What Factors Influence the Progression of Childbirth?

Your body is perfectly designed to promote a healthy pregnancy and childbirth. For the majority of healthy women, childbirth progresses spontaneously without complications. However, there are steps you can take to promote this normal progression, and there are factors that can interfere with it.

What are the physical factors?

Many physical factors can promote the progression of labor.

The position of your baby might play a role. Most babies navigate best through the pelvis if they are head down, with their face toward your spine. This is called an anterior position. During the last weeks of pregnancy, try to promote this positioning of your baby. Avoid lying on your back. When relaxing, choose forward leaning positions such as sitting on a physical therapy ball with your legs apart. When resting or sleeping, lay on your side as far to your stomach as you comfortably can.

As contractions begin, choose positions of comfort. Freedom of movement and frequent position changes can help the baby choose optimal positions for birth. Upright positions allow you to use gravity to promote the downward movement of the baby.

You might find it very difficult to move during a contraction. That's okay - just relax as much as possible during the contraction, breathe slowly and deeply, and move when it is over. You might also find that changing to a new position makes the contraction more intense or painful. However, try to avoid switching again too soon - try several contractions in the new position, readjusting and regrouping - before deciding to abandon it. Alternate upright positions with positions of rest, such as sitting in a rocking chair or side-lying in bed.

How can support and touch help?

The active participation of your partner, doula, labor nurse, midwife, or doctor is another way to promote the natural progression of labor. Research shows that the presence of a doula or other supportive person is associated with many positive benefits during childbirth, including shorter labors, less use of pain medication or epidurals, fewer cesarean sections, and successful breastfeeding. Your midwife, doctor, or labor nurse may spend considerable time supporting you, but they might also have responsibilities for other laboring women as well. A doula, on the other hand, is likely to spend much of your labor with you.

Human touch can also help labor progress. This touch can take many forms: back and hip counter-pressure to help alleviate pain, massage to promote relaxation, acupressure to alleviate pain or promote effective contractions, or energy work such as Therapeutic Touch [1] or Reiki [2] to promote relaxation and pain relief. It can even be as simple as holding someone's hand for support.

How can water therapy help?

Many childbirth professionals promote the use of water therapy-immersion in a warm tub or warm shower-to cope with labor. Research on water therapy has produced some interesting results.

• When women enter the water during active labor, their average labor time is shorter than women who do not labor in water.
• When women enter the water during early labor, contractions might become less strong or less frequent. This might not necessarily be a disadvantage. If early labor contractions have been occurring for a long time, entering the water could give you a break and a chance to rest and regroup. You might even be able to sleep when you emerge from the water, and once rested, your labor might return in a better and more effective pattern. In general, though, it is best to wait until labor is well established before entering the water.

How can emotions impact labor?

Your emotional wellbeing [3] is very important during labor. Do what you can during pregnancy to address fears and concerns so you can enter labor with confidence in yourself, your partner, your other birth attendants, and your midwife or doctor.

You can also use guided relaxation or meditation [4] at any time during labor to help you build images of safety and strength, or to identify fears that might need to be addressed.

Women in labor are often advised to let go and release control of labor to their bodies' own innate ability. In order to do this, you will need to feel safe with the environment and with your chosen care providers and support people. Because labor is a time when many women feel vulnerable, you should ask for understanding, support, and respect from those around you to help enhance your feelings of safety and strength.

How can the environment help?

The environment can also promote the progression of labor. One of the pioneers in the natural childbirth movement, obstetrician Robert Bradley, compared the medicated and difficult childbirths of women in brightly lit, tiled delivery rooms with the relatively easy births of animals that chose dark, comfortable places of safety. Thus, his initial recommendation to promote the natural progress of labor was to choose a dark, quiet environment.

Of course, the environment [5] is also inclusive of more than just the lighting and comfort of the surroundings. You might want to include music that you enjoy, find meaningful to you, or feel simply promotes feelings of relaxation.

You might also want to consider aromatherapy [6], which can contribute to feelings of wellbeing and thus influence your course of labor. Many birth professionals recommend the use of lavender during labor. If you are giving birth in a hospital or birth center, you might not be able to use candles, but you could use an infuser, or make a small sachet.

Check ahead of time for any hospital policies on "scent-free environments."

What factors may interfere with the natural progression of labor?

It should come as no surprise that the opposites of some of the promoting factors we discussed above can interfere with labor progress.

Being restricted to bed, especially if you spend most of your time lying on your back, or sitting up at a small angle, interferes with labor progress in more than one way. In this position:

• Gravity works against you, and the baby might be more likely to settle into a posterior position.
• Pain might increase, especially back pain.
• Blood circulation to your uterus decreases, which could lead to less effective contractions.
• Blood circulation to your baby also decreases.

Electronic fetal monitoring, which is often used in birthing units in the United States, frequently confines women to bed. This prevents women from using gravity to encourage movement. Note that there is no evidence that continuous monitoring provides a safer childbirth experience than intermittent monitoring, and its use has been associated with increased cesarean sections and other interventions.

Even if you require continuous fetal monitoring, you can use almost any position-with some adaptation. If available, you can use telemetry monitoring that transmits data wirelessly to a central monitoring station. If telemetry monitoring is not available, don't just lie down-you can still stand at the side of the monitor, walk a very short distance, sit on a birthing ball or rocking chair, labor on your hands and knees, or use a variety of other positions.

Emotional concerns, such as fear, embarrassment, or a lack of support, can also interfere with labor progress. Fear and anxiety release hormones, such as adrenalin, which can slow labor contractions. If you had a particularly difficult time at a certain point in a previous labor, you might find yourself approaching that same point with fear. Most healthcare providers can provide many stories of labors that seemed to have stopped progressing, but progressed well after talking about emotional concerns, expressing fears aloud, and perhaps clearing the air with some tears.

Lack of support can also be detrimental. Sometimes, those you have invited to provide support might instead create tension or have difficulty dealing with the demands of labor. If this happens, although it might be difficult, you might consider asking them to leave for awhile. If you feel more emotionally centered in their absence, you can ask them to return after the baby has been born. If you find that you miss their support, you can ask them to rejoin you, after a brief discussion on how they can better help.

One topic that merits special discussion is the topic of sexual abuse. Women who have experienced sexual abuse, whether in the recent or far-distant past, might have unique fears about childbirth. Memories of pain may resurface during labor. If you have experienced abuse in the past, we encourage you to bring this up with your midwife or doctor, so that they are aware of your experiences. If you have not had counseling or therapy and would like to, ask for a referral. Your birth partner(s) might also be able to help you more effectively if you talk with them about this. Ask your birth partner(s) to remind you that you are giving birth to your baby and that you are safe in the birth center (or wherever you are). They can remind you that you are feeling contractions that are opening the cervix, or pressure from the baby's head stretching your tissues. They should not use expressions such as "just give in," or "don't fight it," as these might be phrases that were used by your abuser.

What about a combined effect?

While individual factors might not have a large impact on the progress of labor, they could lead to what is known as a cascade of interventions, which could have a cumulative effect on the progression of labor.

Here's an example. A labor induction should theoretically promote labor progress. However, most induction methods require bed rest and monitoring. A woman receiving pitocin, for example, will require an IV and continuous monitoring. These interventions might restrict the woman's movement, and, at the very least, make it more difficult to move around because of the monitor cables, IV poles, and IV pumps. Being restricted might increase pain levels and the chance of the baby settling into an unfavorable position. Increased pain could result in early use of pain medication or epidural anesthesia, which further limit movement. Epidural anesthesia could make pushing efforts less effective and increase the likelihood of a cesarean section, vacuum, or forceps delivery. A vacuum or forceps delivery might increase the likelihood of an episiotomy or an extended tear.

What effects can pain medication and epidurals have on the progression of childbirth?

Pain medication and regional anesthetics (such as epidural, intrathecal, or spinal anesthesia) bear special mention. Most midwives and physicians agree that the use of pain medication or regional anesthesia during early labor can slow labor progress. A common midwifery text by Varney describes this very well, cautioning midwives about using IV pain medication too early in labor: "although you have made the woman extremely comfortable, you have lengthened the total labor by several hours (for which she would probably not thank you if she knew)."

Most researchers have concluded that epidurals or other regional anesthesia may be associated with longer labors, longer pushing, increased risk of vacuum, forceps, and cesarean sections, as well as increased risk of other complications, such as low blood pressure (which might adversely affect the baby), fever, headache, and nerve damage. (It should be noted however that a newer research study challenges the association with longer labor lengths and increased cesarean sections.)

However, in some instances, pain medication or epidural anesthesia might help to promote labor progress.

• Medication might help women who are very fearful and who have not been able to alleviate this anxiety with emotional support.
• Anesthesia might help the pelvic muscles relax when a woman cannot relax using breathing, relaxation, and supportive techniques.
• Epidurals might help women with an uncontrollable urge to push against an only partially dilated or swollen cervix to stop pushing, allowing the swelling of the cervix to subside and dilation to continue.

What you should ask about medications

You should make a decision to use medications or interventions during labor carefully and take plenty of time to ask questions about this during your prenatal exams. Ask your midwife or physician for input if you are considering these choices. Informed consent for medications, or for other proposed labor interventions, means that you know the following:

• The name of the drug, procedure, or other intervention.
• The reason the drug, procedure, or intervention is being proposed (the benefits).
• The potential risks of the proposed therapy.
• What would happen if you did not use the proposed therapy, or if you waited.
• What alternatives exist to the proposed therapy.

Unless there is an emergency, it is always appropriate to ask questions, and to ask to be given time to talk privately with your partner as you make a decision. We've mentioned this before, but it is worth saying again: try not to make a decision about pain medication in the middle of a contraction!

A very brief description of some medical forms of pain relief for labor and their risks and benefits can be found at SutterHealth.org [7].

Additional Reading

The Thinking Woman's Guide to a Better Birth. 1999. Henci Goer. Perigee Trade.

References

American College of Obstetricians and Gynecologists (ACOG). (2005). Intrapartum fetal heart rate monitoring. ACOG practice bulletin No. 70. 2006 Compendium of Selected Publications. Washington, D.C.: ACOG.

Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, El, & Hofmeyr, J. (2000). A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. New York: Oxford University Press. The full text of this book is available online [8].

Simkin, P., and Ancheta, R. (2005). The labor progress handbook, 2nd ed. Oxford: Blackwell Publishing.

Thorp, J.A., Hu, D.H., Albin, R.M, et al. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. American Journal of Obstetrics & Gynecology, 169(4), p. 851-858.

Varney, H., Kriebs, J.M., & Gregor, C.L. (2004). Varney's midwifery, 4th ed. Sudbury, MA: Jones and Bartlett.

Wong, C.A., Scavone, B.M., Peaceman, A.M. et al. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. New England Journal of Medicine, 352, p. 655-665.