During the last weeks of pregnancy, the fetus’s head drops lower into the uterus. On their weekly visits to the health-care provider, women, such as Kim in the opening chapter vignette, may be told, “It should be any minute now.” The uterus begins to contract as it prepares for birth. The cervix thins out and softens under the weight of the child. Anticipation builds . . . and then—she waits!

I am 39 weeks and desperate for some sign that labor is near, but so far NOTHING—no softening of the cervix, no contractions, and the baby has not dropped—the idea of two more weeks makes me want to SCREAM!!!

What sets off labor? One hypothesis is that the trigger is a hormonal signal that the fetus sends to the mother’s brain. Once it’s officially under way, labor proceeds through three stages.

This first stage of labor is the most arduous. The thick cervix, which has held in the expanding fetus for so long, has finished its job. Now it must efface, or thin out, and dilate, or widen from a tiny gap about the size of a dime to the width of a coffee mug or a medium-sized bowl of soup. This transformation is accomplished by contractions—muscular, wavelike batterings against the uterine floor. The uterus is far stronger than a boxer’s biceps. Even at the beginning of labor, the contractions put about 30 pounds of pressure on the cervix to expand to its cuplike shape.

The contractions start out slowly, perhaps 20 to 30 minutes apart. They become more frequent and painful as the cervix more rapidly opens up. Sweating, nausea, and intense pain can accompany the final phase—as the closely spaced contractions reach a crescendo, and the baby is poised for the miracle of birth (see Figure 2.11).

The fetus descends through the uterus and enters the vagina, or birth canal. Then, as the baby’s scalp appears (an event called crowning), parents get their first exciting glimpse of this new life. The shoulders rotate; the baby slowly slithers out, to be captured and cradled as it enters the world. The prenatal journey has ended; the journey of life is about to begin.

In the ecstasy of the birth, the final event is almost unnoticed. The placenta and other supporting structures must be pushed out. Fully expelling these materials is essential to avoid infection and to help the uterus return to its pre-pregnant state.

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Just as with pregnancy, a variety of missteps may happen during this landmark passage into life: problems with the contraction mechanism; the inability of the cervix to fully dilate; deviations from the normal head-down position as the fetus descends and positions itself for birth (this atypical positioning, with feet, buttocks, or knees first, is called a breech birth); difficulties stemming from the position of the placenta or the umbilical cord as the baby makes its way into the world. Today, these in-transit troubles are easily surmounted through obstetrical techniques. This was not true in the past.

For most of human history, pregnancy was a grim nine-month march to an uncertain end (Kitzinger, 2000; Wertz & Wertz, 1989). The eighteenth-century New England preacher Cotton Mather captured the emotions of his era when, on learning that a parish woman was pregnant, he thundered, “Your death has entered into you!” Not only were there the hazards involved in getting the baby to emerge, but a raging infection called childbed fever could also set in and kill a new mother (and her child) within days.

Women had only one another or lay midwives to rely on during this frightening time. So birth was a social event. Friends and relatives flocked around, perhaps traveling miles to offer comfort when the woman’s due date drew near. Doctors were of little help, because they could not view the female anatomy directly. In fact, due to their clumsiness (using primitive forceps to yank the baby out) and their tendency to spread childbed fever by failing to wash their hands, eighteenth- and nineteenth-century doctors often made the situation worse (Wertz & Wertz, 1989).

Techniques gradually improved toward the end of the nineteenth century, but few wealthy women dared enter hospitals to deliver, as these institutions were hotbeds of contagious disease. Then, with the early-twentieth-century conquest of many infectious diseases, it became fashionable for affluent middle-class women to have a “modern” hospital birth. By the late 1930s, the science of obstetrics gained the upper hand, fetal mortality plummeted, and birth became genuinely safe (Leavitt, 1986). By the turn of this century, in the developed world, this conquest was virtually complete. In 1997, there were only 329 pregnancy-related maternal deaths in the United States (Miniño and others, 2002).

This watershed medical victory was accompanied by discontent. The natural process of birth had become an impersonal event. Women protested the assembly-line hospital procedures; the fact that they were strapped down and sedated in order to give birth. They eagerly devoured books describing the new Lamaze technique, which taught controlled breathing, allowed partner involvement, and promised undrugged births. During the women’s movement of the 1960s and early 1970s, the natural-childbirth movement arrived.

Natural Childbirth

Natural childbirth, a vague label for returning the birth experience to its “true” natural state, is now embedded in the labor and birth choices available to women today. To avoid the hospital experience, some women choose to deliver in homelike birthing centers. They may use certified midwives rather than doctors, and draw on the help of a doula, a nonmedical pregnancy and labor coach. Women who are committed to the most natural experience may give birth in their own homes. (Table 2.4 on page 62 describes some natural birth options, as well as some commonly used medical procedures.)

At the medical end of the spectrum, as Table 2.4 shows, lies the arsenal of physician interventions designed to promote a less painful and safer birth. Let’s now pause for a minute to look at the last procedure in the table: the cesarean section.

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The Cesarean Section

A cesarean section (or c-section), in which a surgeon makes incisions in the woman’s abdominal wall and enters the uterus to remove the baby, is the lifesaving final solution for labor and delivery problems. This operation exploded in popularity during the 1970s. By the turn of this century, c-sections accounted for an astonishing 1 in 3 U.S. deliveries (Martin and others, 2005).

Some c-sections are planned to occur before labor because the physician knows in advance that there are dangers in a vaginal birth. If the woman is affluent, she can sometimes choose to have a c-section rather than go through labor on her own. As one South African woman graphically explained, “I don’t want to push and sweat and moan and tear . . . I don’t want to lie and pooh in front of everyone” (Chadwick & Foster, 2013).

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Most c-sections, however, occur when there are difficulties once labor has begun. To what degree are these procedures unnecessary, due to health care workers fears of legal liability (“I might get sued unless I get this baby out”)? We don’t know. What we do know is that the best-laid birth plans may not work out, and some women can feel upset if they had been counting on having a child “the natural way”:

“I sort of feel like I failed in the birthing arena,” said one Australian woman . . . “Logically I knew that the c-section was necessary, but somehow I think if I was slim . . . and had not eaten as much ice cream that would not have happened.”

(quoted in Malacrida & Boulton, 2014, p. 18)

Finally, while affluent women may bemoan their c-sections, the real tragedy is the horrifying lack of access to high-quality medical interventions in the least-developed regions of the world. In 2010, an estimated 287, people died of pregnancy-related causes, typically postpartum hemorrhage, infections, or pregnancy blood-pressure complications that would prompt an immediate c-section in the developed world (Souza and others, 2013; Buttenheim & Asch, 2013). While some relatively poor nations—for instance Iran, Honduras, Thailand, and most central European countries—have made great progress in reducing maternal mortality, others have lost ground. Perhaps due to its chronic wars, child marriage, and the prevalence of HIV (Raj & Boehmer, 2013), sub-Saharan Africa had worse maternal death statistics in 2010 than in 1990 (Lawson & Keirse, 2013)! So let’s keep in mind that billions of developing world mothers-to-be still approach birth with a more basic concern than their Western counterparts. Their worries are not, “Should I choose a c-section?” It’s not, “What birth method should I use?” Unfortunately, all too often, it’s still: “Will I survive my baby’s birth?” (Lester, Benfield, & Fathalla, 2010; Potts, Prata, & Sahin-Hodoglugil, 2010).

Question 2.19

Melissa is in stage 1, effacement and dilation of the cervix. Sonia is in stage 2, birth.

Question 2.20

“You might want to forgo any labor medications, and/or give birth in a birthing center under a midwife’s (and doula’s) care. Look into new options such as water births, and, if you are especially daring, consider giving birth at home.”

Question 2.21

C-sections may sometimes be overused in the developed world. But they are seriously underutilized in poor areas of the globe.