Third Trimester: Labor & Delivery (29 weeks – Delivery)

Cesarean Birth

Cesarean birth is the delivery of a baby through incisions made in the mother's abdomen and uterus.

Cesarean births are typically done for the following reasons:

• Failure of labor to progress
• Concerns for the baby or possible distress of the baby during labor
• Twins or Triplets in pregnancy
• Placenta problems
• Abnormal presentations of the baby
• Maternal infections like herpes or HIV
• Maternal conditions like hypertension or diabetes
• By maternal request (not common and only after careful discussion of risks and long-term consequences)

The incision for the cesarean is made through your skin and the wall of the abdomen. The skin incision may be transverse (bikini) or vertical. The muscles of the abdominal wall are separated (not cut). Another incision will be made in the wall of the uterus. The incision in the wall of the uterus also can be made vertically or horizontally, depending on the reasons for the cesarean delivery.

The baby will be delivered through the incision, the umbilical cord will be cut and then the placenta will be removed. The uterus will be closed with stitches that will dissolve into the body. Dissolving stiches are used to close the skin of your abdomen as well.

Complications from the cesareans are uncommon and include:

• Infection
• Blood loss and sometimes transfusions of blood
• Blood clots of the legs, pelvis or lungs
• Injury to the bladder or the bowel
• Reaction to medication or anesthesia that would need to be used

You're typically awake but without pain for the procedure, so you can hold your baby soon after delivery. You will be taken to a recovery area for monitoring and then a room to recover while you stay in the hospital. Breastfeeding is encouraged and can start right away. The first few times that you get out of bed (encouraged) a nurse will need to help you. The abdominal incision will be sore for the first few days and your doctor will decide on the proper medication for you and your recovery. The hospital stay after the operation is typically two to four days. When you go home, you may need to take special care of yourself and limit your activities. You may need extra help at home for the first couple of weeks. Your doctor will see you in the first three weeks following surgery, and then thereafter through your complete recovery.

Cord Blood Banking

The American Academy of Obstetricians and Gynecologists (ACOG) recommends educating expectant parents about cord blood banking.

Cord blood is collected by your OB/GYN or hospital staff at the hospital where you give birth. The process used to collect cord blood is simple and painless. After the baby is born, the umbilical cord is cut and clamped. Blood is drawn from the cord with a needle that has a bag attached. The process takes about 10 minutes.

Some advantages of using cord blood to treat disease include:

• Stem cells from cord blood can be given to more people than from bone marrow.
• Cord blood can be frozen and stored. It's ready for anyone who needs it. Bone marrow must be used soon after collection.
• Stem cells in cord blood can be used to strengthen the immune system during cancer treatments. Bone marrow stem cells don't have this capability.

Read more about cord blood banking from ACOG.

Group B Strep and Pregnancy

Group B streptococcus is one of the many types of bacteria that live in the body and usually don't cause serious illness. It's found in the digestive and reproductive tracts of men and women, including the vagina and rectum. It's NOT a sexually transmitted infection.

Pregnant women who are colonized (they have the bacteria present but no symptoms) can pass the bacteria to their baby during labor. This can cause infections in your baby's lungs and blood stream and may also cause meningitis. These infections, which can occur just after delivery or up to one week after delivery, can be severe and life threatening.

Your doctor will test for Group B strep between 35 and37 weeks by swabbing the mother's vagina and rectum for a culture. If the result is positive, antibiotics will be given during labor to prevent infection being passed to the baby. The antibiotics work only if they are given during labor.

If you had a previous baby with GBS infection or if your urine has GBS bacteria during this pregnancy, you are at higher risk of passing this to your baby during labor.

You and your doctor will discuss your results and how this impacts your deliver.

How to Tell When Labor Begins

As labor begins, the cervix opens (dilates) and thins. The uterus contracts at regular intervals. When this happens, the abdomen becomes hard. Between contractions, the uterus relaxes and becomes soft. Up to the start of labor, the baby typically will continue to move.

Signs that your body is getting ready for labor include:

• The sensation that the baby is lower in the abdomen and pelvis (dropped)
• An increase in vaginal discharge and mucus

These signs may happen weeks before labor or at the onset of labor; every mother is unique.

Differences between false labor and true labor

Call your doctor if you have any questions or aren't sure if you're in labor. During normal business hours call 713-481-5347. After hours call our 24/7 OB Hotline at 713-442-BABY (2229).

Labor Induction

Labor induction is the use of medication or other methods to bring on (induce) labor. Labor is induced to stimulate contractions of the womb (uterus) in an effort to have a vaginal birth. Inductions of labor may be recommended if the health of the mother or baby are at risk. It is the goal to not do inductions before full development of the baby by 39 weeks if possible.

To prepare for labor and delivery the cervix begins to soften (ripen), thin, and open. These changes usually start a few weeks before labor. To support the induction, your doctor may consider softening or ripening the cervix as part of the induction process. Labor is then stimulated with medication or at times medical devices that help move the process toward a safe vaginal delivery.

Your doctor will discuss the options and methods that best fit your individual circumstances and needs and that will achieve the safest success for a vaginal delivery.

• The risks of an induction are rare and include:
• Overstimulation of the uterus
• Infections in the mother or baby
• Damage to the uterus
• Increase risk of cesarean section

Inductions may not always be successful. A failed attempt at induction may mean that you will need to try another attempt or a cesarean delivery. First time mothers carry a higher risk of cesarean delivery especially when the cervix has not yet softened.

You and your doctor will discuss the different aspects of inducing labor when and if the circumstances become necessary for the safety of your baby and your pregnancy.

Newborn Male Circumcision

Circumcision is an operation where the loose skin of the tip of the penis is removed. Circumcision may be done for cultural or religious reasons but is rarely needed for medical reasons. No national or international medical societies recommend circumcision.

The Children's Health & Human Rights Partnership published an educational video for expectant parents about circumcision. Dr. Christopher Guest, M.D., F.R.C.P.C., discusses the history, medical myths, and human rights aspects surrounding circumcision of children, as well as the function and anatomy of the intact penis. This video is a powerful resource tool for prenatal education.

Watch this video to learn more about circumcision.

Premature Labor and Birth

A premature baby is one who is born too early, before 37 weeks. Premature babies may have more health problems and may need to stay in the hospital longer than babies born later.

What are the signs and symptoms of preterm labor?

Call your doctor right away if you have any of these signs and symptoms of preterm labor:

• Change in your vaginal discharge (watery, mucus or bloody) or more vaginal discharge than usual
• Pressure in your pelvis or lower belly, like your baby is pushing down
• Constant low, dull backache
• Belly cramps with or without diarrhea
• Regular or frequent contractions that make your belly tighten like a fist (the contractions may or may not be painful)
• Water breaks

Your physician may do a pelvic exam or a transvaginal ultrasound to see if your cervix has started to thin out and open for labor. Your cervix is the opening to the uterus (womb) that sits at the top of the vagina (birth canal). A transvaginal ultrasound is done in the vagina instead of on the outside of your belly. Like a regular ultrasound, it uses sound waves and a computer to create a picture of your baby. If you're having contractions, your doctor monitors them to see how strong and far apart they are. Other may be needed to help your doctor determine whether you're really in labor.

If you're experiencing preterm labor, your doctor may provide treatment to help stop it. Or, you may get treatment to help improve your baby's health before birth. Talk to your doctor about which treatments may be right for you.

Are you at risk for preterm labor and premature birth?

We don't always know for sure what causes preterm labor and premature birth. Sometimes labor starts on its own without warning. Even if you do everything right during pregnancy, you can still give birth early.

These three risk factors make you more likely to have preterm labor and give birth early:

• You've had a premature baby in the past.
• You're pregnant with multiples (twins, triplets or more).
• You have problems with your uterus or cervix now or in the past.

Medical risk factors before pregnancy for preterm labor and premature birth include:

• Being underweight or overweight before pregnancy. This can include having an eating disorder, such as anorexia or bulimia.
• Having a family history of premature birth. This means someone in your family (mother, grandmother or sister) had a premature baby. If you were born prematurely, you're more likely than others to give birth early.
• Getting pregnant again too soon after having a baby. For most women it's best to wait at least 18 months before getting pregnant again. Talk to your provider about the right amount of time for you.

Medical risk factors during pregnancy for preterm labor and premature birth

Having certain health conditions during pregnancy can increase your risk for preterm labor and premature birth including:

• Connective tissue disorders, such as Ehlers-Danlos syndrome (also called EDS) and vascular Ehlers-Danlos syndrome (also called vEDS). Connective tissue surrounds and supports other tissues and organs. EDS can cause joints to be loose and easy to dislocate; skin to be thin and easily stretched and bruised; and blood vessels to be fragile and small. It also can affect your uterus and intestines. vEDS is the most serious type of EDS because it can cause arteries and organs (like the uterus) to rupture (burst). EDS and vEDS are genetic conditions that can be passed from parent to child through genes.
• Diabetes. Diabetes is when your body has too much sugar (called glucose) in your blood.
• High blood pressure and preeclampsia. High blood pressure (also called hypertension) is when the force of blood against the walls of the blood vessels is too high. This can stress your heart and cause problems during pregnancy. Preeclampsia is a kind of high blood pressure experienced by some women during or right after pregnancy. If not treated, it can cause serious problems and even death.
• Infections, including sexually transmitted infections (also called STIs) and infections of the uterus, urinary tract or vagina.
• Intrahepatic cholestasis of pregnancy (also called ICP) is a liver disorder that occurs during pregnancy.
• Thrombophilias. These are conditions that increase your risk of making abnormal blood clots.

Other medical risk factors during pregnancy include:

• Late or no prenatal care.
• Not gaining enough weight during pregnancy. This can include having an eating disorder, such as anorexia or bulimia.
• Bleeding from the vagina in the second or third trimester.
• Preterm premature rupture of the membranes (also called PPROM). Premature rupture of membranes (also called PROM) is when the amniotic sac around your baby breaks (your water breaks) before labor starts. PPROM is when this happens before 37 weeks of pregnancy. If you have any fluid leaking from your vagina, call your provider and go to the hospital.
• Being pregnant after in vitro fertilization (also called IVF). IVF is a fertility treatment used to help women get pregnant.
• Being pregnant with a baby who has certain birth defects, such as heart defects or spina bifida. Birth defects are health conditions that are present at birth. They change the shape or function of one or more parts of the body. Birth defects can cause problems in overall health, how the body develops or how the body works. Spina bifida is a birth defect of the spine.

Risk factors in your everyday life for preterm labor and premature birth:

• Smoking, drinking alcohol, using street drugs or abusing prescription drugs
• Stress
• Low socioeconomic status (SES), which includes education, job, and income.
• Domestic violence, including physical, sexual, and emotional abuse
• Working long hours or having to stand a lot
• Exposure to air pollution, lead, radiation and chemicals in things like paint, plastics and second-hand smoke. Secondhand smoke is smoke from someone else's cigarette, cigar, or pipe.

Age and race as risk factors for preterm labor and premature birth

Being younger than 17 or older than 35 makes you more likely than other women to give birth early. In the United States, black women are more likely to give birth early. Almost 17 percent of black babies are born prematurely each year. Approximately 10 percent of American Indian/Alaska Native and Hispanic babies are born early, and less than 10 percent of white and Asian babies. We don't know why race plays a role in premature birth; researchers are working to learn more.

Can you reduce your risk for preterm labor and premature birth?

Yes, you may be able to reduce your risk for early labor and birth. Some risk factors you can't change, like having a premature birth in a previous pregnancy. Others you can do something about, like quitting smoking.

According to the March of Dimes, here's what you can do to reduce your risk for preterm labor and premature birth:

• Get to a healthy weight before pregnancy and gain the right amount of weight during pregnancy. Talk to your doctor about the right amount of weight for you before and during pregnancy.
• Don't smoke, drink alcohol, use street drugs, or abuse prescription drugs. Ask your doctor about programs that can help you quit.
• Go to your first prenatal care checkup as soon as you think you're pregnant. During pregnancy, go to all your prenatal care checkups, even if you're feeling fine. Prenatal care helps your doctor make sure you and your baby are healthy.
• Get treated for chronic health conditions, like high blood pressure, diabetes, depression, and thyroid problems.
• Protect yourself from infections. Talk to your provider about vaccinations that can help protect you from certain infections. Wash your hands with soap and water after using the bathroom or blowing your nose. Don't eat raw meat, fish, or eggs. Have safe sex. Don't touch cat poop.
• Reduce your stress. Eat healthy foods and do something active every day. Ask family and friends for help around the house or taking care of other children. Get help if your partner abuses you. Talk to your boss about how to lower your stress at work.
• Wait at least 18 months between giving birth and getting pregnant again. Use birth control until you're ready to get pregnant again. If you're older than 35 or you've had a miscarriage or stillbirth, talk to your doctor about how long to wait between pregnancies.

T-dap Immunization

T-dap vaccination during pregnancy is critical for the prevention of pertussis in newborns until they're old enough to be vaccinated. The American College of Obstetrics and Gynecologists (ACOG) website shares answers to commonly asked questions about the T-dap vaccine:

What is pertussis?

Pertussis (also called whooping cough) is a highly contagious disease that causes severe coughing and difficulty breathing. People with pertussis may make a "whooping" sound when they try to breathe and gasp for air. Pertussis can affect people of all ages and can be serious, even deadly, for babies less than a year old. In recent outbreaks, babies younger than 3 months have had the highest risk of severe disease and of dying from pertussis.

What is T-dap?

The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is used to prevent three infections:

• tetanus
• diphtheria
• pertussis

I'm pregnant. Should I get a T-dap shot?

Yes. All pregnant women should get a T-dap shot in the third trimester, preferably between 27 weeks and 36 weeks of gestation. The Tdap shot is a safe and effective way to protect you and your baby from serious illness and complications of pertussis.

When should I get the T-dap shot?

Experts recommend that you get the Tdap shot during the third trimester (preferably between 27 weeks and 36 weeks) of every pregnancy. The shot will help you make protective antibodies against pertussis. These antibodies are passed to your fetus and protect your baby until he or she begins to get vaccines against pertussis at 2 months of age. Receiving the shot early in the 27 to 36-weeks-of-gestation window is best because it maximizes the antibodies present at birth and will provide the most protection to the newborn.

When Pregnancy Goes Past the Due Date

The date your baby is due is your estimated due date (EDD) and determined from the actual or calculated first day of your last menstrual cycle. The EDD is used to guide the progress of your pregnancy and the tracking of the growth and development of you your baby.

Once the due date has been selected, it does not change, regardless of how many additional ultrasound exams you may have during your pregnancy.

The average length of the pregnancy ins 280 days or 40 weeks. A pregnancy lasting 41 to 42 weeks is called "late term." A pregnancy that lasts longer than 42 weeks is called "post term."

The causes of post term pregnancy are unknown; the following factors contribute to its occurrence:

• First pregnancy
• Male babies
• A prior pregnancy that went "post term"
• Obesity

The health risks for you and your fetus may increase if a pregnancy is late term or post term. Most of these pregnancies will deliver without complications but the risks are:

• Stillbirth
• Macrosomia (abnormally enlarged growth of the baby)
• Post maturity syndrome
• Meconium stained amniotic fluid
• Decreases in the fluid around the baby
• The need for assisting the delivery with vacuum or forceps
• Cesarean section
• Post-delivery excessive bleeding (postpartum hemorrhage)

At 41 weeks your doctor may recommend testing the baby for his or her well-being. The testing uses electronic fetal/baby monitoring and sometimes ultrasound to assess and reassure that the baby is doing well.

Labor induction may be recommended if your pregnancy reaches 41 weeks. Induction is started using medication or other methods.

Your doctor will discuss your options and together you will be able to share in the decision for the timing and process of delivery.