Pregnancy: Labor and Delivery

hildbirth is one of the most memorable and rewarding events of a couple's life. No matter how often a woman gives birth, each experience is an intimate and unique celebration of life. Though labor and delivery are not without pain and some degree of anxiety, if you remain confident, well-informed and fully supported by your partner and your doctor, you're likely to have no problem handling the awesome task of bringing a child into the world

Because the unexpected can happen at any time, you may not always be able to control every aspect of your labor and delivery, but don't let this bother you. You can maintain a sense of emotional control by asking questions, challenging assumptions about routine procedures, and openly sharing your hopes and fears with your partner and your physician. Whether you deliver vaginally or by cesarean section, receive anesthesia or experience “natural” childbirth, use a hospital delivery room or birthing center, the experience is yours alone, and every decision will be made in your best interest and that of your child.

Toward the end of your pregnancy, you eagerly await the arrival of your child as the culmination of nine months of careful planning and preparation. If this is your first child, you may feel a mixture of excitement and nervousness when you think about the delivery. And to be perfectly honest, you may also feel restless and irritable as the growing baby exerts greater demands on your body.

This jumble of emotions is completely normal and natural. As your due date draws near, you'll want to know exactly when labor will start and when your baby will be born. But although the process of labor is well understood, no one knows exactly why it starts, and your doctor won't be able to predict either the start of labor or how long it will last. Your due date is a best estimate, but only about 5 percent of women who carry their babies to term actually deliver on that day. The rest deliver from several days to several weeks before or after their due dates.

Nevertheless, you may begin to notice changes in your body that are commonly recognized as signs of impending labor. During a first pregnancy, the baby may “drop,” or engage in the birth canal 2 to 3 weeks before labor begins. You may suddenly feel as though you can breathe more easily, though the increased pressure on your bladder may also cause you to urinate more frequently. In subsequent pregnancies, this “lightening” may occur only a few hours before labor.

The irregular contractions you may have experienced throughout your pregnancy or the third trimester may increase in frequency and intensity. You may have a sudden burst of energy, often referred to as the “nesting instinct,” and feel compelled to take on a major domestic project, such as waxing a floor, baking bread, or reorganizing a closet. Hours to days before labor, the small mucus “plug” that has sealed your cervix throughout pregnancy may begin to stretch, then break apart as the cervix shortens and thins out in a process called “effacing.” Once this occurs, pink-tinged mucus, or “bloody show,” may be discharged from your vagina.

When you notice these signals, you should begin to finalize plans for the care of other children, arrange your transportation to the hospital, and call your doctor for last-minute instructions. Pack a small suitcase, placing any items you will need during labor in a separate bag. Continue to practice any breathing techniques you may have learned during childbirth preparation or Lamaze classes. They can help to distract you from pain and relax you during labor. (See the box “Breathing Techniques Help Bring Relief.”)

One additional sign often indicates that labor is imminent. The downward pressure of the baby's head against the amniotic sac may cause these membranes to rupture. The breaking of your “water” can occur as a trickle or a gush of odorless, colorless amniotic fluid. Alert your medical attendants as soon as this happens. Once the sac has broken, labor is imminent, often beginning spontaneously within 12 to 24 hours. In fact, in many women, the membranes don't rupture until labor is already underway.

Once your water breaks, keep your vagina clean to minimize the risk of infection. Don't take a bath, douche, or engage in sexual intercourse. Be prepared to describe when and how the membranes ruptured, and also be alert to any discoloration of the fluid—from yellow or tan to brown or green. This indicates the presence of meconium, a waste product discharged by your baby's bowels, which can be an indicator of fetal distress.

When Labor Begins

Your uterus is a powerful muscle that tightens and relaxes rhythmically during labor, allowing the cervix to stretch open and help to push your baby through the birth canal. Although every woman's labor is different, at the outset, you may begin to feel a pattern of dull cramps similar to menstrual cramps in your lower back or pelvis. If these remain regular for an hour or more, last at least 30 seconds, and gradually increase in intensity—even if you change position or move around—your labor has begun.

Your physician will probably have given you some guidelines about when to contact him or her once labor begins. If this is your first pregnancy, stay home awhile, so you can relax and remain unencumbered by the hospital routine and environment. Take a walk, catch a nap, enjoy a long shower, sip liquids (clear liquids only), read a book, or engage in any activity that will entertain and distract you and allow you to preserve your energy. Most physicians recommend that during a first labor, a woman wait until contractions are five minutes apart for an hour before coming to the hospital or birth center. In subsequent pregnancies, you may be advised to come sooner, since your labor can progress much more quickly.

You should contact your physician immediately if you notice any vaginal bleeding other than the pinkish “show,” if the baby doesn't move for an unusually long time, or if you have constant, severe pain rather than intermittent contractions. These signs can indicate such potentially serious conditions as placenta previa, in which the placenta may be blocking the exit from the uterus, or placental abruption, in which the placenta begins to prematurely separate from the uterus and limit the baby's oxygen supply. If your physician suspects any complications, you'll be asked to come to the birth center as quickly as possible so your condition can be checked and your baby can be monitored throughout the remainder of your labor.

LABOR FROM BEGINNING TO END

As the first contractions of labor begin, the baby's head lies waiting on the inner side of the still-closed cervix (A). During the early and active phases of the first stage of labor, the cervix begins to open (dilate), finally reaching a diameter of 8 centimeters (B). In the transition phase that follows (C), the cervix dilates an additional 2 centimeters and the baby's head advances towards the birth canal. During the second stage of labor (D and E), the baby's head emerges from the birth canal, followed almost immediately by the rest of the body. In the third stage, which quickly follows delivery, the placenta and membranes are expelled by a few final, weak contractions. From start to finish, the process averages 12 hours for a first baby, less for later children.

After you are admitted to the hospital, your physician, nurse or birth attendant will want to discuss the events leading to labor. Your vital signs will be checked and recorded, and special attention will be paid to your baby's fetal heart tones and fetal heart rate (FHR), both important indicators of the baby's response to the stress of childbirth. You will be asked when you last ate and how much you consumed. Be sure to tell your physician if you want your partner or older children to be present at the delivery, or if you have made any other special arrangements.

Unless there's concern about complications such as placenta previa or the risk of infection, your doctor will perform a vaginal examination to check the baby's position, the dimensions of your pelvis, and the effacement and dilation of your cervix. A blood sample may be taken and a urine specimen may be tested for protein. You should challenge any hospital procedures that seem medically unnecessary, such as extensive shaving of your pubic area or administration of an enema. There is rarely any need for these outdated rituals, but though they have been eliminated in many birth centers, they persist in some institutions.

Depending on the status of your labor, your baby's position and heart rate, and additional factors such as a previous cesarean delivery or a post-term pregnancy, your physician may recommend electronic fetal monitoring now or at some point during your labor. Many hospitals routinely use external electronic FHR monitoring for 20 to 30 minutes after admission to establish the baby's baseline heart rate and check variations, such as beating slower during uterine contractions. If you need fetal monitoring, the doctor or birth attendant will place two belts around your abdomen to hold two small monitoring instruments in place.

Once your membranes have ruptured, the baby can be monitored internally with a small electrode threaded through your vagina. At the same time, if there's any question about the force of labor, your doctor may place a small plastic tube, or catheter, in your uterus to measure the strength of your contractions.

Numerous studies comparing continuous FHR monitoring and listening to the baby's heart rate with a stethoscope or other device have shown little difference in detecting fetal distress during labor in an otherwise uneventful pregnancy. If your baby's heart rate is normal and your labor is progressing steadily, continuous monitoring is probably unnecessary—and unduly restrictive. Instead, your birth attendant should encourage you to walk around, lean against your partner, urinate when necessary or simply change positions to stay as comfortable as possible.

Occasional intervals of FHR monitoring may still be recommended throughout labor. You will need continuous monitoring only if there are any signs of fetal distress, such as the presence of meconium-stained amniotic fluid, vaginal bleeding, a drop in your blood pressure, or an interruption in your cervical dilation despite regular contractions.

The Stages of Labor

Labor is divided into three stages. The first stage begins with the onset of contractions and ends when the cervix is fully dilated (to 10 centimeters). The second stage involves delivery of the baby, and the third stage entails delivery of the placenta and membranes, or “afterbirth.” Although the length of labor varies considerably, women experiencing their first full-term childbirth usually have the longest labors. About half will exceed 12 hours, and 2 in 10 will last longer than 24 hours. After the first baby, labor is usually shorter. Three-quarters of women deliver within 12 hours, and only one in 50 labor for more than 24 hours.

The first and longest stage of labor has three distinct phases: the early, or latent, phase; the active phase; and the transition. During the early phase of labor, contractions are often widely spaced—perhaps 10 minutes or more apart—and feel like a tightening or pulling in your back or groin. They can vary considerably in frequency and intensity. At this point you may feel excited, sociable and talkative, or you may be a bit nervous. Most women remain at home during this phase, during which the cervix dilates from 0 to 4 centimeters, and later arrive at the birth center in active labor.

The Active Phase

As you progress from the early to the active phase, your attention focuses completely on labor. Your contractions occur about 3 minutes apart, last about 45 to 60 seconds, and become more centered in your abdomen. They also become stronger and more rhythmic, peaking and receding like waves.

Your determination may waver during this phase of labor. Extra reassurance from your partner and birth attendant can help you stay focused. Breathing exercises and other relaxation techniques also become more important as your cervix dilates to 8 centimeters—nearly wide enough to allow for your baby's birth.

During the active phase, you may begin to long for relief from the pain and tension of labor. Though medication is an obvious solution for your discomfort, you must consider the safety of the baby. Many drugs cross the placenta and affect the baby, making its heartbeat and breathing more sluggish throughout the remainder of labor and after delivery. For this reason, many doctors recommend concentrating on one contraction at a time and relying on your partner, rather than medication, to help maintain your focus.

If your pain is so intense that it actually impedes your progress, however, medication may help you to relax so that contractions can remain steady and vigorous. Two basic kinds of pain medication—analgesics and anesthetics—are used during childbirth.

Analgesics will relieve most of the pain. Drugs used include Demerol, Sublimaze, Nubain, Stadol, morphine, and fentanyl injected into a muscle or vein. These medications are not designed to provide a pain-free labor, but, in appropriate dosages, they can make you more comfortable.

Potential side effects of these drugs include nausea, vomiting and an abnormally fast heartbeat. They present some additional risk to the baby, but if handled properly pose no significant threat. Large doses, however, can interrupt your labor pattern, and if this happens, additional medications such as oxytocin (Pitocin, Syntocinon) may be needed to reestablish strong contractions.

Regional anesthetics completely eliminate the pain. The most common types used during labor include:

Paracervical block. Medication is injected into your cervix, usually during the first stage of labor, to provide you with pain relief from contractions and dilation without interfering with the urge or ability to push. This drug may not work properly in up to one-third of women, and it must be repeated every hour to maintain numbness. It is no longer used frequently.

Pudendal block. The anesthetic is injected through the vaginal wall during the second stage of labor to relieve pain in the perineum (the area between the vagina and the rectum). It may be used in an otherwise unmedicated childbirth. The medication does not interfere with the urge or ability to push and generally masks the effects and repair of an episiotomy—the incision made to enlarge the vaginal opening.

Spinal or saddle block. A single injection of regional anesthetic is made into your spinal canal, numbing the complete lower abdominal and perineal area. This type of anesthetic is rarely used during labor but may be suggested if a forceps or cesarean delivery is required. Administration of a spinal block completely removes the urge to push and may lower your blood pressure. In rare cases, it causes a severe headache when it wears off.

Epidural or caudal block. A needle holding a thin, flexible tube is threaded into the space between your spinal cord and your vertebrae. When the needle is removed, the anesthetic can flow continuously through the tube. Like a spinal block, this procedure provides full pain relief in the perineal area. Dosages can easily be changed or discontinued. Most physicians consider the epidural block to be the optimal method of pain relief for uncomplicated labor or non-emergency cesarean births because it allows a woman to remain fully alert. Nevertheless, the anesthetic requires up to 20 minutes to take full effect and may leave a painful “hot spot”. In addition, it may diminish uterine contractions, bringing on the need for oxytocin. The risk of a forceps delivery is also increased.

Transition

Transition is the time when the cervix dilates the final two centimeters. This is the most difficult phase of labor, and produces the hardest, longest, and most frequent contractions. Fortunately, transition is relatively short, sometimes lasting for only two or three contractions. Even in a first labor, transition rarely takes longer than one hour.

During transition, contractions occur every two to three minutes and last 60 to 90 seconds. You have little relief between them, and their intensity may cause you to feel frightened and overwhelmed. While you may have enjoyed your partner's presence and physical touch throughout the early part of labor, transition may suddenly make you feel withdrawn, irritable, and short-tempered. You may develop chills, become nauseous, or feel the urge to have a bowel movement. These physical sensations reflect the descent of your baby into the birth canal and can become more intense as you enter the second stage of labor.

Though you may feel overwhelmed by the power of your own body, transition is not the time to begin analgesics. The best strategy for withstanding transition is to cooperate with your contractions instead of fighting them. Heating pads, hot water compresses, changes in position, breathing exercises, music, meditation, and visualization techniques all can serve as effective alternatives for pain relief. Even women who have received a regional anesthesia may want to consider withdrawing their medication as their cervix nears full dilation so they can begin to feel their contractions and push more effectively.

Common Complications of Labor

The rate of cesarean births in the United States has skyrocketed from 5 percent in the 1960s to nearly 25 percent since the 1980s. Many factors have contributed to this increase, including the frequency of repeat cesarean delivery, the use of electronic fetal monitoring, the declining use of vaginal breech and forceps deliveries, and the drift toward surgical intervention for “failure to progress” in labor. While cesarean delivery is certainly safer today than during the 1960s and obviously indicated in extremely high-risk situations or emergencies, it still causes a higher rate of maternal injuries than vaginal delivery.

Cesarean delivery is often accepted as the inevitable outcome to a complication arising during labor. Based on the experience of the past two decades, however, most experts agree that surgical intervention is not always in the best interests of the woman or baby. In order to make an informed decision, it's important to understand some of the common complications that can occur during labor.

Premature Rupture

Most women begin labor spontaneously when their membranes rupture and their pregnancies have reached full term. When labor does not begin within 12 to 24 hours, the situation is described as “premature rupture of the membranes” (PROM). Because PROM certainly plays a role in high cesarean rates, more doctors are proceeding with a quick induction of labor after a PROM at full-term. Although the “wait-and-see” approach has been associated with fewer cesarean deliveries than the use of oxytocin to stimulate contractions, one large study has concluded that induction of labor using vaginal suppositories containing prostaglandin E2 is a viable option for handling PROM—especially in women experiencing a first labor. In the study, the rate of cesarean section in the women who received prostaglandin was half that of those who either received oxytocin or waited for the onset of labor.

Failure to Progress

Physicians generally agree that once active labor has begun, a woman's cervix should dilate 1.2 cm to 1.5 cm per hour. Sometimes dilation falters during the active phase despite regular contractions. This condition is known as “failure to progress.” Because labor can be interrupted for a variety of reasons, the immediate cause is not always clear to the woman or her physician. Should this occur, your doctor will perform a pelvic exam, check your vital signs, and monitor the baby for a short period of time. If all appears well, he or she can take a hands-off approach or consider the possibility of “actively managing” your labor.

A number of procedures are effective in reestablishing labor. If your amniotic sac has not yet broken, your doctor may suggest breaking it manually, a procedure known as amniotomy. Because rupturing the membranes commits a woman to delivery, this can be a risky strategy during the latent phase, when false labor is always a possibility. Several research studies have concluded, however, that amniotomy performed during active labor actually shortens its duration by up to 2 hours. Moreover, the rate of vaginal delivery increases, and there is no added risk of injury to the woman or baby.

Physicians disagree on how to handle the 10 percent of pregnancies that extend beyond 40 weeks. The main goal is to avoid injury or death to the baby due to lack of oxygen or intake of meconium in the lungs—established risks in post-term pregnancies. Some doctors advocate inducing labor at 41 to 42 weeks, while others recommend fetal monitoring until labor begins spontaneously. In one large study of women with post-term but otherwise uncomplicated pregnancies, the induction of labor resulted in a lower rate of cesarean delivery, mainly because there was less fetal distress. In any event, few clinicians allow a pregnancy to continue past 42 weeks. In these rare instances, labor is often induced with prostaglandin gel or oxytocin.

Pelvic Size

Certain variations in a woman's anatomy also can lead to complications during labor. During vaginal delivery, the baby must be propelled through your pelvic area by the contractions of your uterus and your own “bearing down.” In general, a woman's pelvis is large enough and shaped properly to allow for the baby's passage. In fact, unless you have a history of pelvic fracture or bone or neuromuscular disease, your physician should not discourage you from trying a natural delivery strictly on the basis of your pelvic dimensions. Even if your pelvic area is smaller than average, it may still be big enough for your baby if the rest of your labor progresses normally.

Nevertheless, in some cases, the size of the baby's head does exceed the dimensions of the birth canal. If this happens, labor will almost certainly fail to progress during the second stage; and the first stage of labor may be irregular as well. If the size of the baby is the cause of a woman's “failure to progress,” she will need a cesarean.

Position of the Baby

In more than 95 percent of full-term labors, the baby's head is “presenting” —pointed toward— the cervix. Typically, the baby's head is tucked against its chest, with the crown of the head facing the birth canal in preparation for delivery. In some unusual situations, a baby's face, forehead, or top of the head is presenting. If the baby remains in either of the latter two positions throughout labor, a cesarean delivery may be necessary since the broadest part of the baby's head may be too wide to clear your pelvis. A full-face presentation is very rare. Unless you've already had several children, your physician will almost certainly insist on cesarean delivery should this occur. Vaginal delivery increases the risk of injury to the baby's neck or spinal cord.

DANGERS OF A BREECH PRESENTATION

When the baby passes head-first through the birth canal—as it does 95 percent of the time—the rounded top of the cranium has a chance to mold to the contours of the passage and slide through without incident. But when the baby is delivered buttocks or feet-first, the chances that the head will be caught in the narrow canal increase dramatically. Deaths following breech deliveries are 4 times more likely than normal, usually as a result of nerve damage or suffocation. A breech presentation is now generally considered a signal for cesarean delivery.

When the baby's buttocks or feet are presenting at labor, the position is commonly called “breech.” Prior to the 1960s, when cesarean delivery carried much higher risks for the mother, these infants were nearly always delivered vaginally, even though they faced a greater risk of injury or death during childbirth. Safer cesarean procedures have all but eliminated the rigors of labor for breech babies. Nevertheless, some physicians are attempting to reduce the incidence of breech cesarean deliveries by attempting to reposition the baby just prior to labor—a procedure known as “external version.” Documented reports indicate that version is often successful, though 1 out of 3 babies may revert to breech presentation afterwards, and there is a risk of complications such as a twisted umbilical cord. An attempt at vaginal delivery in a breech presentation under well-managed conditions, including continuous fetal monitoring, is gaining some support within the medical community.

The position—or attitude—of the baby is another consideration in determining the safest method of birth. More than 99 percent of the time, a full-term baby lies vertically in the uterus. In the remaining cases, known as a transverse lie, the baby's back faces the birth canal. A baby in this position when labor begins almost always must be delivered by cesarean.

A Past Cesarean

More and more women are being encouraged to attempt a vaginal birth, after a previous cesarean delivery (VBAC). If you are considering VBAC, you and your doctor need to discuss several factors, including the type of incision made in your uterus during your previous cesarean delivery, the size of your pelvis, whether you are carrying twins or have a breech presentation, and certain medical conditions you may have, such as diabetes or high blood pressure. Despite the slightly higher risk, none of these factors necessarily eliminates the VBAC option.

Fear of uterine rupture has been the reason most often cited for the outdated medical dictum, “Once a cesarean, always a cesarean.” Rupture of a uterine scar can result in the baby's death and severe injury to the mother. Nevertheless, widespread adoption of the low transverse, or horizontal, cesarean incision in the uterine wall has dramatically reduced the risks faced in future vaginal deliveries. Moreover, many of the factors that led to an initial cesarean—breech presentation, fetal distress, failure to progress—may not be present during a second labor. Counterbalancing the risks is the fact that vaginal delivery has fewer complications and a shorter recovery period than a cesarean.

In 1988, the American College of Obstetricians and Gynecologists issued guidelines making VBAC a preferred, rather than optional, procedure under most circumstances. Specifically, the College recommends that women with one previous low transverse cesarean should be encouraged to attempt labor in a later pregnancy, and women with two or more low transverse incisions should not be discouraged from trying vaginal birth. However, the group cautions that women with a classic vertical incision should not risk labor, and it advises physicians offering the VBAC option to have the staff and equipment available to perform an emergency cesarean if necessary.

MEASURING LABOR IN CENTIMETERS

The second stage of labor officially begins when the baby's head settles into the upper end of the birth canal, 3 centimeters from the center of the pelvis. When the top of the head reaches the center point, the baby has achieved “0” station. Three centimeters later, the baby has reached the lower end of the birth canal, and delivery is underway. This centimeter-by-centimeter advance can last more than 2 hours—or be over in 15 minutes!

Vaginal Delivery

When the widest part of the baby's head has settled into the birth canal, it is said to be engaged, or positioned for the second stage of labor. At this point, your contractions may slow to four or five minutes apart and become less intense. Your birth attendant will encourage you to push when each contraction begins and will monitor the baby's “descent” on a regular basis. When the baby's head is even with the lower bones of your pelvis, its position will be recorded as “0” station. As the baby's head continues to move through the birth canal, the stations will be identified as +1, +2, +3, etc., in reference to the baby's progress in centimeters.

Throughout the second stage of labor—which can last from 15 minutes to more than 2 hours—your baby will continue to descend through the birth canal. As the force of your contractions, combined with your conscious pushing, propel the baby, you may become very tired—especially if your labor has been long or rigorous. Most women find, however, that the second stage of labor is physically and emotionally satisfying. The contractions are often easier to tolerate, and your excitement over the baby's imminent birth usually outweighs your fatigue.

Your partner can help at this point by bracing you as you push. If you're attempting a VBAC delivery, don't hesitate to push vigorously. The nine months of pregnancy and the rigors of your labor have provided a reliable test of your incision's strength.

As the second stage of labor progresses, the perineal area between the vagina and rectum will begin to stretch. Your doctor may make a small incision or episiotomy, in this region, to prevent the perineal skin from tearing during childbirth. Though fewer physicians advocate episiotomies as a routine part of every delivery, they are still commonly performed. Some women vigorously object to episiotomies as the antithesis of the natural birth process. If you have strong feelings about this procedure, tell your physician or birth attendant beforehand.

THE EPISIOTOMY ISSUE

As the baby emerges, there's a chance that skin between the vagina and anus will be stretched to the breaking point. To prevent uncontrolled tearing, many physicians routinely make the minor incision called an episiotomy. Because the procedure is considered routine, if you don't want it done you should be sure to let your doctor know in advance.

As your baby approaches the bones and soft tissue of your pelvis, its pliable head will mold slightly to the contours of the birth canal. Once its head slips under your pubic bone, delivery is imminent. At this juncture, your partner can help support your back or legs, or with the delivery itself.

As the top of your baby's head appears, or “crowns,” your birth attendant will apply subtle pressure with one hand while reaching beneath your pelvis to prepare for the baby's birth. In rare cases, forceps or vacuum extraction may be necessary to help guide the baby's head through the birth canal.

At this point, you may be told to pant, rather than continuing to push, so the baby's head can be delivered gently rather than bursting out. You may want to watch the birth in a mirror. When the head is through, your birth attendant will check to ensure that the umbilical cord remains free of the baby's neck. He or she will then immediately clear the baby's mouth and nostrils of mucus. With your next contraction, the attendant will deliver the baby's body, then clamp and cut the cord. As soon as the infant's general condition has been assessed—usually using Apgar scores—you will be able to cuddle and enjoy your baby.

Within a few minutes of birth, your rapidly diminishing uterine contractions will cause the placenta to separate from the uterine wall. Generally, you can expect the placenta to be expelled rapidly. You may be given oxytocin to stimulate contractions while your uterus is massaged to reduce bleeding. If you delivered by VBAC, your birth attendant will carefully check your old incision for any evidence of injury.

The doctor will examine the placenta, and inspect your cervix and vagina for any tears or bruises. If you have had an episiotomy, the doctor will stitch it closed. In the meantime, you and your partner will probably be oblivious to these final details as you share the joy of your new child.

Cesarean Delivery

Despite its detractors, cesarean delivery continues to be one of medicine's most important and—often lifesaving—operations. Physicians continue to recommend cesarean delivery when they consider labor unsafe for either mother or baby, when delivery is necessary but labor cannot be induced, when the baby's size or presentation precludes vaginal birth, and when a medical emergency occurs.

A cesarean may be called for if the placenta is blocking the exit of the uterus (placenta previa), if you have had a classic cesarean incision, or if you have a history of uterine surgery or abnormalities. If such medical conditions as diabetes mellitus or hypertension threaten the baby's welfare, you may need preterm cesarean delivery if labor induction fails. Cesarean birth also is a safe alternative when anatomical problems of the uterus or birth canal prevent successful vaginal delivery.

Maternal or fetal emergencies necessitate immediate delivery. These include untimely separation of the placenta from the uterus, bleeding from placenta previa, protrusion of the umbilical cord, or an active vaginal infection such as herpes. Roughly one-fifth of all cesarean deliveries are prompted by an emergency condition.

Although repeat cesarean delivery is no longer mandatory, approximately 40 percent of women attempting VBAC ultimately require another cesarean. If this occurs, you should be proud of your efforts and never feel that you have failed yourself or your baby.

Cesarean deliveries are classified by the type and location of uterine incision. The two most common incisions in the United States are vertical cut in the upper portion of the uterus—often called a “classic” incisiony—and the transverse, or “Kerr” incision in the lower portion of the uterus. The transverse incision is a safer procedure than the classic.

Although a variety of anesthetic techniques are used, an epidural block is often the anesthesia of choice for a cesarean delivery. During a particularly difficult or emergency cesarean, when there's no time to wait for an epidural anesthetic to take effect, the doctor may use general anesthesia. Though it can slightly increase such additional risks to the mother as the chance of inhaling gastric backflow (aspiration) and the danger of cardiac or respiratory arrest, the value of the surgery usually outweighs the risks of anesthesia. The baby usually suffers no harm because delivery often takes place before the anesthesia has time to cross the placenta.

Prior to surgery, a nurse or attendant may wash and shave your abdomen and cleanse the area with a special antiseptic lotion. You will probably need a catheter to remove urine from your bladder during the operation and will likely be given an intravenous (IV) line to provide you with additional fluid.

As the cesarean delivery begins, the physician will cut open your abdomen and uterus in quick succession, rupture the membranes, and carefully guide the baby's head through the incision. You may feel a tugging sensation around your abdomen. The baby's mouth and nostrils will be suctioned, then the body gently delivered. The entire process can take less than five minutes.

Once the doctor has checked the baby, you or your partner may be able to hold the infant while the doctor manually removes your placenta, checks your uterus, and begins to stitch the incisions closed. The doctor will gently massage your uterus to expel any blood clots. You will be carefully watched for any signs of bleeding or infection during the period immediately following the birth.

Possible complications of cesarean delivery include fever, wound infection, bleeding, aspiration during general anesthesia, urinary tract infections, inflammation of the endometrium and blood clots. Complications are estimated to occur in 25 percent of all cesarean operations; the mother dies in roughly one out of every 1,000 cesarean deliveries. As many as one-fourth of these deaths are related to anesthesia.

Most women should begin walking within a day of their cesarean delivery, when a urinary catheter is no longer necessary. You can usually start eating a soft diet on the day after the operation, and you'll probably leave the hospital approximately 3 days after delivery. During your recovery, you may have to use a stool softener and a mild pain reliever. You will probably need to visit your doctor 2 to 3 weeks after leaving the hospital so he or she can examine your incision and remove any sutures or staples.