Sharla’s birth story:
I was pregnant with my first baby in 2005, and looking forward to having a completely natural, non-interventive labor and birth. I wanted to bring my baby into this world without drugs in her system, and I wanted to experience all of my labor. I prepared myself for all the aspects of labor I could read about, but I was not prepared to have to make a change in plans.
My labor began in the early hours of the morning on a Thursday. I had contractions throughout the day, saw my midwife to be checked in the office, and was very disappointed to find out I was only 1 centimeter dilated. I went back home, and rested, drank water and ate lightly, and walked and walked. I didn’t get more than a few minutes sleep that night, and by Friday morning I was already exhausted. Back to the midwife’s office, to find out that I was 2 centimeters dilated. I can’t describe how discouraged I felt. I had been having contractions every two or three minutes for over 24 hours, and I was only 2 centimeters? My midwife recommended that I take something she would prescribe to help me sleep, but I was determined not to do anything that could potentially harm my baby. By Friday night, about 11 p.m., the contractions were painful enough that I went to the hospital. My midwife checked me there and said I was still 2 centimeters. I walked for several hours, and she rechecked me. No change. Back home we went, again refusing the medicine she offered to help me sleep. My second night without sleep passed slowly, with contractions continuing every two or three minutes.
Saturday morning, we went back to the hospital, and I was delighted to find out I was now 4 centimeters. Since that was the “magic number” the hospital required in order to be admitted, my husband and I were thrilled. I refused the IV and immediately got into the jacuzzi, which felt wonderful. I could be very active in the large tub, moving and swaying with the contractions, which seemed to help the pain. I asked the midwife not to check me until I requested it, and she said that was fine. When I did ask to be checked, at about 6 p.m., I’d already been at the hospital for hours, and had now been having contractions and not slept more than a minute or two between contractions in over 48 hours. I was not eating or drinking very much fluid, but refused the IV. I was feeling nauseous, which I took as a good sign (transition), so I was dismayed to find out my cervix had not changed at all since I’d been admitted. My contractions were painful enough now that I was crying pretty loudly through each one, and I was so tired that I could not focus on breathing or relaxing with the contractions. Instead, I was tensing up and fighting each one. The midwife tried to talk to me about options for sleep, pain relief, or strengthening the labor so I would dilate, but I was not willing to consider them.
By midnight, six hours later, I still had not dilated any more, though the contractions were very painful. The midwife couldn’t figure out why I wasn’t dilating, because she said the baby felt to be in a normal position, and my contractions felt strong to her. She now strongly urged me to accept some medicine to help me sleep, because I was so exhausted. I decided to take the shot of Demerol she offered, and was able to sleep for four hours. The midwife said that 85% of women who have long prodromal labors will wake up in active labor after having a shot of Demerol or morphine, but that was not the case with me. I woke up early in the morning on Sunday, and was still only 4 centimeters dilated. At that point, I was so tired I was barely coherent, and yet I still was adamant that I did not want any interventions. Finally the midwife talked seriously with me, and told me that she was concerned for my wellbeing, both because I was exhausted and because I had not dilated. She said her goal was to help me have a normal birth, but things were not progressing normally, and by this point she had begun to hope we could avoid a c-section. She recommended an epidural so I could sleep, breaking my water to be able to measure my contractions internally, and a small dose of pitocin. I refused all of this, and tried laboring for another four hours, becoming increasingly miserable and in pain. I was not coping or working with the pain any more, I was suffering. Another check, and no change. At noon I finally agreed to her suggestion. I got the epidural first, and then my midwife put in an internal pressure catheter to measure my contractions. She said that my contractions were strong and regular enough that I should be dilating, and she did not know why I was not. She was able to examine the baby’s position much more accurately with me not fighting the pain of the exam, and said that the baby was in proper position. She suggested the lowest dose of pitocin, to be given very slowly, to see if just a little more strength to the contractions would make a difference. I agreed. Within twenty minutes, my cervix began to dilate. Two hours later, I was ready to push my baby out. By then, the midwife had turned off the pitocin, saying I no longer needed it. She took out the internal pressure catheter, and we started pushing. Because of the epidural, I had been able to rest while the baby “labored down” until it was visible at the perineum. I only had to push for about 15 minutes before she was born. We never did find a reason why my labor stalled for so long at 4 centimeters. I had tried every natural thing I knew of to help move things along–nipple stimulation, walking, position changes, and herbs, but nothing made a difference. While I was initially disappointed about the change in plans, I realize that an important part of a birth plan is being able to be flexible when birth throws you a curve ball. I hope to be successful in having a completely natural birth next time, but if not, I know I am strong and powerful enough to give birth, even if I need a little help.
The Midwife Comments:
I asked Sharla to write her story for the blog, because it is classic for some of the long, prodromal labors I see. As a midwife who strongly believes in natural, non-interventive birth, it is hard for me to recommend interventions to my clients. However, I have experienced this scenario enough times to know that in some cases, a small intervention now may prevent a big intervention (c-section) later.
Studies indicate that the average length of prodromal labor (from the onset of regular, frequent contractons to 4-5 centimeters dilation) is about six to eight hours in first-time mothers. The labor is considered abnormal when the prodromal phase exceeds 20 hours. Sharla’s prodromal stage was closer to 72 hours, without a break. Many women who experience this are given a diagnosis of “failure to progress” or “cephalopelvic disproportion”, when they really are not even in active labor. It is difficult sometimes to know whether the labor is dysfunctional or the woman is just not in active labor yet. It seems that long prodromal labors are more common when the baby is occiput posterior (sunny-side up) or the head is crooked in the birth canal, which causes a much more painful labor than typically seen at this early stage.
So why did I recommend interventnions to Sharla? I look for certain signs in deciding when to recommend an intervention:
- Mother is exhausted, and unable to rest
- Mother is dehydrated. She may have ketones in her urine, indicative of dehydration and exhaustion. This can lead to a dysfunctional labor pattern, because when the mother is exhausted, the uterus is exhausted.
- Mother is suffering with the contractions, rather than coping.
- There is any sign of abnormal blood pressure, abnormal fetal heart rate, or other indication that mom and baby are not doing well
When any or all of these factors are present, an epidural–usually something I like to avoid–can be a blessing, allowing mother complete pain relief and the opportunity to rest. Pitocin can be used carefully without creating additional pain for the mother. An internal pressure monitor allows us to safely assess whether we are giving enough–or too much–pitocin, if the mother’s uterus is resting adequately between contractions, and if her contractions are actually strong enough that she does not need pitocin. I am very respectful of pitocin’s power.
What can you do to work with a long prodromal labor? The following suggestions are given with the assumption that you have already tried all the natural things you can do:
- REST REST REST. Early labor is the time to conserve your energy. You don’t know how long your prodromal stage will last. Sleep as much as you can. There will be ample time to walk and move later, when you are making progress.
- Consider a sleeping aid. If you have not slept in 24 hours, and labor is not making steady progress, consider something to help you sleep. This, in my opinion, is the most important thing you can do to conserve your energy. A tired body makes a tired uterus that does not contract normally.
- Hydrate and eat. If you are unable to eat and drink enough to keep your urine free from ketones, accept IV fluids. Hydration can make the difference between a normal and a dysfunctional labor.
- Consider progressive interventions. Interventions don’t have to be an all or nothing proposition. You can accept a very low dose of pitocin, without breaking the water. Or you could break the water, but not have pitocin. You could try a little pitocin to get things moving, and then turn it off once you begin to dilate. There are many options. Accepting one small intervention does not mean you need to accept them all.
- If you are exhausted and suffering, consider an epidural. As much as I write about the risks and side effects of epidurals, there are occasions when they are a blessing. An exhausted mother can get a few hours of sleep and a little pitocin without feeling increased pain. A midwife can better assess the baby’s position without putting the mother through a painful cervical exam. A baby can be manually turned into a better position more easily when the mother is not involuntarily fighting against the movement. In a normal labor, this intervention could cause more problems, but in an abnormally progressing labor, especially prolonged prodromal stage, it can be very beneficial.