Labor and delivery – everything you need to know
Are you wondering what to expect with your labor and delivery experience? Mary Sinéad, a mother of two, a labor and delivery RN in downtown Chicago, with past nursing experience in adult and pediatric oncology in Seattle, shares the top things your provider didn’t tell you about labor and delivery.
*Disclaimer: Always consult your provider with any labor and delivery concern and protocols unique to your labor and delivery. We recognize that not all deliveries will look like the information described below and that some situations are emergent. All information provided is not intended to take the place of your provider.
A little about me
Mary Sinéad is a mom of two, a labor and delivery RN in downtown Chicago, with past nursing experience in adult and pediatric oncology in Seattle. She is originally from a beach town in Northwest Indiana (where she lives now) but has spent over 10 years living in the Pacific Northwest. Mary was a NICU mama, where she exclusively pumped and donated breastmilk. She breastfed (and later supplemented) her second child who is now 20 months. Mary is a grief support coordinator through the nation’s only 7-part holistic healing program for mothers who have suffered the loss of a child, which has become a passion of hers after surviving the death of her own daughter. She loves all things related to pregnancy, labor and delivery, postpartum and breastfeeding! Her clinical expertise as a L&D nurse in combination with her own pregnancies (medically complex and healthy), deliveries (C Section and VBAC), time in the NICU and breastfeeding journey has driven her love for educating and empowering women on their own unique journey to motherhood.
Guide to labor and delivery
Hi Bumblebaby! First and foremost, congratulations on your pregnancy and upcoming delivery. I’m so excited to share with you what to expect during your labor and delivery hospital experience. My goal as a Labor and Delivery Consultant is to provide you with insight to all things pregnancy, L&D and postpartum to help you feel prepared and empowered as you welcome your sweet baby earthside.
As you approach your due date, I know from my own experience and in working with pregnant mothers that you may be feeling a wide and ever-changing range of emotions envisioning HOW and WHEN you will meet your baby. I want you to know that all these feelings are valid and to be expected, having a baby is a monumental life experience. If this is your first pregnancy or delivery, you may especially be feeling much awaited anticipation.
Maybe you are like me and have been envisioning the birth of your child for a long time, or maybe you are still warming up to this upcoming transition into parenthood. As a first-time mom myself, I read books, took birthing classes with the birthing guru Penny Simkin, and asked questions at my OBGYN’s office. But if I am being honest, I didn’t quite feel as prepared as I had hoped to be.
Checkout out these labor and delivery virtual classes to prepare:
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I hope to shed light on what it may look like from the moment you walk in the hospital door through pushing and the delivery of your baby. I believe that if you can feel prepared for what is to come, the more confident and in tune with your birthing experience you will be. While every labor and delivery experience is completely unique (and may vary by hospital), this guide can be used as a tool no matter if you’re being admitted in spontaneous labor or an induction (medical or elective).
Things to consider before heading to the hospital for labor and delivery
Chances are, you already have your hospital bag in the car and have a mental note to shower before heading to the hospital. Have you given thought to what will be your last meal before heading to the hospital? Did you know that once you are admitted, chances are that you will be put on a clear liquid diet? This means you cannot have any solid food (aka your favorite carbs or late-night snacks) until after your baby arrives. Clear liquids include water, beverages like Gatorade, apple juice, Sprite and ginger ale, chicken broth, Jell-O, and popsicles. I definitely did not know this, and once the nerves of my unscheduled medical induction wore off, I was starving! I cannot tell you how many of my patients have been in the same boat and have assumed they should not eat before coming in. Unless your doctor specifically gives you this instruction, I suggest eating a solid meal because it may be many hours until you are cleared to eat after your delivery.
Stages and phases of labor
In order to understand where you are in the labor process, it’s important to know the stages of labor.
- The first stage is dilation, it begins with contractions that progress in strength, length and frequency and end when your cervix is completely dilated (10 centimeters). The first stage of labor is broken into three phases, latent (early labor), active (beginning at 6 centimeters) and transition.
- The second stage begins when you are fully dilated through the birth of your baby.
- The third stage is the delivery of the placenta and typically lasts 10-30 minutes.
- The fourth stage consists of the first few hours of your postpartum recovery.
*photos from @mommy.labornurse
Spontaneous labor vs. scheduling an induction
If you have decided to wait for labor to happen spontaneously (expectant management), it is important to know when to call your provider. Your midwife or doctor will give you guidelines for when they would like you to call them if you think you are in labor. They will have you track and time your contractions and give you specific parameters when to call. These parameters may be unique to each woman depending on their cervical dilation and previous delivery history. Another positive sign of labor is medically known as rupture of membrane (ROM) or “breaking your bag of water.” Even as a spontaneous laborer, you may require augmentation of labor if your contractions or cervical dilation stalls. This may include Pitocin or amniotomy (ROM). Some hospitals have a designated triage area for laboring patients to first be evaluated if you believe you are in labor or think your bag of water is broken. In triage, you will be evaluated for labor by looking at cervical dilation, contraction pattern, and presence of amniotic fluid.
In most cases, waiting for spontaneous labor to start will be the plan your provider discusses with you unless there is a medical reason for example hypertensive disorders in pregnancy or post term pregnancy >42 weeks. In some institutions, elective inductions can be scheduled as early as 39 weeks. While we know your due date months in advance, did you know elective inductions are usually only scheduled 5-7 days in advance?
Talking to your provider and creating a plan is a great way to feel prepared for your labor and delivery experience. Being an advocate for yourself and participating in your plan of care is one way to feel empowered in your birth experience.
Arriving to the hospital
You and your partner will check into the hospital, get your ID band and head to the waiting room. Before the big day, I suggest doing a mock run through to map out the best route to the hospital, find where the parking garage is and learn to get to labor and delivery so that it is second nature when it’s go-time. If you live in an urban area, feel free to check Google Maps on the way in to see if there is a more efficient route. The last thing you need is the stress of being stuck in unforeseen traffic!
The admission process
Welcome to your labor and delivery unit! Here your nurse will greet you and bring you back to your birthing suite. Depending on the hospital, you may stay on the same floor during the postpartum recovery period or be transferred to another unit after your immediate recovery period. Don’t be alarmed if your nurse is covered head to toe in PPE (personal protective equipment). As you walk through the unit, they may give you a quick walking tour since chances are you likely were not able to schedule an in person visit during the pandemic. Once you are in your room, you will be shown your new digs for the next few hours (your personal bathroom, the newborn bed, how to navigate your room and hospital bed). If you aren’t given a tour or provided an explanation of the room and would like to have a lay of the land, be sure to ask! Eekk! Queue the excitement, it’s getting real!
Okay, before we get too excited, let’s get you through your dreaded COVID19 test. Quickly and gently your nurse will swab your nose (I promise, if you handle labor pains, you can get through this too). This is done right away in hopes results come back quickly for your peace of mind and so your nurse can shed some protective layers! While your test is processing, your nurse will apply belly bands to your stomach, and place external fetal monitors to your abdomen. This is how we assess your baby’s fetal wellbeing during labor. In low-risk pregnancies, intermittent monitoring may be an option for you. If this is important to you, speak with your nurse and provider to come up with a plan for monitoring the baby.
Once you are settled, your nurse will walk you through admission questions, which may include your health, surgical and social history, your ideal birth plan, and begin to talk to you about your personalized labor plan set by your OBGYN. Until your results come back, both you and your partner will be required to wear a mask. If you are confirmed negative (and depending on your hospital), you may take off your mask.
*disclaimer: COVID protocols are unique to each hospital. please consult your provider to check on the current hospital protocols and regulations regarding masks and all COVID and health protocols.
Sending blood work and starting your IV
You may be wondering if an IV is necessary for the birth of your baby. While it is important to talk to your provider about any concerns you may have, it is generally best practice to have at least a saline lock in place in case of emergencies or to give medications if needed. Your nurse will ask consent before placing your IV in a place that is most comfortable for you (I suggest your non-dominant arm) and may connect you right away to Lactated Ringers (hydration fluids). If your birth plan is to be more mobile throughout labor, you may request a saline locked IV. In this case, we will encourage that you push oral fluids like water or Gatorade to keep you well hydrated. This may be ideal for patient’s who are coming into the hospital already in labor (contractions leading to progressive cervical change). If you are being induced, chances are Pitocin (oxytocin) is going to be an important medication that runs through your IV to jumpstart labor.
**Did you know that once your IV is placed, the needle is no longer left in your arm? The needle is replaced with a thin plastic catheter but should not cause pain or discomfort.
Final ultrasound and cervical evaluation
After your nurse has checked you in, a doctor or midwife will come to your bedside to confirm that the baby’s head is down with an ultrasound prior to starting any induction or augmentation methods. Next, they will ask for consent to do a cervical exam. This is how we will know where you are starting in the labor process and to compare your future cervical checks, too.
It’s important to remember that labor is not a one size fits all model. Many first-time moms may arrive with a closed cervix, while a woman who has had prior vaginal deliveries before may be 2-3, even 4 centimeters. The opposite can be true too, nothing is impossible in labor and delivery (we have seen it all!)
During your cervical exam, your provider will score your cervix based on 5 criteria, each of which can score between 0-3 points (dilation, effacement, station, cervical consistency, and position of the cervix). This is known as the Bishop’s score. A score of <3 is considered “unfavorable” while a score of >6 is considered favorable. A favorable cervix is shown to have a higher rate of vaginal delivery whereas the opposite is true for a cervix that is still closed and thick.
Cervical ripening
If you are admitted to labor and delivery for an induction (medical or elective), methods of induction will be used to kick start your labor. If your cervix is favorable (soft, dilated, effaced), oxytocin will be administered to stimulate contractions. If your cervix has not begun to thin and dilate for labor, a cervical ripening agent (prostaglandins) may be used to prime your cervix first. Pharmacological and/or mechanical methods are the two go-to methods. Let’s break those two methods below.
Medications most used to soften a cervix are Misoprostil (Miso) or Cervidil. This is mainly dependent on the institution and provider preference. Miso can be placed vaginally by your provider, under your tongue or in the pocket of your cheek to dissolve. This medication may be given once or hours apart if indicated.
A cervical ripening induction balloon (aka CRIB or foley balloon) may be used to mechanically dilate your cervix. A flexible and soft catheter is guided through your cervix and filled with saline to inflate the balloon. This balloon will be placed during an extended cervical exam. This can be quite uncomfortable for some women. Speaking from experience (and a very firmly closed cervix both times), I opted for the pain medications that were offered to me to keep me relaxed during the placement. Pain medications can be given safely at this point because delivery is not imminent at this time. The use of balloon catheters has been associated with a change in Bishop score of 3.3-5.3 and in my clinical experience the cervix is anywhere from 3-4 centimeters dilated when it is removed or falls out spontaneously.
The CRIB can be in place up to 12 hours but may fall out on your next trip to the bathroom (yay!). Usually, your midwife or doctor will check to see if it is ready to come out between 4-6 hours. I encourage my patients to mobilize, walk, and stretch while the balloon is in place. Heat packs and other pain medications can be given to help with any cramping you may have.
Once your CRIB balloon falls out, the next step of your induction is starting Pitocin and evaluating for breaking your bag of water.
Pitocin and amniotomy
During labor at home or in the hospital, your bag of water may rupture on its own spontaneously (SROM). There are also instances in an induction that amniotomy (AROM) will be done to augment labor. Your provider will first evaluate your cervical dilation and baby’s position prior, as the baby’s head must be engaged firmly on your cervix. If you rupture spontaneously prior to arriving at the hospital, remember the letters CAT, and be sure to examine the Color (clear, bloody, yellow, green or brown), Amount (light trickle or gush), and Time it occurred. This information will be important to share with your provider when you call with the exciting news!
Did you know that only 6% of labor occurs with their bag of water rupturing spontaneously (SROM)?
Pitocin is medication given to stimulate uterine contractions via your IV. It can be given to patients in spontaneous labor to augment their contractions or during an induction to get contractions started. The goal of Pitocin is to establish strong contractions every 2-3 minutes apart. Pitocin is started low and can be increased incrementally every 15 minutes (or longer) until the desired labor pattern is achieved. Continuous fetal monitoring is required during the infusion.
You’ve made it to 10 centimeters! Now what?
Pushing
I always encourage patients to take a moment to take a few deep breaths and really soak this moment in. While it may be anywhere from a few minutes to a few hours, you are entering the final moments before your baby is in your arms. The moment is fleeting so be sure to savor it!
When the time comes and your cervix is fully dilated, you are now at the start of the second stage of labor. This is a huge milestone, and soon you will meet your baby! Some possible signs of this transition stage include noticeable shivering, feeling fearful or nervous, hot flashes, and nausea and vomiting due to high levels of the adrenaline hormone. Your urge to push may be more noticeable (or you might not feel that sensation as strongly, that’s okay too), with feelings of stretching, fullness and rectal pressure, especially if you are unmedicated or using nitrous oxide. All these feelings are completely normal. The excitement, the buildup of emotions and anticipation to finally be in this moment feels surreal. Once you begin to start pushing, you will find your rhythm with your support team and the calm and readiness will return.
While the most common position to push is lithotomy (laying on your back) there are so many great positions to try. The average pushing time for a nulliparous patient is around two hours. There are many pushing positions, like side lying, squatting or using the birthing bar, that can be great options to mix it up and see what feels right for you. It also makes time go by quickly! If your urge to push is strong, you may have a great sense of when the right time to push is, use this and listen to your body! Your nurse or provider can also feel your contractions to guide you when to push (directed pushing). Try not to focus on the progress you are making (it can be slow, but it is happening), your nurse and provider will help you adjust your form if it’s needed.
As a nurse, I find the second stage of labor (pushing) to be the biggest welcomed surprise for patients who are epiduralized. While it takes stamina, focus and strength, once you practice a few times it becomes rhythmic. Many of my patients who have their pain well managed have expressed “wait this is it?” Trust me, it is not like it is portrayed in the movies!
For the unmedicated patient, there are many great pain options for you that don’t include the epidural such as nitrous oxide, TENS, massage, hydrotherapy, and guided support by your partner, nurse or doula. Unmedicated patients have even described pushing as the best pain reliever, putting all of their focus and sensation into birthing their baby.
The most recognized methods of pushing are open glottis and Valsalva pushing. Open glottis is the gold standard for pushing, although you might find that providers still encourage patients to push with a closed glottis (I.E., take a deep breath and hold it in while pushing for 10 seconds). Both methods are widely used, I find it is best to practice them both to see what feels right for you. Your support team will show you what this looks like and do a few practice pushes with you to get started. Open glottis pushing looks like this: take a deep breath in during the peak of your contraction, curl toward your baby and bear down with your glottis (airway) open. With this method air can pass through your airway. Valsalva pushing differs in that you will hold that air in like you are going under water. With each contraction, you will push 3 times, for 8-10 seconds and with each push baby is closer to delivery. This is a great time to play your favorite music and have some fun with it.
Did you know that your doctor may pop in and out of the room during pushing? This is normal practice, and they are receiving updates from your care team as you progress.
Delivery and the golden hour
The delivery of your baby is sure to be an emotional experience! No matter what delivery method (cesarean or vaginal) it is an incredible moment of relief and excitement. In an uncomplicated vaginal delivery, your doctor can place your baby directly on your stomach or chest (based on what the length of your umbilical cord allows) while they wait for 1 minute to allow the passage of cord blood into the baby. You have now entered the golden hour. During this sacred bonding time, your provider will clamp the cord and offer your partner to cut it if they wish. Your nurse will gently stimulate or suction the baby, if need be, and assist you in your first skin to skin moments! The golden hour is an evidence-based practice that has been shown to significantly improve thermoregulation, regulate respiratory status, and decrease maternal and neonate stress levels. Immediate bonding is shown to decrease time to feeding at the breast and increase duration of feed! In a cesarean delivery, skin to skin can and should be done immediately after delivery too and is equally as important. Please advocate for this if cesarean delivery is indicated.
During this time, all baby assessments (heart rate, respirations, and temperature) and neonatal medications (erythromycin and vitamin K) will be done on your chest and tasks like baths, obtaining weight and length will be delayed. If your baby needs more immediate support like deep suction or oxygen support following either delivery method, they will be taken to the baby delivery bed first, to be assessed by the nursing and/or NICU staff prior to the golden hour.
Immediate postpartum recovery
Directly after the birth of your baby, you will deliver the placenta. Once the placenta is delivered, your provider will examine your perineum and assess what type of laceration you may have and begin to repair it. If you have an epidural, it will continue to infuse during the repair.
Your nurse will initiate postpartum Pitocin through your IV, which acts to contract your uterus and decrease postpartum bleeding. They will assess your bleeding often by pressing externally on your abdomen, at the top of your uterus (known as a fundal examine) to ensure your uterus is firm and assess your bleeding. This examination will be done every 15 minutes in the immediate recovery period. If bleeding is heavy, additional medications and fluid will be given to you to assist in contracting your uterus further to control the bleeding.
GOOD LUCK!!
Your labor and delivery experience will be completely unique to you. My two deliveries were completely different, but both were beautiful in their own way. Whether your baby is delivered via c-section like I did with my first, or vaginally, the journey to holding your baby in your arms is unlike any other experience and deserves to be honored!
You are the best parent for your baby. Your body created, nourished, comforted and birthed LIFE. Be proud of the time, energy, preparation, and love (maybe a few tears) that you have put into this process. You are superhuman!
It is my deepest hope this guide brings clarity to any unanswered questions you may have about the Labor and Delivery process and allows you to reflect on what is most important to you for your own delivery. We are here to help you along the way. Please reach out if you have any questions, I would love to hear from you.
Check out Bumblebaby’s hospital bag essentials blog post and Amazon store.
Don’t forget to download our free hospital checklist here.
Other helpful blog posts:
- Postpartum essentials for mom
- Postpartum essentials for baby
- Tips for navigating a c-section
- First time baby registry
- Hospital bag essentials
Have more questions? Schedule a text or video chat consult with Kate, Lauren or Natalie (NICU RNs) and they can help answer any questions that you have!
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- talk about what to expect in this period, how you are feeling and adjusting
- discuss perinatal anxiety, PPD/A
**This post is educational and not meant to take the place of your provider. Bumblebaby makes a small commission on some of the items listed above.
*Disclaimer: Always consult your provider with any labor and delivery concern and protocols unique to your labor and delivery. All information provided is not intended to take the place of your provider.
Resources:
- Labor Induction Versus Expectant Management in Low-Risk Nulliparous Women, 2018. Grobman et.al.
- Providing Evidence-Based Care During the Golden Hour, NURS Women’s Health, 2017, Neczypor, J and Holley, S.
- Pregnancy Childbirth and the Newborn, The complete guide, 5th edition, 2016, Simkin, P; Whalley,J; Keppler, A; Durham, J; Bolding, A.
