AROM, Cervical Checks, Epidural, Failure to Progress, Fear, Fetal Malposition, First Baby, Home Birth, Labor, Long Labor, Midwife, Midwife's Assistant, optimal fetal positioning, start-and-stop contractions, Vaginal Exam

Long Labors: Part 2, Physiologic Strategies

Long Labors: Part 2 is a follow-up to Long Labors, Part I.

We don’t need to feel entirely helpless when labor lasts a long time. The following physical strategies can help shift challenging labor patterns and keep a person’s strength up:

Consider that you may not be in labor at all. Start-and-stop contractions patterns are not that uncommon.

When I was a very new midwife, I had a first-time couple who had a lot of faith but also a lot of fear. During the last few days of her pregnancy, my client would start having contractions right around dinner time. By midnight, she was beside herself with panic, and would call me to the house. I’d spend an hour or so with her, monitoring the baby and doing my best to be a comforting presence. She would decline a cervical check, which is fine. The contractions would eventually stop, and I’d head home to bed around 2 AM. This went on two nights in a row.

Mama was coping ok because she was on maternity leave with no other little ones who needed minding, and could sleep as late as she needed the next morning. I was worried about wearing out:  I still had to be up early for office visits and shifts at the birth center.

On day three I called the clients midday with a plan: “Tonight we’re going to do a dinner-time phone check-in, rather than waiting til midnight when you are alone and panicking.” That night, nothing about her contraction pattern was different, but checking in by phone somehow helped. They never called me to the house and I slept through the night.

On night four, she answered the dinner-time phone call and commented that “something’s changed.” It was bound to happen – they called me to the house around 10 PM, and her 9 lb, 3 oz baby was born at home 12 hours later.

Unfortunately, your care provider can’t tell you when the start-and-stop pattern will turn into “real” labor. Do what my client did and reach out to your care provider for strategies and reassurance. Rest, rest, rest if you can. Please know that your care provider needs to get some rest, too, not because she doesn’t care about you, but because she cannot responsibly attend a birth if she is hallucinating with sleep deprivation.

Simply waiting out a long early labor. There are countless excellent blog posts and birth books that will encourage you to “do nothing” and wait out a longer labor. Keeping your energy up with food and drink is essential. Keeping your spirits up can be more challenging. Surround yourself with support, or shut the world out. Whatever works best for you. This is a great strategy for first time birthers who fall under the category of “slow and steady wins the race.” There often isn’t anything the matter; it just takes first-time bodies more time to open up!

“Should we get labor going?”  When a laboring person is having a long early labor, parents and doulas often ask me, “How do we get labor going?” I usually answer, “Please don’t.”  I’ve developed a healthy aversion to forcing labor. It more often results in disappointment and exhaustion than a productive, active labor.

When considering the possibility of a short cord or other complications, trying to force labor to happen can be useless at best, and at worse, dangerous. When considering the possibility of a malpositioned baby, why would we try to shove a poorly positioned baby down further into the pelvis?

People will usually report that getting in certain positions will “bring on” labor, and other positions will space out the contractions. Consider spending more time in positions that slow down labor, as a way of releasing your expectations and allowing yourself rest.

Stay out of squats in early labor (avoid the birth ball, too). Yes, squatting opens up the pelvic outlet a great deal, but in early labor your baby’s not yet moving into the outlet. When you open up the pelvic outlet, the inlet closes to compensate, possibly keeping baby a high baby from dropping.

My general belief system is: When labor is ready to work, it will work. If getting labor going is a medical need, or the laboring person has truly reached the end of their ability to cope, that’s ok! Transitioning to hospital for a Pitocin/epidural combo might do the trick and your baby can at least be monitored for safety.

Hydration and Nourishment: Contractions will be more painful, frequent and unproductive when the laboring person is dehydrated or exhausted. In a “what came first, the chicken or the egg?” fashion, dehydration can cause contractions, and contractions can contribute to dehydration.

Many women vomit during labor. For the pukers, it can be tempting to “slam” fluids between bouts of vomiting. This will only make you more likely to vomit. Have one or two very small sips after each contraction, or set an alarm to remind you to have just a few bites of food every hour or two. This may help keep the nourishment down. Assign someone on your birth team the job of putting a beverage in front of your face every other contraction. Bendy straws are an essential tool so that the birth team can offer fluids when the laboring individual is in any position.

Vomiting is usually due to pain and hormonal changes, in which case you have little control. If you think vomiting and nausea may be due to fear or anxiety, use your usual grounding techniques.

Some vomiting during labor is normal.  Not being able to keep anything down for hours upon hours is potentially dangerous. If you are puking a lot, IV fluids can work magic. Advocate for yourself.

Rest. Learn to snooze between contractions. No, it will not be the best sleep of your life, but it will take you far. Benadryl (check in with your care provider before taking meds) or a glass of wine can help for those women who feel comfortable with “downers.”  Some women report that when they lie on their side their contractions are worse, so staying upright is more comfortable…but then they can’t sleep. Seated positions in which you can lean forward and support your head in between contractions may help.

Many people find that they feel very sleepy towards the end of labor, just before they start pushing. This is not a bad thing – let yourself drift off! You need the rest and you’ll get a big rush of adrenaline when you start to push.

Differentiate between early and active labor. Many women will dilate far less than a centimeter per hour, starting at 4 cm. What happens before 4 centimeters is wildly variable:

First time pregnant people will usually start labor with a closed cervix and experience their first 4 cm as some kind of labor pattern, which can last for many hours or a few days. Usually the contractions are short, less painful, and more widely and unevenly spaced.

Some of early labor doesn’t involve any dilation at all. Your cervix is still ripening.Your care provider might not even want to check your cervix because she knows there will be nothing very useful to report.

So, when your contractions are 4 minutes apart or longer, with the duration of each contraction less than minute, and you are able to watch a movie and laugh at the funny parts, I’m going to guess you are 0-4 centimeters dilated. And I would expect nothing more. The great news about this is that an early labor pattern will rarely put stress on the baby. Thus, you are encouraged to stay home from the hospital or birth center, or if you are planning a home birth, to hold off on calling the midwife to the house.

Active labor starts at 4-6 centimeters. The contractions are longer (usually 60-90 seconds), much more painful, and closer together (2-3 minutes apart, and very regular). At this point there is more potential for stress on a baby or mother, and you are so much closer to giving birth, which is why 4-6 cms is considered “admit time,” for many hospitals, birth centers, and home birth providers. At this point, monitoring becomes more important and everyone will be present for second stage (pushing).

Most people who are experiencing labor for the first time tend to over-estimate how far along they are, which results in disappointment and feelings of failure, even though the care provider isn’t concerned at all and, clinically, you are doing great.

Knowing this, would you go out to a movie in early labor? Get some chores done around the house? Try and get some sleep? I’ve had moms get up and go to their actual jobs while in early labor. While this is not my expectation, I believe it served those women very well to have something to do while waiting for active labor.

Cervical Scarring.If you’ve ever had any surgeries or biopsies related to your cervix, consider that you may have some scar tissue that could slow the cervical changes needed to let a baby out. Tell your care provider about it.

I typically recommend cervical ripening measures in pregnancy such as breast pumping or acupuncture. Some midwives will recommend vaginally inserting evening primrose oil to soften the cervix, however one study linked this to premature rupture of the bag of water. I recommend against EPO for this reason.

If you have a lot of cervical scarring and you are in very active labor, your midwife may manually break up the scar tissue with her fingers, with your permission, of course.

Optimal fetal positioning. When early or active labor seems to go on forever, or when the laboring person is having a lot of pain in their back, we must consider a malpositioned baby.  Another sign of a poorly positioned baby is contraction or abdominal pain worse on one side than the other, or a contraction pattern that gets more and more painful but continues to be very irregular.

There are several excellent resources with many specific ideas for repositioning babies before and during labor.

If you are laboring without experienced labor support, do not be intimidated by all the fancy suggestions. Most of these positions, movements, and techniques are harmless. So if the laboring person seems to be having difficulty, trying any technique that feels intuitive isn’t going to do any damage, and may help a lot!

An experienced doula or midwife will have a better handle on the anatomy of your particular situation and will be able to come at it with a little more sophistication.

I really like rebozo work. The effects are two-fold: Having one’s belly or buttocks shaken allows for relaxation of the belly and pelvic muscles, and the shaking movement can manually dislodge a funny-positioned baby, which is now more free to move because the birthing person is more relaxed! Most laboring people report that the rebozo just feels good!

Rebozo can be done at home or in the hospital with a traditional rebozo or a king-sized pillow-case or a bath towel. I know some doulas are afraid to do rebozo without the ability to listen to a baby. They are worried that the baby might shift onto its cord by the shaking action. I stop to listen to babies periodically during rebozo to make sure this very thing isn’t happening (midwives can auscultate baby heartbeats, which is typically out of a doula’s scope of care). I’ve never had a baby react poorly to the rebozo, so I don’t really worry about people spending some time doing it at home without medical supervision. But it’s something to keep in mind.

Consider calling an acupuncturist or a chiropractor to the labor. Find out in advance of labor if your chiropractor or acupuncturist might be willing to go on call for you.  When we adjust the laboring person, often a baby adjusts. Regular chiropractic work during pregnancy can be beneficial to balance the pelvic bones and muscles and prevent malposition.

Position of baby is not always clear or easy to ascertain. Sometimes we guess at a position of the baby based on labor pattern. Sometimes a provider will be able to get an idea of position by feeling for landmarks on the head. Occasionally, an ultrasound machine might be used to check position…

…But, and this is a REALLY BIG BUT:

Even if we think we know position, we still cannot predict whether the baby will shift into a better position or will remain stubborn. All we can do is rotate through our strategies and keep mama’s spirits and strength up. Labor is old-fashioned that way.

Big baby. What if your care provider thinks your baby is “too big?” I can’t speak to every case, but at least some of this is bullshit. Ultrasound measurements for weight and size get less and less accurate as the baby gets closer to term. On the other hand, some excellent techs really do get it right. (Just like any technology, ultrasonography continues to improve.)

The fear of a big baby is real, and one must do some soul searching. Perhaps the baby isn’t as big as your provider thinks. Perhaps the baby is big but it’s the perfect size baby for you to birth. Perhaps giving birth vaginally to a suspected large baby is something you do not want to attempt. It’s your choice. But we simply cannot predict difficulty of labor based on a suspected large baby.

There’s evidence that all these measures will help you grow the right size baby for your pelvis:

  • Start pregnancy at your healthiest weight
  • Exercise at least 150 minutes a week during pregnancy
  • Reduce sugar and carbohydrate consumption
  • Consider limiting dairy
  • Test for and treat gestational diabetes

Remember: Positioning of the baby is so important. A malpositioned 6 lb baby may have a lot of trouble. A well-positioned 9 lb baby may ease right out.

Maternal age and high BMI. Lifestyle choices make up for much of these two risk factors. Following the above bullet points for a healthy-sized baby will also reduce your risk of high blood pressure, and you’ll recover from birth more quickly. For older moms, expect to be in labor for longer than your younger friends and siblings, and know that that’s ok.

Stubborn Bag of Water: Your water can break at any point, before during, or even after birth. But the most common scenario is water breaking during that 6-10 cm dilation we call, “transition.” When the water breaks, it allows baby to descend more and put more pressure on the cervix.

Sometimes I’ll have a person who’s been laboring for hours and hours with no cervical change, no fetal descent, and bulging bag of water. If the laboring person is getting very discouraged or exhausted, I will offer to break the bag of water. This is called, “Artificial Rupture of Membranes,” or “AROM.”

I do not take AROM lightly. Breaking the water can increase the risk of infection, can make a malpresentation worse (we don’twant to cram a malpositioned head deeper into the pelvis) or can cause cord compression or prolapse. These risks are a part of the AROM conversation I have with my clients so that they can make an informed choice.

Should the laboring person choose AROM, I always do some rebozo first, with the laboring person in knee-chest position.  This gives the baby another chance to correct its position.  Then I have the laboring person lie flat on the bed and listen to the baby for a little while while I break the bag. While risks of AROM are always present, they must be balanced with the possibility of hospital transport for maternal exhaustion or fetal distress from a prolonged labor.

On the rare occasions that I have done AROM (at the client’s request), I do believe it helped labor to progress. It’s something to keep in your back pocket.

Epidural. Epidurals get so much grief. Avoiding any unnecessary medications is usually a good idea, but the key word here is “unnecessary.” During a very long labor, when we’ve exhausted our bag of tricks and laboring person has had enough, the epidural may no longer be something that is avoided or vilified. Epidurals can relax the floor of the pelvis, allowing the baby to turn while the laboring person gets a much-needed break. On quite a few occasions, epidurals have helped my clients avoid surgery.

Long Labors, Part 3: Psychosocial Strategies, is forthcoming.

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