When Labor Slows

There I was: six days past my due date and feeling as bloated as a whale. So when my first labor pains began at 3 A.M., it was a relief. A recent exam had been encouraging; I was 2 centimeters dilated and the baby was in "take-off" position, head down and engaged. The contractions came about 20 minutes apart throughout the early morning but then abruptly stopped at 9 A.M., just as I was about to call my midwife. By afternoon I was desperate, so my midwife suggested I try taking castor oil. It was disgusting. It gave me a brief bout of diarrhea, but lo and behold, labor started quickly at 8 P.M. I soon delivered a healthy baby girl. If pregnancy sometimes feels like your own personal odyssey, then the start of labor signals the last leg of the journey.

With the end in sight, it becomes even more frustrating when labor doesn't follow a progressive course. "Slowing down happens most often in early labor," says Sylvia Blaustein, a certified nurse-midwife who practices in New York City. "It also is more likely to happen to first-time moms." During early labor (also called the latent phase) the cervix becomes fully effaced and dilates to 4 centimeters or so. Contractions can be irregular and are usually mild. "You hear people say, 'I've been in labor for five days,'" says Allen Toles, an obstetrician-gynecologist at Long Island Jewish Hospital in New York, "but they really haven't started active labor."

Active labor is when contractions increase in frequency and intensity and the cervix dilates from 4 centimeters to 10 centimeters. Toles says that women who are nearing or past their delivery dates sometimes mistake strong Braxton-Hicks contractions for the real thing. Others might notice labor sooner, staying awake with five-second contractions that are 20 minutes apart, for example. When the pains stop or slow down, it seems like labor has halted. Although early labor may stall, women should be assured that it is helping the body prepare for birth. During these fits and starts, the uterus is contracting and the baby is moving into a good position for birth. But if early labor stalls after the 41st week, practitioners suggest some techniques to start it again.

The simplest one is to relax; have a warm bath and get some rest. Now is the time to pamper the mom. She deserves a back rub, a foot massage, a comfortable bed, and relaxing music. Disconnect the phone and, if possible, send the other children to a friend's house. "I've seen it work really well; a woman rests and things suddenly pick
up," says Blaustein. Once a woman is rested, she can try to get labor going by taking walks, climbing stairs, or even having sex. If a woman's labor is slow or stalled but she has already started dilating and the baby is in a good position for birth, some midwives recommend taking castor oil. This unpleasant oil can cause diarrhea, but it doesn't hurt the baby and can be effective at starting up contractions.

A more pressing reason (than being overdue) to get labor going is that a woman's membranes have ruptured. Most hospitals set time limits once this happens. At Virginia Mason Medical Center in Seattle, where nurse-midwife Judy Lazarus practices, the policy is that women need to begin active labor-either by medical induction or on their own-24 hours after membranes rupture. In some practices, routine management of ruptured membranes includes the expectation that women will deliver within 24 hours. The reasoning behind this decision is that the risk of infection rises once the amniotic sac is broken. This is especially true for women with certain medical conditions, or if the woman has had several pelvic exams to check the cervix.

Lazarus had a patient whose membranes ruptured at 8:30 A.M. on a Tuesday. An exam showed no problems, so the woman returned home, where she spent the night having mild contractions. By the time Lazarus saw her again, 30 hours had passed and they began to discuss using Pitocin, a drug that is used intravenously to induce or augment labor. The woman was set against using Pitocin, worried that it could lead to other medical interventions. Instead Lazarus did an internal exam where she stretched the cervix. She told her patient that she'd let her go another nine hours, then she'd have to start Pitocin. The woman walked for several hours, rested, then she and her husband did nipple stimulation for an hour and a half-it's a natural way to get the body to release oxytocin, the active ingredient in Pitocin. It worked: Four hours later, Lazarus' patient
delivered a healthy baby girl.

Jennifer Hammer, 32, also of Seattle, had planned to have her baby at home. Then her labor failed to speed up 48 hours after her water broke, she used acupuncture treatments and also took black cohosh, an herb believed to induce labor. "It was by far the easiest labor I had," says Hammer, mother of three.

If labor slows or stops altogether during its active phase, it can signal a problem; the pelvis might be too small to accommodate a large baby or the baby might be in the wrong position to descend further. There is clinical evidence that epidurals, given to relieve pain, can also stall labor, says Toles. Sometimes dehydration can prevent labor from progressing, so simply supplying fluids can get labor going again. Obviously, if labor fails to progress and the mother or baby begins experiencing problems, it is imperative to get labor going as quickly as possible, usually by augmenting with Pitocin.

In the end, labor is an individual experience. Some women progress quickly through every stage and deliver after just six hours of contractions. Others poke along in early labor for several days or go back and forth to the hospital while contractions begin and then stop. Just as every labor is slightly different, so too are practitioners' attitudes. Talk to your midwife or doctor beforehand about issues such as how long to wait for delivery after your water breaks or what techniques they might use to augment labor.

Induction. The rate of induction more than doubled between 1989 and 1998, the most recent date the figure was actually calculated. When a woman is induced, she has technically not begun labor. If labor has begun and a woman receives Pitocin, that is called augmentation. According to Richard Henderson, an obstetrician/gynecologist at St. Francis Hospital in Wilmington, Delaware, the reason for this increase in the number of women being induced is that "we have much better antenatal testing, so we are able to identify fetuses in trouble before a woman goes into labor."

More precise and detailed ultrasound exams are able to show if a baby is not growing or moving adequately. There are other reasons for inductions. In Lazarus' practice, post-date pregnancies and ruptured membranes are the most common reasons for induction.

Although a mother and baby can be doing well after the delivery date, careful monitoring is necessary to be sure the placenta is still nourishing the fetus and that there is adequate amniotic fluid to cushion the baby. Practitioners will also check the mother's blood pressure and other vital signs. In some cases, practitioners are now less willing, in these circumstances, to wait for a woman to go into labor on her own. Part of that is worry about lawsuits, says Toles, and part of it is that induction techniques have improved so that the risks of waiting outweigh the risk of inducing.

Elective inductions. A final reason for increased inductions is the rise in elective inductions-cases in which either the prospective parents or a practitioner choose the procedure for nonmedical reasons. Examples include a woman who lives far from the hospital and is worried she won't make it in time once labor begins, or another woman who is feeling a lot of discomfort late in her pregnancy or may have a partner who is available only at certain times. Jodi Brumble, a home-healthcare marketer in Scottsdale, rizona, found out that her doctor was going to be away at the time she was due to deliver. She decided she wanted to have him induce her before he went away because she feared delivering with a stranger. Elective induction is not risk-free. Studies show that it leads to more cesarean deliveries in women who are having their first babies and significantly increases the length and costs of hospital stays.

The chances of a successful induction increase greatly when a woman is already somewhat dilated, the baby's head is engaged, and the woman has already had one previous vaginal birth. In some cases, practitioners will use creams or suppositories that contain prostaglandin-hormone-like substances that "ripen" the cervix, causing it to thin and dilate. The cervical-ripening agents alone can sometimes start contractions, but more often Pitocin is needed to get active labor going. Because Pitocin can cause more intense contractions, most women choose to have pain relief-either Demerol or an epidural-while they are being induced.

Induction can also cause a cascade effect of unintended interventions, especially in first births. A Pitocin-induced labor is more painful, and the mothers often request pain relief earlier in labor. When epidurals and narcotic-like drugs are used, it can slow the progress of labor, and higher doses of Pitocin are needed to move the labor forward. Pitocin can cause enough distress in the baby that additional interventions, such as forceps, vacuums or a cesarean section are needed for the baby's safety. That is why elective induction in a first-time mother should be carefully evaluated.

* taken from "Come On, Baby," by Naomi Freundlich, Every Baby magazine, Issue Four