Becoming a mother is an amazing thing, but it can also be scary when it’s your first time, or if your situation is different from a previous pregnancy or delivery.
We connected with Dr. Nichole Van de Putte, a board-certified obstetrician gynecologist with Methodist Hospital | Metropolitan, to learn more about what women can expect from the process.
She gave incredible insight into some of the biggest questions about labor and delivery.
1. When should a mom go to the hospital if she’s having contractions or her water has broken?
A water bag breaking will most commonly happen if you’re full term or close to term, but if you have any concern it might have broken, you should go to your delivery facility to be evaluated.
Pre-labor rupture of membranes -- or “water bag breaking” -- that occurs preterm or before 37 weeks gestation complicates approximately 2-3% of pregnancies in the United States.
“It can be a sudden gush of fluid or a light trickle,” Van de Putte said. “Most of the time your water bag will break in labor, or it’s facilitated during your delivery by your medical team. When the bag breaks, there’s an increased risk of infection. The amniotic sac serves as a wonderful barrier to protect baby from potential harmful bacteria and agents that could cause an intrauterine infection, so when it breaks, you no longer have that barrier.”
Depending on the gestational age, your OB-GYN will discuss options of pursuing delivery versus expectant management.
Labor contractions typically begin in the back, move to the front, and then the whole belly will get tight.
“There’s a strong sense of pain that feels like a really intensified menstrual cramp, and it’ll last about 45 seconds to one minute,” she said. “If you have this type of contraction pain and it occurs every two to three minutes for more than an hour, that’s when we recommend you go to your delivery facility for an evaluation.”
Ultimately, if there are any seemingly unusual symptoms, contact your delivering facility and they can determine if it requires an ER visit or an acute obstetrical evaluation.
2. How might labor be induced?
“Some women may choose to have their labor inducted electives and other times there may be medical indications that require delivery at a gestational age,” Van de Putte said. “When the intrauterine environment is no longer the safest environment for baby, or continuing the pregnancy poses significant risks to mom, delivery is recommended. It is always about considering what is the best thing for both mom and baby, as we have two lives to consider.”
Inducing labor is essentially using medical management to facilitate labor, and there’s a variety of agents that can be used to achieve this goal.
“Cervical ripening agents are medications that can be used orally, intravenously or vaginally,” she shared. “There are also mechanical dilators, which are used to ripen the cervix.”
Ripening means to prepare the cervix to be in a more prepared state for labor. After that, a series of medications can help support contractions.
3. How long can labor take?
There are distinct stages of labor: latent (the early phase), active and delivery.
“The latent phase varies widely among women and it is the time it takes from onset of contractions to 6 cm dilation,” Van de Putte said. “This can take up to 18 hours or more in first-time moms, and typically veteran moms will progress through the latent phase much faster.”
Once the mom is 6 centimeters dilated or greater, they enter active labor.
“The expectation in active labor is that the cervix would change a centimeter about every hour or faster. If the active or latent phase of labors become protracted (taking longer than expected) or arrested (stop progression) your OB-GYN may offer medical management to assist intensifying the strength of the contractions to help dilate the cervix. Once you’re ready to start pushing -- meaning you’re 100% dilated or 100% effaced -- the cervix is very thin and 10 centimeters dilated to accommodate the fetal head.”
This part can take several hours, but they must be able to see progress.
“Labor is all about momentum and progress,” she continued. “You want to move from that latent phase to that active phase to the pushing phase, and we want to be able to support that process.
“I will usually tell my patients: ‘You can expect to be in labor 18 to 24 hours. Be ready for a day committed to being in labor.’ If we’re having to use a ripening agent, you might add an extra half day to that. It can take a while.”
4. When is an epidural available? What are other options?
An epidural’s primary use is for pain management. Once a mom reaches a level of pain that requires some level of intervention, there are options of IV medications or an epidural.
“About 90% of labors are performed with an epidural,” Van de Putte said. “The benefit is good pain management; the downside is your mobility is limited. Because it’s a regional type of anesthetic, you’re not going to be able to walk, move about in the hallways or get up to use the bathroom.”
A patient who wants to move around or use breathing balls and props might choose to get an epidural later or not at all.
“I find the epidural is very beneficial to help a female relax,” she continued. “Oftentimes, I’ll see my patients really tense up in response to that pain. For patients who can use other techniques -- like breathing -- to keep themselves in a more relaxed state, sometimes that epidural isn’t necessary for them.”
Another choice for pain management is IV medication, but the downside is that anything given intravenously can move on to the fetus.
“If the delivery of the baby occurs quick and in closer proximity to when the IV medication was given, there’s a chance the baby may be born a little bit on the sleepy side, due to the effects of this narcotic. However, our nursing teams are trained to deal with that in our delivery facilities and can assume the appropriate interventions to help support the baby in that setting.”
Because of this risk, IV medication is typically used earlier in the labor process. When you’re actively pushing and facilitating efforts for delivery, that’s when an epidural can be more helpful.
5. When are episiotomies performed? How are tears treated?
An episiotomy is performed to create an intentional extension of the perineum to help facilitate the birth of the baby.
“If an episiotomy must be performed, it’s to extend or expand the posterior vaginal wall,” Van de Putte said. “The goal is to support the delivery in a way that is going to be least problematic for mom and baby. They’re done purposefully and to help avoid further trauma.”
For example, if you have a very large fetus and there’s concern you might have an impending shoulder dystocia or a need to do additional maneuvers, an episiotomy will create more space for the obstetrician to safely deliver that child. It is a very specialized and indicated extension.
However, episiotomies aren’t performed as routine.
“If everything’s going well and mom’s delivering, there’s a high likelihood that she is going to tear naturally. After that, we will evaluate and repair the laceration. They are typically done in real time after the delivery.”
When a woman has an epidural, there’s not a significant need for additional interventions. The epidural ensures the woman is not in pain so the doctor can repair appropriately. Alternately, the mom can be given additional medication or a local anesthetic for pain management during the repair.
6. What can mom expect during delivery of the baby?
“Delivery is a unique and life-impacting experience,” Van de Putte said. “What’s important is to help guide mom on pushing efforts so she has good sense of where to push, how to push and the length of pushing. We normally have the patient take a deep breath, hold it and then push for about 10 seconds. This will occur consecutively three to four times, to occur simultaneously with length of the contraction. She then relaxes and will resume pushing efforts with contractions.”
The length of the pushing effort varies but can last a few hours. Once the baby’s head begins to deliver, there is an increase in pressure and sometimes pain, followed by a big sense of relief.
“Most of the time it’s quick,” she said. “There are times when the head may deliver, but the shoulders may require additional maneuvers to help facilitate the delivery of the baby. Mom may feel more pressure during that time. In this event, we have mom stop pushing for a moment to facilitate the appropriate maneuvers. Interventions are very intentional to deliver the baby safely.”
The medical staff will be hands on to help support safe deliveries.
“I always say labor delivery nurses are just magical because they do such a great job of guiding moms during this very intimate moment in their lives,” Van de Putte said.
Once the baby is delivered, delayed cord clamping is recommended for about 30-60 seconds while the doctor stimulates the baby and uses bulb suction to clear out any secretions or mucus.
After that, they promote the mom having time with her baby.
“We support a golden hour, which is skin-to-skin time. Mom needs baby, baby needs mom. At Methodist Healthcare, we really support a family-centered approach to labor and the birth experience.”
7. What kind of situations can arise during childbirth that might warrant switching gears for delivery?
It’s important patients understand there’s a lot that can go right and there’s a lot that can take a turn in the wrong direction. While women shouldn’t anticipate something will go awry, they should know it’s a possibility.
“There are always two patients to consider, and the goal is always a safe delivery,” Van de Putte said. “It comes down to communication, doing what is medically necessary to support mom and baby, and doing everything we can to get mom and baby back together as quickly as possible.”
She listed various things that could happen: “You could have slow labor (dystocia) and labor arrest. There are interventions, medical management that we can do in those settings. There are times where there could be fetal distress, where we can’t facilitate the delivery as quickly as we need to. The situation may escalate, and we may need to perform a cesarean delivery to get the baby out in a prompt fashion. There are also situations where we need to expedite delivery for the benefit of the mom.”
She said the C-section rate in Texas and the United States is about 33%.
“We typically make a transverse incision about 2 centimeters above your pubic bone, through the abdominal wall and down to the peritoneal level, below your muscles. We then make an incision on uterus and deliver the baby. The placenta is delivered. Bleeding is evaluated and controlled, and the uterus and abdomen then repaired.”
There are also situations that could lead to the need for forceps or a vacuum facilitated delivery.
“These are referred to as operative deliveries, and the risks associated with using these interventions need to be clearly communicated,” she said. “Using a vacuum could bruise the baby’s head and there could also be lacerations associated both on the maternal and fetal side when using forceps.”
Van de Putte said there’s nothing that’s risk free, which is why it’s important to have open communication.
“Women and families can spend a lot of time and energy on the what ifs that can cause an enormous amount of anxiety for women. I try to empower my patients on what they have control over, empower them in the ways they can take ownership, ensure they understand what roads may come along and discuss an action plan.”
8. How long can a mom expect to stay in the hospital after the baby is born?
Moms often stay in the hospital about two days after delivery, while veteran moms typically stay for a shorter term. Moms who have had a C-section will stay a little bit longer.
“The important part is that milestones are met,” Van de Putte said. “We want moms walking, eating and urinating without difficulty, passing gas, their pain under control, and make sure they’ve been supported in their breastfeeding efforts.”
If there are any medical comorbidities like hypertension or complications that occurred during labor -- like hemorrhage or other escalations -- those moms will require a longer hospital stay.
9. How is breastfeeding supported?
Moms will receive aid in breastfeeding before they leave the hospital.
“Breastfeeding is the best thing for mom, best thing for baby, and we really support that. We have lactation nurses starting almost right after delivery to help support moms.”
Methodist Healthcare also offers further education and support for moms who may need additional support in their breastfeeding efforts.
Leaving the hospital
Van de Putte said several tests will be run on the baby before leaving to ensure they are healthy. Moms must also schedule a follow-up appointment with the baby’s pediatrician within a short interval to check on the newborn and ensure things are going well.
After returning home, moms should be feeling physically better every day.
“It’s important to know the postpartum period can be intense,” Van de Putte said. “It’s important to have support and talk about any struggles you have in a very open way.”
Ultimately, the goal will always be to get through delivery in the safest way possible for mom and baby and to ensure they can be together as quickly as possible for bonding.
Having a baby can be one of the most exciting and wonderful experiences in life. Methodist Healthcare delivers more babies than any other hospital system in San Antonio and has physicians specializing in obstetrics and a compassionate team of healthcare professionals offering family-centered care.
To learn more about delivery options at Methodist Healthcare, click here.