American Medical Association Family Medical Guide - American Medical Association [299]
Inducing Labor
Inducing labor is the act of starting labor mechanically or medically. Labor is usually induced when the risks of allowing the pregnancy to continue—such as retarded growth of the fetus (see page 529), extremely high blood pressure in the pregnant woman (see page 520), or a postterm pregnancy (see page 530)—are greater than the risks of inducing labor. Labor is seldom induced before the baby’s lungs are sufficiently developed to survive outside the uterus. Before inducing labor, your doctor will evaluate the health of the baby and examine you internally to see if your cervix has begun to dilate.
One way to induce labor is to drain the amniotic fluid (the liquid that surrounds the fetus). To “break the bag of water,” the doctor will make a small, painless incision in the membranes of the amniotic sac.
If draining the fluid does not trigger labor, you may receive an injection of the hormone oxytocin, which stimulates uterine contractions. However, 1 in 50 injections of oxytocin fails to stimulate labor.
If your due date has passed, your doctor may try to induce labor by separating the amniotic membranes from their attachments in the cervix and lower wall of the uterus (called stripping the membranes). There is no risk involved, but you may feel mild cramps or contractions after the procedure.
Episiotomy
An episiotomy is a surgical incision that is sometimes used during labor to enlarge the opening of the vagina, usually to avoid putting unnecessary pressure on the baby’s head during delivery, especially during a forceps delivery. An episiotomy is also sometimes performed to avoid irregular tearing of the vagina, which can be more difficult to stitch up than a straight cut. Episiotomies are usually performed toward the end of the second stage of labor, before the baby’s head emerges.
After injecting a local anesthetic, the doctor usually makes a small, straight cut in the perineum (the area of skin between the opening of the vagina and the anus) from the vagina to the anus; this is called a midline episiotomy. For a mediolateral episiotomy, the cut is made at an angle from the vagina to the left or right of the anus. After delivery, the incision is closed with stitches that gradually dissolve. The incision usually heals rapidly, although the scar may cause discomfort for up to 3 months.
To relieve discomfort in the area around the incision, your doctor will recommend periodically using an ice pack for a few minutes, sitting in a shallow tub of warm water, or sitting on a doughnut-shaped pillow. To help prevent infection, rinse the area with warm water and pat it dry each time you use the toilet.
Episiotomy
In a midline episiotomy, the incision is made straight from the vagina toward the anus. In a mediolateral episiotomy, the incision is made to the side and at an angle to the anus. A midline incision is the most common type of episiotomy because it cuts through less tissue and usually causes less discomfort than a mediolateral episiotomy. A mediolateral episiotomy may be necessary if a baby is very large or if forceps are used for delivery.
Forceps
Obstetrical forceps are two wide, blunt, curved blades designed to fit around a baby’s head to assist delivery. There are several different types of forceps used for different circumstances. For example, they may be used to protect the baby’s head in a breech (buttocks first) presentation (see next page) or in a preterm delivery (see page 529). When epidural anesthesia (see page 532) has been used toward the end of labor, forceps are often used to assist delivery because a woman may not feel the urge to push. Forceps also are frequently used if