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Labor and birth : Special Cases (part 1) - Premature Birth, Induction of Labor

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You may know in advance that a condition or factor in your pregnancy means that intervention, such as an induction or a cesarean section, will be needed. At other times, events can occur in labor that mean assistance is needed, or a premature labor can mean that your baby needs special care. In all cases, rest assured that procedures are in place to ensure your own and your baby’s safety.

NOTE

Each labor is different and there are times when some type of intervention is needed

Premature Birth

The term “premature” describes both the time of birth, before 37 weeks, and how well prepared your baby is for life outside of the uterus. Premature births account for 12.7 percent of U.S. births.

Your baby may be born prematurely either because an early delivery is advised on medical grounds (see Advising an early delivery), or you go into spontaneous preterm labor. The earlier the birth, the higher the chance of complications in the baby, such as breathing problems or infections. Nowadays, however, huge advances in the care of premature babies means that babies born as early as 23 or 24 weeks may survive. If your baby is premature, he may need to spend time in a neonatal intensive care unit .

Seeing your tiny baby hooked up to monitors and tubes can be alarming, but take comfort from the fact that these are helping your baby to breathe and feed and in turn to develop.

Advising an early delivery

A decision may be made to deliver a baby early if the mother’s or baby’s health is in danger. For example, an early delivery may be recommended if the mother has a medical problem, such as a heart condition that could increase her physical stress, or preeclampsia, which could endanger her own and her baby’s health. An early delivery may also be advised if a scan shows that the placenta is not functioning well and the baby is not receiving enough oxygen. Forty-seven percent of babies in the US delivered before 32 weeks are born by cesarean, as are about a third of babies born between 34 and 36 weeks.

Spontaneous preterm labor

The cause of spontaneous labor before 37 weeks is often unknown. However, it is more likely if a woman has a major abnormality of the uterine wall, such as large fibroids , a weakness in the cervix, which may have been present from birth, or have occurred after surgery to the cervix or is pregnant with more than one baby. Infections like bacterial vaginosis can also set off contractions at an early stage.

What might be done?

Preterm labor can’t be stopped, but medication can slow the process and reduce some risks.

Steroids can promote the production of a natural chemical in the baby’s lungs that reduces the effort of breathing. They must be given 24 to 48 hours before the birth to have maximum benefit.

You may also be given oral medicine or an injection to reduce the frequency of contractions. This can prolong pregnancy for a few days, during which time the steroids can take effect. Also, if necessary, you can be transferred to a hospital with NICU facilities.

Finally, you may be advised to have injected antibiotics since preterm babies are susceptible to bacterial infections caught via the cervix during birth.

Predicting premature labor

It’s hard to predict who will go into labor prematurely. However, if you’ve had a previous preterm birth, tests may be done to find out if it is likely in your current pregnancy. A cervical scan may be done around 23 weeks since a shorter cervix increases the risk of early labor. Pelvic swabs detect bacteria that are linked to preterm labor, and “fetal Fibronectin” test between 24 and 34 weeks shows whether a protein is present that, during the second half of pregnancy, generally can’t be detected until 1–3 weeks before labor and delivery. Sometimes, a short cervix is strengthened with a stitch. Antibiotics can be given if abnormal bacteria are found. Progesterone may be given to stop contractions.

Induction of Labor

For 22.3 percent of women in the US, labor is started by artificial means, or induced, to reduce the risks to mother and baby.

An induction may be offered if it’s felt that continuing the pregnancy poses a risk to your health or to the health of your baby. The most common reason for an induction is the continuation of a pregnancy beyond 41 or 42 weeks, in which case the placenta may begin to fail. Induction may be offered earlier if you have twins, or a medical condition such as diabetes. Before setting a date for induction, your doctor may offer to strip your membranes  to help you go into spontaneous labor.

Induction is not the same as an augmentation of labor, which is when drugs are used to increase the efficiency of your contractions when you’ve already gone into labor spontaneously .

Assessing the cervix

Before an induction, you’ll have an internal examination to assess the cervix. Induction is easier if your cervix is short and soft, described as “favorable” or “ripe,” rather than long and firm. The findings may be logged in a table called the Bishop’s Score, which also assesses how far the cervix is dilated , the position of the cervix, and the station of the fetal head in the pelvis . A total score over six indicates good conditions for an induction of labor.

Softening the cervix

If your cervix isn’t ripe, it can be softened with prostaglandins. These are naturally occurring chemicals that help stimulate contractions. Artificial prostaglandins can be given in the form of vaginal tablets of gel, which are placed at the top of the vagina near the cervix, or a vaginal suppository or an oral pill. This is usually effective, but sometimes prostaglandins fail to soften the cervix and may be tried again after a few days. On the other hand, some women experience dramatic effects after a small dose.

Breaking the water

Amniotomy, or artificial rupture of the membranes (ARM), is one of the most important steps in the induction process, often referred to as “breaking the water” and it’s done once the cervix is soft and slightly dilated, and the head has started to enter the pelvis. A thin plastic probe is passed through your cervix and used to make a small hole in the amniotic membranes, which allows some of the fluid around your baby to leak out. This softens the cervix even more and can provoke contractions in the muscular wall of the uterus. If contractions don’t become established after ARM, then you’ll require treatment with Syntocinon or Pitocin (see Oxytocin, Syntocinon, Pitocin).

Oxytocin, Syntocinon, Pitocin

Oxytocin is a natural hormone that stimulates the uterus, increasing the frequency and strength of contractions. A synthetic form, Syntocinon or Pitocin, is used with the same effect. It’s diluted in fluid then dripped into a vein in your arm or injected into a large muscle. This is safe and effective when used correctly; however, it must be used with care since excessive contractions can reduce your baby’s oxygen supply in labor. Your contractions and your baby’s heartbeat will be continuously monitored .

Q: Are medical interventions more likely with an induction?
A: If your labor is induced, the chance that you will need an assisted delivery with forceps or vacuum or a cesarean is increased. This is even more likely if you are having your first baby, if the cervix is unfavorable, or if you’re being induced relatively early in your pregnancy. The reason for these medical interventions is usually that the labor is proceeding too slowly, or that it cannot be started at all, despite all of the steps taken. Also, concerns about the baby’s well-being during the induction process can sometimes lead to intervention.
Q: Is induction of labor more painful than a spontaneous labor?
A: Some women find that they experience strong contractions very quickly after an induction. Since they haven’t been able to build up gradually to more painful contractions, they may be less able to tolerate the pain, which can result in an increased need for stronger types of pain relief such as an epidural.
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