also happen, but those two are the most common.

If the reason you’re coming in is for blood pressure issues, then your providers might be concerned about “postpartum preeclampsia” which is preeclampsia that continues even after you give birth. They will likely do bloodwork and give you blood pressure medication. Some people may need to stay in the hospital if we are not able to control your blood pressures easily.

Today, we are joined by Dr. Kirstin Leitner, an Ob/Gyn, who answers our questions about what happens when we are 10 cm dilated, or what we call "the second stage of labor." 

1. What is the second stage of labor and how long does it take?

Before we talk about the second stage of labor, let’s go back and talk about how labor is divided up. The first stage of labor is when someone is contracting, and the cervix is changing, from 0 to 10 cm. This, I think, is what people traditionally think of as “labor.”

The second stage of labor starts when the person is 10 cm dilated, and ends when they give birth to their baby. And finally, the third stage of labor is after the baby is born, up until the placenta, or the afterbirth, is delivered.

People’s experience of second stage sometimes depends on if they are a first time mom or if they have had babies before. I want to highlight that pushing during the second stage is a hard process. It’s lots of work, just like exercising! Also, for a first time mom with an epidural, it can be normal to push for up to four hours, as long as they are making progress and pushing the baby’s head down in the pelvis. Not everyone needs four hours, of course! But most first time moms need maybe one or two hours of pushing, especially with an epidural, before they give birth.

With people who have had babies before, this is usually a shorter process. It can still be normal to push for up to 3 hours with an epidural, but many times, for people who have had babies before, it can even be just a few pushes before birth.

This time is also shorter for people who don’t have epidurals, simply because sometimes with an epidural, it may be difficult to feel exactly where to push. But without an epidural, you can’t mistake it!

What is key here is that we want you to listen to the guidance of your nurse, midwife, or doctor during this part of labor.

Pushing can be different for everyone. If something is working for that person, and the baby’s head is coming down through the birth canal, then that is the correct way for them! But, I also understand that for first time moms, this may be a challenge and they may need some more guidance.

We usually tell people to wait for a contraction to push, so that they are working with their bodies to give birth. We usually ask people to take in a big deep breath, hold the breath in their lungs, curl up around their belly, and push downward, into their bottom, almost as if they have to poop.  

The most effective way to push is to hold the push for as long as possible, usually about 10 seconds is what most people can manage. Then, because most contractions last anywhere between 30 seconds to 1.5 minutes, we ask our patient to try and push three times with each contraction. That means three times taking a big deep breath and pushing down, for a total of 30 seconds of pushing with each contraction.

So first, what is an episiotomy? An episiotomy is when your midwife or doctor uses scissors to cut a small portion of the skin or muscle on the perineum, which is the area between the vagina and the anus. This is usually done to allow for the baby’s head to deliver more quickly or to allow for other necessary procedures to be performed. Also, the thought used to be that if we cut an episiotomy, mom will have less tearing from the baby’s head coming out.

That being said, we don’t normally cut episiotomies anymore if everything is going well. We have many studies that now show that it is better for mom if we allow there to be natural tearing of the area from the baby’s head instead of cutting an episiotomy. If you do need to have an episiotomy, your doctor or midwife will tell you and explain why. But again, this is not something that we routinely do anymore.

Sometimes, pushing can be a very easy process, but sometimes, even though birth is natural, there are some things that can go wrong. That is why we always keep monitors on the baby.  In the Induction of Labor podcast, we talked about different types of monitors, including the contraction monitor and the fetal heart rate monitor.

Both of these monitors can be placed either inside the uterus or on mom’s belly, whichever is best to keep track of the contractions or the baby’s heartbeat.

If we compare labor to a marathon, the second stage of labor, or when mom is pushing, is very much like that last leg of the marathon. We know that both mom and baby are tired. This can be a very vulnerable time for the baby, and we always want to make sure by looking at the heart rate monitor, that the baby is not becoming too stressed out. We want to make sure that the baby is still getting good oxygen from the placenta.

Any time that we are afraid a baby is not getting enough oxygen from the placenta during labor, we have to think about 1) how do we correct that so baby can get the oxygen it needs or 2) if we can’t correct it, how do we deliver the baby soon so that the baby can start to breathe and get oxygen on its own.

Inside the uterus, the baby will get oxygen from the blood flow from the placenta, so sometimes, the problem is as simple as the baby is laying on its umbilical cord. That can certainly decrease blood flow to the baby! If this happens, we may ask someone to move to a certain position, like on their side, when they are pushing so that the baby rolls off of the umbilical cord. Other times, we may give a person more fluid through the IV so that there is more blood flow to the uterus.

But sometimes, if we try all of those things, and they don’t work, we need to think about delivering the baby very quickly because we want to prevent the baby from being deprived of oxygen for too long. As we said before, a baby that is deprived from oxygen for a long time can have brain damage or even pass away.

There are two ways of delivering baby quickly: 1) C-section, and 2) assisted vaginal delivery.

We all wish that everyone can deliver their babies vaginally. This is usually the best way for both the pregnant person and the baby. The pregnant person has a shorter recovery time, and the baby often has an easier time transitioning from living inside the womb to the outside world. However, as you can imagine, it may not always be the safest thing for baby if the baby is not getting enough oxygen from the placenta and we think it may be several hours before the pregnant person can push out the baby. That could lead to other very serious complications for the baby that we want to prevent.

This is usually when we would talk to our patients about having a C-section. We will go more into details about what exactly happens during a C-section in our episode called, “Reason for Having a Cesarean Section,” so I won’t go into that too much here. However, you can imagine that if mom has been pushing for a long time, and the baby’s head is very low in the pelvis, trying to deliver the baby through a C-section may be harder because the doctor has to reach their hand into the pelvis to get to the baby’s head. Sometimes, it may also take more time for us to get the patient to the operating room, wash off their belly, give them antibiotics, and perform the surgery.

If the baby’s head is low enough in the pelvis, and we think that the baby would otherwise fit through the pelvis, we can sometimes offer what’s called an “assisted vaginal delivery” or “operative vaginal delivery.” 

An assisted vaginal delivery is exactly what it sounds like: it is when a doctor helps someone to deliver the baby through the vagina, usually much more quickly than they would be able to on their own.

It is overall very safe in the hands of a trained physician. The biggest risk of both of these procedures is causing a bruise or mark on the baby’s head or face that usually goes away in a short time after birth. Very rarely are there other complications, like some weakening of a face nerve of the baby, but again, this usually goes away after a few weeks. Another rare complication is bleeding that occurs under the baby’s scalp. Permanent injury is very rare, and if we look at studies, the rate of permanent injury is about the same for patients in this situation who choose to have a C-section instead.

Remember, we do not perform these procedures if everything is going well. We only take on these risks because we think that if we do not deliver the baby quickly, there could be even worse outcomes for the baby from having low oxygen levels.

We only perform assisted vaginal deliveries for two reasons: one we already talked about, which is if the baby needs to come out very quickly and is low enough in the pelvis. The second is for the pregnant person. Some people have heart conditions where they cannot push for very long, and may need to be assisted in their vaginal deliveries so that they don’t put too much strain on their heart. Another reason would be if someone has been pushing for a long time and is too tired to continue pushing. Then, if the baby is low enough, we can also help.

But overall, the chances of a patient needing an assisted vaginal delivery is very low. Right now, only 3% of all births in the United States are done through assisted vaginal delivery.

Like we talked about before, there are actually three stages of labor, and finally giving birth means that we are only done with two of the three stages. We usually will perform something called “delayed cord clamping,” meaning that we will allow for some more blood flow from the placenta to the baby so the baby can have a good buildup of blood.

Once the baby’s cord has been cut, we will start to deliver the placenta. Luckily, this is a more passive act. Usually, your doctor or midwife will have you relax, and they will put one hand on your belly. With their other hand, they will put pressure on the remainder of the umbilical cord that is still attached to the placenta. The placenta will slowly start to detach, and you may feel some pressure as the placenta comes down the birth canal as well. We may ask you to push a little at the very end so that the placenta can come out.

Then after, the nurse, midwife, or doctor will push very, very hard on the top of the belly over the womb to massage the womb and get it to contract down. This is uncomfortable, but we need to do it to prevent too much bleeding. We will give you more medicine through the IV, called Pitocin, which will help the uterus contract as well and prevent bleeding. Sometimes, if mom is having more bleeding than normal, we may need to do more exams and give more medications that are injections.

It is very normal for some people to get tears in the vagina or on the skin between the vagina and the anus, called the perineum. You can also have tears in the muscle of the vagina. Unfortunately, while we do all we can during the delivery to support this area, some tearing cannot be prevented.

Most of the time, your midwife or doctor can repair these tears quickly, meaning in about fifteen to thirty minutes, after you give birth. If you have an epidural, you will already have numbing medicine going through the epidural to help you with the discomforts of the repair. If you don’t, your doctor or midwife can inject lidocaine, which is a numbing medication, into the area that they have to repair. For more information on this, please listen to the Complications of Labor and Birth Podcast!

Today we are joined by Dr. Florencia Polite, an Ob/Gyn, who discusses with us reasons for having a C-section. 

We answer the following questions: 

1. What is a cesarean section?

• A cesarean section, or C-section, as many people call it, is a type of abdominal surgery that allows your doctor to get the baby out from the womb through an incision or cut on your belly--often near your bikini line. It is very common -- about 30% of babies in the United States are born via C-section.

• In a scheduled C-section, you would have talked to your doctor beforehand, and you will be scheduled for a C-section on a specific date. You will be asked not to eat or drink anything beforehand, for about 8 hours. You can still have clear liquids like black coffee or water up to 2 hours beforehand. You will have your blood drawn, and you will meet with an anesthesiologist right before to talk about expectations for anesthesia. 

Just like anywhere else on your body, if you get injured there, you can have a scar. When you have a C-section, your body will also create a scar. That scar is not just on your skin. It can actually scar all the way down to your uterus. Sometimes, when you have scarring inside your belly, it can cause different things inside your belly to stick together in ways that wouldn’t happen without having surgery. So for example, it could cause your bladder to be stuck to your uterus. Because of this, every C-section you have can make your next surgery harder, because it will change the normal anatomy around. Your surgeon has to be very careful, which can make your second, third, or fourth C-section take longer.

For every single C-section, the pediatricians are there to assess the baby. If everything looks ok with the baby, sometimes we can bring your support person to see the baby or even bring the baby over to you. However, it may take another thirty minutes to an hour for your surgeon to sew everything back together. It takes that much longer because we want to make sure that we are putting everything back together correctly. Once we are done there, we will bring you and your support person to the recovery area.

3. What are the different types of C-section?

Now, most patients will have something called a “low transverse” C-section. This means the cut that we make on the uterus, not on the skin! Most people will have a “bikini cut” or a cut that goes very low on the belly that is slightly curved and horizontal. The “low transverse” means that you also have a low, horizontal cut on the uterus on the inside.

There are other types of cuts that can be made on the uterus. These are not as common, but may need to be done to help get the baby out. Some words that you may hear are things like “classical” C-section, which is a vertical cut on the uterus. You may also hear “T-incision,” which means that the incision on the uterus looks like an upside down T.

The main difference is that if you have had one previous low transverse incision (or even two, depending on certain things) you could have a trial of labor with your next pregnancy. Of course, you should talk to your provider about this to see if it is the right decision for you. However, if you have a classical or T-incision on your uterus, you should not labor again, because there is a higher risk that that inside incision could open up, which would be very dangerous for you and your baby.

4. Why is a C-section necessary?

For a scheduled C-section, we already talked about one of the reasons, which is a previous C-section with one of those scars: a T-incision or classical C-section. Another reason would be if you have had three or more C-sections. We do not recommend that you labor after that many C-sections. Patients can also, of course, decide that they have an elective C-section, which means that they choose to have a C-section. Some patients may also have medical problems that make having a vaginal delivery unsafe, but your doctor would let you know if that is the case. And finally, one of the most common reasons is if the baby is not head down.

There are some studies that show that if a baby is breech (or butt down), that there can be some increased risk for babies if they are born vaginally, like getting stuck. There are even more risks if the baby is in a different position, like if the feet are coming first, or if the baby is transverse, or lying horizontally. We really do not recommend having a vaginal delivery if baby is not head down. If your baby is not head down, though, your doctor can also talk to you about other options about trying to turn the baby,  but we won’t discuss that here

Most of the time, if we are doing an urgent or emergent C-section during labor, it is either for mom or for baby. In terms of baby, most of the time it is because we think that the baby is not getting enough oxygen and is in distress.

While labor and birth are both very natural things, sometimes things can go in a way that we don’t plan. During labor, the uterus contracts a lot to open the cervix to allow for a baby to come down into the birth canal so that they can be born. These contractions can be stressful for both mom and baby. While we understand that contractions are very uncomfortable for mom, it can cause a different kind of stress for baby.  Some babies just don’t tolerate these contractions very well, and they show us signs that they may not  be getting  enough oxygen during labor. We can detect signs of that on the labor monitor, which we put on almost every mom and baby. Of course, these monitors are not foolproof, but if the baby is telling us that they may not be getting enough oxygen, we may talk about a C-section with you to get the baby out as soon as possible. Not having enough oxygen for a baby could mean something very bad, like brain damage or death.

There are lots of other reasons. We also talked about reasons for mom. One of the more common ones could be that mom reaches full dilation of her cervix, but is not able to push the baby out. Sometimes, some babies are just too big for certain moms’ pelvises. If that baby is not able to come out of the vagina, then that is another reason for a C-section.

Another reason is if mom has been in labor for a long time, but her cervix is not changing. Usually, that by itself is not a reason for us to do a C-section, and we can sometimes give medication to give mom more powerful contractions to change the cervix. But if her cervix is not changing for many hours that might be a reason why we talk to you about a C-section.

When this happens, this is usually an unplanned C-section. While the surgery itself is usually the same as a planned C-section, some of the things we do to prepare for the surgery is different. For example, if it is an emergency and you don’t have an epidural, the anesthesiologists may have to put you to sleep so that you don’t feel the C-section. But if you already have an epidural, usually the anesthesiologists can use that to give you more medicine so you don’t feel the C-section. 

Today we are joined by Maggie Power, a midwife, who talks to us about the normal labor process. 

We answer the following questions: 

1. What is labor?

Labor is when a pregnant person has uncomfortable contractions of their uterus, or womb, and their cervix starts to open. If everything goes as expected, at the very end, the person is able to push and deliver their baby (or babies) vaginally.

There can be many reasons for contractions other than labor. Some are normal and expected, like Braxton-Hicks contractions. Braxton-Hicks are practice contractions, which feel like painless tightening of the uterus, which is preparing your uterus for labor, but doesn’t open the cervix. Other reasons for contractions may include things like dehydration. If you are less than 37 weeks along and having more than four contractions in an hour that don’t go away with rest and hydration, constant pain or if you are having painful contractions, and don’t feel that it is normal, please call your provider or come into the hospital to be evaluated.

This is a common worry, especially if it’s your first baby. Most of the time, when someone is in labor, they will have consistent, painful contractions that get more and more intense with time. Usually, these contractions don’t go away or get better with anything you do and take your full attention. Most low-risk, first time moms can follow the 5-1-1 rule. If you are having painful contractions every five minutes, each contraction lasts a minute or more, and this has been happening for an hour, it may be time to call your provider or come in. The contractions should be intense. You may have to breathe through them, and you may not be able to talk through them.

Of course, you should always have a discussion with your provider if you have any further questions or concerns.

While contractions may be uncomfortable, it does not always mean that the cervix is opening.  A cervical exam may be discussed to assess for labor progress.  A cervical exam involves placing two fingers into the vagina and measuring with the fingers how dilated (or open) the cervix is. If you are in labor, the cervix will gradually open eventually to about 10cm. 

Sometimes, even if you’re having contractions, your cervix may not yet be open, or may only be open a few centimeters. Depending on your comfort level and your provider’s, they may let you know that you’re still early in labor, and can likely go home and be more comfortable there.

The reason we don’t recommend admitting everyone as soon as they start to have contractions is that sometimes in early labor, contractions can go away or get less intense. This early part of labor is called “latent labor,” and for some people, contractions might start and stop over the course of several days. We wouldn’t want to keep people in the hospital for days unless we absolutely have to! There are many ways and tools to stay more comfortable at home.

That’s why your provider might tell you to go home and come back if the contractions become closer together or more intense. 

Some people might hear that if you’re 4 cm or 6 cm you’ll definitely get admitted, and while it’s more likely you’ll be admitted the more dilated your cervix is, there are no definitive answers. This is because some people may be walking around very comfortable at 3 or 4 cm dilated at full term, and they don’t necessarily have to be admitted. However, sometimes, if we see issues with the baby or if a person has a higher risk pregnancy, we might admit them even earlier, like at 2 cm. Everyone is different. For most patients without previously discussed risks, I recommend to call or come to the hospital if you are experiencing the 5-1-1 rule, vaginal bleeding, think that your water is broken, or if the baby is not moving normal for you (kick counts less than 10 in 1-2 hours).  

However, if you have broken your water, and we have confirmed it, we would usually recommend admission.  

First, we have to do a lot of stuff upfront to make sure that you and your baby are safe and comfortable during your hospital stay. This MAY include putting in an IV in case we need to give fluids or medicine later. We also usually get bloodwork unless you have bloodwork that is up to date. This bloodwork includes blood counts, what blood type you have, and tests for some sexually transmitted infections, like HIV and syphilis. We also usually do an ultrasound to make sure that baby is head down.

We also check on your baby.  This can be done by different types of monitoring which can be continuous or intermittent.  Many people will also get two monitors on their belly: one is to listen to the baby’s heartbeat, and the other is to monitor your contractions. If you are low risk, and don’t have an epidural in place, we can also do something called “intermittent monitoring.” This is when your provider or nurse will listen to the baby’s heartbeat every once in a while to make sure that it is still normal with your contractions. When you get further in your labor, your provider will need to listen more often. Also, if there are any abnormalities in the baby’s heart rate, we would recommend that you be placed on the monitor continuously.

While labor is uncomfortable, it leads to meeting your baby which is often different than a lot of pain that we have experienced in our lives. It is typical that contractions are painful for about a minute and then go away.  It can be helpful for you and your support people to know what is normal to make the labor process a little less scary or overwhelming.  There are many ways to deal with discomfort in labor that don’t include an epidural. One way is to keep moving in different positions, even if you do have an epidural in place. There are also lots of different positions that people feel more comfortable in, like standing, rocking, sitting on a birth ball, being on all fours, side-lying, squatting or leaning over the bed. You don’t have to labor lying down! There may be circumstances where it is safer for you to remain in bed which will be discussed with your team. When an epidural is in place, it makes the legs heavy, and we can assist you to move around in your bed.  We can help you find a position that you are most comfortable.

Some people also bring in things to help them relax. Always discuss with your provider if certain things are ok to bring, as we don’t allow for certain items like candles because of open flames (however, battery operated are ok!). Many people will bring music or essential oils. Some people might have their partners or support person give them a massage. We have aromatherapy scents and locations available for use- lavender and ginger. Also, heat packs can be very soothing to the back or lower abdomen. We also have lots of birthing balls that you can use as well. Also, hydrotherapy or water therapy can feel great.  I encourage this prior to coming to the hospital whether that is a shower or bath.  We also have showers in every room if monitoring allows.  Some people also find that a doula is helpful. A doula is a certified person that can provide guidance and support during your pregnancy and labor course. This can be arranged prior to labor or we can contact to see if one is available when you come to the hospital to deliver your baby.  (Could discuss TENS units, they were popular for pt’s to bring at my last hospital)

And finally, if you do need to get an epidural, that is also ok. I think of it as another tool in the toolbox. Go check out our podcast on anesthesia in labor to find out more.

Everyone is different. There are some people who are only in labor for a few hours, but there are some people who are in labor for much longer than that. Usually, we say that people who have had babies before tend to have shorter labors, but again, that is not always the rule! Even for many of us who have been doing this for many years, it is sometimes hard to predict how long someone will be in labor.

Your provider will check your cervix periodically to see how you are progressing, and you should also tell us how you’re feeling during your labor.

I will also add that some people may have some vomiting during labor, especially when they are close to having their baby. Also, some people may experience shaking right before, during, or after delivery. All of this is very normal, and we see it all the time.

“Normal” has a wide range, so what is normal for you may not be normal for someone else. But if you or your provider are concerned about your progress in labor, there are certain things that we can do to help make the labor go a little quicker.

One of those things is to break the bag of water around the baby. This may make the contractions more intense. Another thing we offer is a medication through the IV called Pitocin. Pitocin is just the brand name for the hormone that your own body makes called oxytocin. Oxytocin is something that a pregnant person makes during labor, and it helps to create contractions and continue the labor process. Essentially, we are just giving you a synthetic hormone your own body makes to put you into labor.

If Pitocin is used, we do recommend that you and your baby be on the monitor at all times so we know how much of the medication should be given. Alternative options may include nipple stimulation.  This is when the nipple is stimulated either manually or with a breast pump.  This typically makes the body release more oxytocin hormone to bring on more contractions. 

Pitocin, when indicated, can be a helpful tool to increase the power or strength of the contractions to help the baby move towards delivery.  We have some studies that show that Pitocin or inducing labor itself does not increase the rate of C-section. But just like anyone who is in labor, there is always a risk of needing a C-section. For more information on that, please listen to our specific podcast on “Reasons for having a C-section”!

Usually, once someone is 10 cm, the pregnant person may feel the urge to push. Sometimes, if an epidural is in place, there may be less of that sensation. You may feel the urge to push or if not, we will work together to starting pushing with your contractions to help your baby out. I want to highlight that pushing during the second stage can be a hard process. It requires lots of work, just like exercising! Also, for a first time parent with an epidural, it can be normal to push for up to four hours, as long as they are making progress and pushing the baby’s head down in the pelvis. Not everyone needs four hours, of course! But most first time parents need maybe one or two hours of pushing, especially with an epidural, before they give birth.

With patients who have had babies before, this is usually a shorter process. It can still be normal to push for up to 3 hours with an epidural, but many times, for people who have had babies before, it can even be just a few pushes before birth.

The time is also shorter for people who don’t have epidurals, simply because sometimes with an epidural, it may be difficult to feel exactly where and how to push.

What is key here is that we want you to listen to your body, and we will work together as a team including your support people, nurse, midwife or doctors in this process of meeting your baby. 

Today, we are joined by Dr. Jennifer Mccoy, a Maternal Fetal Medicine specialist, to answer our questions about complications of labor and birth. 

We answer the following question: 

1. How common are complications in labor and birth?

• While most people have safe, normal labor, sometimes, even pregnant people who are at the lowest risk can have problems or complications during labor and birth. Some of these cannot be predicted until they arrive and are in labor.

• The pregnant person 

Sometimes, during pregnancy or in labor, the pregnant person can develop high blood pressures even if they have never had high blood pressures in the past. This is very unpredictable, and is not caused by anything anyone does. However, we know that it can come on very suddenly. While we don’t really know why this happens, we know it is due to the placenta and the pregnancy itself because the only way to help cure it is to give birth.

Having new high blood pressures in pregnancy is called preeclampsia. Preeclampsia has many different forms, from a more mild form called gestational hypertension, to the most severe form called eclampsia.

In the more severe forms of preeclampsia, the disease can cause damage to the pregnant person’s kidneys, liver, lungs, and even brain. It is very, very dangerous, and in its most severe form can cause seizures, stroke, and even death. Some symptoms to watch out for are headaches that don’t go away even with medicine like Tylenol, severe pain on the upper right part of the belly, and spots in their vision that don’t go away.

Because preeclampsia can cause people to be very sick, we have to watch them very closely. The only way to resolve it is to give birth, and that is why if pregnant people are diagnosed with it, they need to have a conversation with their doctor about how best to manage it, and also when to give birth so that there is a balance between the risk of that person becoming very sick vs. the risk of baby being born too early.

For baby, the things that we worry about include how the baby is doing during labor -- meaning is baby getting enough oxygen and nutrients--and an abnormal labor course - meaning the cervix is not dilating or the baby is not coming down through the birth canal when the pregnant person is pushing.

When that baby is inside the womb, they get all of their oxygen and nutrients through the placenta. So, there is a little bit of a filter. It’s not really like if the pregnant person eats an apple, the baby also eats part of the apple. Instead, mom’s body will process the apple and give the nutrients to the baby through the placenta through blood flow. So that even when mom is not eating, the placenta is always giving baby oxygen and nutrients through the baby’s umbilical cord.

During contractions, there is decreased blood flow to the uterus. Most of the time, the baby and the placenta have enough reserve that this doesn’t bother the baby. However, if the placenta is not working well, or during a contraction the umbilical cord gets pushed on, then you can imagine that the baby is not going to get enough oxygen.

We can tell by the way the baby’s heart rate is on the baby’s heart rate monitor. A happy, healthy baby’s heart rate monitor pattern looks like a squiggly line. Sometimes, the heart rate will go up a little and then come back down to normal. If the placenta is not working, or if the baby is laying on the cord, the heart rate monitor will show baby’s heart rate dropping to an abnormal point before coming back up. Your doctor, midwife, or nurse can interpret the monitor, and they may try different treatments, like fluid, or stopping your contractions for a while to give the baby a break. They may also ask you to change your position a few times to see if there is a position that gets the baby off of the umbilical cord.

It is very common for have some tearing of the skin or muscle of the vagina and the area called the perineum, which is the place between the vagina and the anus. This is caused by the baby’s head or even arms or hands when the baby comes through the birth canal.

Most of the time, the midwife or doctor can repair these tears quickly, meaning in about fifteen to thirty minutes, after birth. If you have an epidural, you will already have numbing medicine to help you with the discomforts of the repair. If you don’t, your doctor or midwife can inject lidocaine, which is a numbing medication, into the area that they have to repair.

We grade the tearing from one to four. One is when there is a small tear in just the skin. Two is when there is some tearing of the muscle, and three and four means that there is some tearing into the anus, which is rare. If you have a grade 3 or 4 tear, your doctor may talk to you and move you to the operating room for repair because there is usually better lighting, and our anesthesia providers can give you more medication to make you comfortable. Usually, these tears take a  few weeks to fully heal, and it is why we ask that you don’t put anything in the vagina for a full six weeks after delivery. It can be uncomfortable before then, and, it can also cause the stitches that we put there to open or become loose. After a few weeks, when the area has healed, the stitches dissolve.

It is normal to bleed after having a baby. In fact, pregnant people’s bodies account for that by increasing the total amount of blood that is in the body during their pregnancy. This is to help with the amount that is lost after delivery. However, in a small percentage of cases, they may have too much bleeding. We always take precautions against too much bleeding, to keep people from losing too much blood

Even before you start your labor course, your doctors will have talked to you about some things that we can do. One of those things is that they will ask if you would accept a blood transfusion if you have too much bleeding such that it could threaten your wellbeing or even your life. It is very important that if you have religious or cultural reasons for NOT accepting blood transfusions that you tell your provider immediately so that they can make a plan with you about what to do in the event of an emergency.

However, sometimes, if the bleeding is caused by there being a piece of the placenta or afterbirth that gets stuck inside, then we may need to remove that piece of placenta, which involves either being in the delivery room or in the operating room. Very rarely do we have to do other procedures, like a hysterectomy, to get the bleeding to stop. While that sounds very scary, I want to emphasize again that that is very, very rare.

The best way to treat it is to remove the cause. Since the source of infection is the pregnancy, it is best to deliver your baby as soon as you can. You can still have a vaginal delivery, but an infection may be the reason your doctor or midwife suggests some medication to increase your contractions to speed up labor. It is also important for the baby, because by being in the infected womb, the baby can also get an infection and will need treatment after birth.

The other way of treating an infection is with antibiotics, and so if you show any signs of infection, your doctor or midwife will also start antibiotics to help treat the infection. But like I said before, the best treatment is to get rid of the cause of infection. So even though we give antibiotics, we still need to get baby delivered!

Today, we are joined by Dr. Jenny Dworzak, an anesthesiologist, who talks to us about anesthesia. 

On today's podcast we answer the following. 

1) What kinds of medication-based pain relief are available for labor?

• IV pain medications: most have short-lived effects and require repeat dosing with a limit to benefits and more side effects (itching, nausea) for mom, most can affect baby’s heart rate and breathing and may increase the need for more resuscitative efforts for baby when baby is delivered; may interfere with baby’s ability to breastfeed immediately following delivery

2) If I have a high pain tolerance, is there any benefit for me to get an epidural?

• Yes, when the body has a stress response to pain, it releases substances that can slow the contractions of uterus and decrease blood flow to the uterus which houses baby. Also certain breathing patterns associated with painful stimuli can affect baby’s heart rate during labor.

3) How long does placing an epidural take? 

• On average about 10-15 minutes with a few minutes for setup beforehand a few minutes for setup of the pump afterward. This can be longer in patients with anatomical variations or increased soft tissue overlying the spine. It takes another 15-20 minutes for the standard epidural medication used on our floor to have an appreciable effect on contraction intensity.

4) When should I ask for an epidural? And when is it ‘too late’? 

• This is a personal decision. Once the epidural is placed you will remain in bed and a nurse will catheterize you every 4 hours to eliminate urine from your bladder. Some moms who want to walk around their room or otherwise be more mobile prefer to wait until a significant amount of discomfort before requesting an epidural.

5) What should I do while getting an epidural? 

• Always face forward in a straight line with your arms and legs in front of you.

6)  Does getting an epidural hurt? 

• Before localizing the space in your back with the epidural needle, your anesthesiologist will inject local numbing medication into the skin and soft tissue overlying your bones. This numbing medication can sting slightly before it creates a numbing sensation that makes the rest of the procedure much more comfortable. Throughout the epidural you may feel pressure and manipulation but the local anesthetic will blunt sharp pain.

7) Can I be paralyzed by an epidural? 

• Extremely unlikely. A rare complication of an epidural that usually occurs in patients that have risk factors for bleeding or an inability to clot blood because they have underlying medical problems, blood count aberrancies, or are on blood thinners is an epidural hematoma, which is a bleeding collection that can compress the spinal cord. The rate of this complication is 1/160,000-190,000 epidurals.

8) Is there anyone that can’t get an epidural? 

• Your anesthesiologist will make an informed decision and involve you in the process if you are not a good candidate for an epidural. If this happens, it is most likely because you have a risk factor for bleeding, an infection at the site where an epidural might be placed, active neurological symptoms or disease, or certain heart conditions.

9) What will I feel during labor if my epidural is working properly?

• You may feel pressure with contractions but a lessened intensity of each.

10) When does an epidural wear off? 

• On our labor and delivery floor, we run medication through your pump every 45 minutes during labor. In addition, you have the option of pressing a button that can provide an extra bolus every 10 minutes. You will not run out of epidural medication during labor. After the epidural is paused, greatest effects of the standard medication we use in labor epidurals on our labor and delivery floor will wear off by 2 hours. Several factors, including exactly which medication was used, how long the epidural was running, how much volume of medication was in the space, and anatomical variation may cause the epidural medication effects to last a little longer.

11) What if my epidural doesn’t work? 

• There are ways we can troubleshoot why it’s not working by making sure the catheter is in the right space, giving the right amount and strength of medication, and in some cases replacing the epidural into a slightly different space if the situation calls for it. A very small % of epidurals don’t work after extensive trouble shooting. This may be because of an anatomic variation/changes due to prior injury/procedures that don’t permit the medication to spread to all the required nerves, abnormal labor patterns.

12) Will an epidural give me a headache? 

• There are many reasons for a headache developing around labor and delivery.

13) Will an epidural give me a backache?

• There are many reasons for back pain surrounding pregnancy, labor and delivery. Most studies that have looked at epidurals specifically have demonstrated no difference in back pain rates in moms that received epidurals for labor pain vs those that did not in the absence of any epidural complications.

14) Is an epidural bad for baby?

• Baby sees only negligible amounts of the medications we use on our labor and delivery floor.

15) Will an epidural slow down my labor?

• There is no reproducible evidence that suggests that the current low-dose motor-sparing epidural medications that we administer on the labor and delivery floor slow labor time, increase rate of C-sections, or change outcomes in baby. There is also no reliable evidence that timing of the epidural changes labor duration.

16) Can I just go to sleep for a C-section?  

• While general anesthesia (going all the way to sleep and having an anesthesiologist take over breathing for you) is considered generally safe in young, healthy patients, being pregnant makes it far more risky for both mom and baby. So, we don’t routinely recommend general anesthesia for standard C-sections unless there is a life threatening emergency or a pre-existing medical condition that necessitates it.