Common Labor Procedures and Interventions

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What is a labor complication or intervention?

Woman in Labor
Photo © Charles Gullung/Getty Images

There are times when things in labor do not go as nature intended and complications arise. This is to say that either mom or baby is having a problem with the pregnancy or labor/birth. At that point intervention, be it a medication, a procedure, or surgery, might be employed to make pregnancy/birth easier, less complicated, or safer for both mom and baby.

While no one really plans on needing intervention or having complications, there are times and places where problems arise, even when you've taken really good care of your body and had supreme care. The good news is that a good portion of what might go wrong in labor is potentially predictable in early pregnancy.

Interventions are sometimes necessary because of complications, however, they are more likely to be used as a matter of policy, either from your place of birth or your practitioner. For example, the use of an IV or fetal monitoring on a routine basis typically falls into this category. These are considered "just in case" procedures. It's important to remember that an intervention is not always a bad thing, despite the negative connotation it may have.

In fact, you may be willing to accept certain interventions in exchange for things like an epidural. The IV, continuous fetal monitoring, and extra maternal monitoring are done to help monitor you and the baby for potential negative reactions to the epidural to ensure the safety of both the mother and baby.

IV/Saline Lock

The IV line or intravenous line is designed to admit a small catheter into a vein, usually in your arm. This allows for the rapid introduction of medications or fluids, should it be needed in an emergency situation. A saline lock (or Heparin lock) is the start of this catheter with no tubing attached so that only the first portion of the IV is in place. This allows more freedom of movement and mobility.

These may be routine at your hospital or birth center. Ask. You may have the ability to choose the lock over a standard IV line, or if you're low risk you may have the option to forgo this all together. This should be addressed in your birth plan.

An IV line will be required for those who are high risk or request medication. You do have the right to ask about the placement and choose a site that is better for you comfort. For example, having it placed in the arm rather than the back of the hand may allow you a bit more flexibility in the wrists.

Catheter

Catheters are inserted into the bladder to help drain urine. A full bladder can prevent the descent of the baby, so it is important to be able to have an empty bladder.

If you choose to have epidural anesthesia or require a cesarean birth, a urinary catheter will be used because you will not be able to have the sensation of a full bladder. The catheter will allow your bladder to remain empty without any effort on your part. When it will be removed depends upon why it was used. For example, after a cesarean birth, you may have the catheter in for up to twenty-four hours.

Prep/Shave/Enema

The shaving of the pubic hair was once thought to prevent infection, this is untrue. If you're concerned you can trim the hairs towards the perineum or shave yourself prior to having the baby.

The enema was to help you pass all the stool in your bowel. Since we know that labor tends to start out with loose bowels, this is generally not needed. It can also be quite uncomfortable and lead to dehydration.

Fetal Monitoring

Fetal monitoring usually calls to mind a woman in bed with monitoring straps around her waist and several people staring at a machine that prints out the numbers of the contractions and the baby's heartbeat. However, that is but one way to monitor baby during labor.

The American College of OB/GYNs states that low-risk women do not need constant fetal monitoring. They also say that monitoring can just as effectively be done by a human being as a machine. They suggest a reactive strip upon arrival at the birth place or arrival of the attendant. This means that the baby is doing well and responding to the contractions with the appropriate accelerations in heart rate. Then they suggest that the baby be "checked" fifteen minutes out of every hour during the first stage of labor and five minutes out of every fifteen minutes during the second stage (pushing).

Types of Monitoring:

It is critical that you discuss monitoring with your practitioner and address the issue in your birth plan. If you prefer to maintain your mobility then continuous monitoring will make that harder to achieve. You may not have even known that you had options.

For those who have a high-risk situation or who develop complications during the monitoring period, a form of continuous monitoring may be implemented. The external monitor works by ultrasound and is less accurate than an internal monitor. There are increased risks with using the internal monitors, but they are more accurate. The increased risks include increased risk of infection, fetal laceration from probe, etc. It is also important to note that the bag of waters must be broken to allow internal monitoring.

Amniotomy

This is the artificial rupture of membranes. It is supposedly done to "speed up" labor, though most studies say that this is not true for most women. Much of the time your water will break until later in labor. Amniotomy may also be used to assess if the baby has passed meconium or to allow the insertion of an internal monitor.

It is done by placing an amnihook (looks very similar to a long crochet hook) inside the vaginal during a vagina exam and scratching the bag until it ruptures.

Drawbacks to this can include:

  • Increased risk of infection
  • Slim risk of cord prolapse (life threatening emergency)
  • Increased intervention, and limited mobility

There are other potential ways to speed labor, including walking, nipple stimulation, position changes, etc. Amniotomy may also be used as an induction technique.

Episiotomy

This is the surgical cut in the perineum to enlarge the area to allow the baby to pass. Recent studies have shown that this is usually not necessary and can actually cause more problems than it prevented.

Most studies agree that rates of episiotomy above about ten percent are excessive. Many state that times small cuts that are made actually lead to an increase in larger tears (third and fourth degree), greater risk of infection, and a longer and more painful recovery.

Episiotomies should be saved for complications such as fetal distress, to angle a cut or tear, etc. Talking to your practitioner about your feelings and theirs will help you in finding the path that is right for you.

There are many things that can be done to prevent the need for an episiotomy and tearing, including positioning, massage of the perineum (both prenatally and during the birth), a slow, controlled pushing stage, and practitioner manipulations.

Other Hospital Policies

There maybe other interventions or policies that are specific to your practitioner or place of birth. Be sure to take a tour and inquire about any such policies. Knowing about these policies ahead of time can help you make changes to your plans or encourage them to make changes for you. Examples might be:

Dealing with Interventions

While an intervention may not be what you had envisioned, remember to get informed consent. Always ask specific questions about the proposed intervention, including why it is being done, alternatives, risks, benefits, and what happens if you choose to not do anything. Satisfaction with birth is not about it going according to plan, but rather that you felt in control of the decisions being made.

What types of medications are used in labor?

  • Analgesia: This describes a medication that is used to alter your perception of the pain or remove the pain without causing numbness. Examples would be Nubain, Demerol, Stadol, Tylenol, etc.
  • Anesthesia: This describes a medication used to remove feeling. This can be a regional anesthetic like an epidural or spinal, or a local anesthetic like an injection of Lidocaine in your perineum for a repair of a laceration or episiotomy. This can also include general anesthesia which will also result in the loss of consciousness. Though use of general anesthesia for childbirth is fairly rare, it does occasionally occur in extreme cases mostly emergencies.

IV medications are usually given via the intravenous line, but can also be given by regular injection, depending on the medication.

These medications have been used for a long period of time for labor and birth. However, timing of these medications are critical because you want there to be a time interval between when these medications are given and when the baby is born to help prevent breathing difficulties at birth.

IV pain medications take effect more quickly that medications like the epidural, but do not remove pain, rather they alter your perception of the pain. They can help promote relaxation or even sleep. Their use can also be combined with epidural anesthesia for the very anxious mother.

Common IV Medications Used

  • Stadol
  • Demerol
  • Nubain

Pain relief for childbirth has run the gamut over the ages. And the battle is still being fought today. Should a woman have medications or not during birth is not a question that I anticipate an answer for anytime soon. However, some women will choose medication and some will require it for surgical deliveries and complications. Let's just all be thankful that we are no longer buried alive for accepting pain relief in labor as was done in the middle ages.

Using something like forceps and vacuum extraction is a fear of nearly every parent. Certain positions or medicines may make it more likely to be needed.

Forceps

There are several shapes and sizes of forceps, but they do look remarkably similar to salad tongs. These are slipped, one at a time, inside the mother's body and then locked around the baby's skull. The practitioner will then pull with the mother's pushes.

Forceps are used in a graded system: high, mid, and low or outlet forceps. When you hear of the forceps horror stories it was usually from the high forceps, which has now nearly universally been replaced by cesarean section.

Mid forceps has mostly been replaced by the use of vacuum extraction and cesarean, leaving only low or outlet forceps to be used.

Forceps have different properties than the vacuum extractor:

  • Can be used to turn a baby in a different position (i.e. posterior, etc.)
  • Can cause more trauma to mother's tissues
  • Can cause less trauma to baby

Vacuum Extraction

Vacuum extraction is a cup-like device that is either attached to a suction device on the wall or by a manual suction pump. It is placed on the back of the baby's head and the suction is increased so that the practitioner pulls with the mother's pushes.

Vacuum extractors have different properties than the forceps:

  • Can be used higher than forceps
  • Can cause less trauma to mother's tissues
  • Can cause more trauma to baby

Medications for Forceps & Vacuums

If you do not have an epidural in place your practitioner will probably use either a pudendal block. This is given by injecting medication through the vagina near the pudendal nerves. This takes effect quickly and is very effective at blocking the pain of the procedure, while still allowing the mother to push.

Other Interventions and Procedures

Certainly, there are other potential procedures or interventions used like induction of labor and cesarean surgery. Those are discussed in separate articles. Some interventions are used together, some are not. Some interventions may be standard for your provider, so be sure to ask. If you need help, use your birth plan as a communication tool to open the conversation.

Sources:

American Pregnancy Association: Narcotics for Pain Relief During Childbirth (2015)

Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2

Costley PL, East CE. Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009241. DOI: 10.1002/14651858.CD009241.pub3

Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major Survey Findings of Listening to Mothers(SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women's Childbearing Experiences. J Perinat Educ. 2014 Winter;23(1):9-16. doi: 10.1891/1058-1243.23.1.9.

Obstetrics: Normal and Problem Pregnancies. Gabbe, S, Niebyl, J, Simpson, JL. Fifth Edition.

Thacker, S. B., Stroup, D., & Chang, M. (2004). Continuous electronic heart monitoring for fetal assessment during labor. Cochrane Database of Systematic Reviews.

Wei S, Wo B, Qi H, Xu H, Luo Z, Roy C, Fraser WD. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006794. DOI: 10.1002/14651858.CD006794.pub4

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