Vagina Vagina Vagina

Eve Ensler is obsessed with vaginas. And so she should be. According to her, vaginas lie at the very core of female empowerment. “I’m obsessed with women being violated and raped, and with incest,” says Ensler. “All of these things are deeply connected to our vaginas.” Her play The Vagina Monologues isn’t just a theatrical success, it’s an international political movement. The play was written and first performed back in 1996 and since then it’s been performed in cities all over the world by some of the biggest names in the business. It’s also raised over $50 million for women’s anti-violence groups through Ensler’s V-Day initiative.

This Sunday the show returns to Sydney for one performance only at the Parade Theatre in Kensington as part of the 10th anniversary of V-Day. All of the performers are volunteering their time and talent. One such performer is much loved actress Jacki Weaver. “The monologue I’ll be doing is The Angry Vagina,” says Jacki. “It doesn’t resonate with me on a personal level as I’ve always been extremely good-tempered in that area! My monologue also mentions loving chocolate and I actually loathe chocolate. And my character claims to have given birth vaginally, whereas I, much to my disappointment, was forced to give birth by emergency caesarean section.”

This year’s V-Day performance aims to raise $50,000 for the NSW Women’s Refuge Movement. It’s a state-wide representative body of women and children’s refuges with a specific focus on providing quality support for women and children escaping or experiencing domestic violence and child abuse. It’s a cause that Jacki’s thrilled to be able to support. “Not just because violence against women remains prevalent throughout society – making it such an important issue – but also because the play itself is so brilliantly ground breaking, it deserves to be playing all the time. It’s a privilege to be part of it all.”

Noni Hazlehurst is another member of the cast, thrilled to be doing her bit for feminism and women in need. “I find nearly every woman I meet to be inspirational,” says Noni. Her list of stand out women include Aussie author Helen Garner and the woman who supervised her two homebirths. “It’s not fashionable but… homebirths and breastfeeding for as long as possible [are] two of the most wonderful experiences a woman could ever have. And I still reckon high heels are stupid.”

Other women in the cast include dynamic television and radio personality Julia Zemiro (SBSTV’s Rockwiz ) will act as MC; well known actresses Pamela Rabe, Genevieve Lemon and Annie Byron, as well as ABC arts journalist Fenella Kernebone and FM radio personality Amanda Keller.

Ensler decided to write the play after conducting a series of interviews with 200 women about their views on sex, relationships, and violence against women. She asked them all one simple question – If your vagina could talk, what would it say? “I took little pieces and strains of their stories and created a theatre text that is really talking about the sexuality of women. The story of women is filtered through the stories of their vaginas and so it ranges from very orgasmic pleasure to quite shattering stories; it goes from celebration to sorrow to happiness.”

The Vagina Monologues is on Sunday 29 Jun at 5pm at the Parade Theatre, NIDA in Kensington. Tickets are $65 adult, $45 concession, with proceeds going to V-Day. Click here to book tickets or call Ticketek on 1300 795 012.

Female Reproductive System Part 8

'Polycystic ovaries'

'Torsion of the pedicle'

Female Reproductive System Part 7

'Cryocautery' - cryoprobe in hand and in use

'Prolapsed uterus'

Female Reproductive System Part 6

Laser treatment

Colposcopy

Female Reproductive System Part 5

Diathermy

Colposcopy - colposcope

Female Reproductive System Part 4

'Dilatation and Curettage' 1 and 2

Hands scraping microscope slide with spatula

Female Reproductive System Part 3

'What are the symptoms'

'What are fibroidse'

Female Reproductive System Part 2

External Female Genitals and Surrounding Muscle, Bones, Blood Vessels.

'What are the symptoms of chlamydiae'

Female Reproductive System Part 1

Colour illustration of cells of vaginal lining showing acidic fluid, vaginal cells and basal cell layer.
Colour illustration showing the uterus, fallopian tube, fimbriae, ovary, bladder, pubic cartilage, urethra, vagina, clitoris, anus, and rectum.

Lopsided Labia are Lovely

Elastic-Vagina Blogspot Dot Com. Some parts of my vulvo-vaginal unit are symmetric, and some are not. However, as loverman points out, all of it has synergy. My vagina itself, and my labia majora (outer lips) are symmetric, except that I have a mole on one lip. It is hidden by fur most of the time.

The right labia minora is bigger than the left one. It is not any fatter, and the two join in matching places on either end of the opening to my vagina, but the one lip is flappier. Maybe twice as big (though they are not particularly big), and kind of wavier.

The one large labia used to distress me and I would wait for the other one to catch up. I would get worried about what someone looking at my vagina would think. I would consider just trimming the one side down with nail scissors. (And I've had email from someone who considered the same thing! I hope nobody out there actually follows through— it is ok to be this way!) I calmed down once someone besides me had seen my vulva up close and not commented on its asymmetry.

Later, at the Smut Shack (at Burning Man), I was reviewing a 70s Penthouse magazine with some friends and noticed that one model in a faux Bond Girl photo spread had notably asymmetrical labia minora. This was a pleasant and comforting surprise, despite involving a pin-up woman splayed out enough to allow analysis of her labia minora.

I am gradually developing a context of expectations for my vagina. It is reassuring to understand where it is coming from, and how it relates to the overall nature of vaginas. That was a bit grandiose, but it is true.

Clitoris

Vagina. I love my clitoris. I just appreciate its clitoral nature. There aren't really any qualities that I am aware of that make a clitoris better or worse. They are not supposed to be a certain colour or size or sensitivity; they are just good. I like that.

I say clitoris like "KLIT-o-riss," although I know people who say "kli-TOR-iss." My way seems easier to say (to me) but I don't know whether either way is the decided right way to pronounce the word.

I mostly use the whole word, but sometimes say "clit," especially when referring to piercings. "Clit" seems hipper, but it is hard to sound uptight when willing to refer to a clitoris in the first place. I think I just like the "lit" syllable, despite the fact that with the exception of lit itself, most -lit words have weird sexual connotations (clit, slit, split...).

Lately I've been finding out all kinds of clitoral anatomy, just by accident. Junior high school sex education taught me where my clitoris was (the top structure between my labia, with a little hood of pink skin over it), but only made reference to it being a small, highly sensitive nub of flesh.

While reading about masturbation using vaginal muscles in an old Germaine Greer article in The Madwoman's Underclothes, I discovered that the clitoris has an extensive internal shaft that is something like 7cm (about 3 inches) long. More recently, while flipping through a Good Vibrations book on g-spots, I found a diagram showing this internal part of the clitoris as forked. Forked! Apparently it straddles the urethral sponge tissue, which swells during arousal.

Forked!
This forking makes sense if you think of the general female genital area, which has a split down the middle. Where men have a single scrotum with a seam down the middle, femmes have two labia, and a a split shaft for the clitoris, although the glans or head is still single.

As far as I know, the whole clitoris is erectile, and swells up when it is aroused. I very much like the fact that my clitoris has a head and a tiny little (external) shaft. I can barely see my wee shaft, even with the hood pulled back out of the way, but it can be felt under the skin when it is excited and swollen up.

The head of my clitoris apparently has as many nerve endings as the head of a penis. Both of these organs develop from the same bud of tissue in embryos. The glans tissue becomes either a glans clitoris or a glans penis. I don't know where I pick up all these tidbits about embryonic stem tissue.

Female Ejaculation?

Vagina. There is a some disagreement whether or not there really is a form of 'female ejaculation'. Female ejaculation is believed to be caused by a release of fluid from the Skene's glands. These glands are located inside the urethra. The Skene’s gland is similar to the prostate gland in guys. It produces a fluid that is similar to the chemical composition of prostatic fluid -- which is what makes up the majority of semen. (It’s possible that some urine may leak out during sex from pressure on the bladder for some women. This is not to say that ejaculation fluid is urine). When 'non-scientific' lab tests were done on fluid produced from from the Skene’s gland and during female ejaculation, it was determined to not be urine at all.

Some women may produce greater amounts of fluid from these glands than others, which explains why some women seem to gush during an orgasm while others many do not.

Remember, not all women will have the capability of ejaculating or certainly not every time they have intercourse. It's not something that takes place every time a female experiences an orgasm either, so it does not reflect the quality or enjoyment of the sexual experience.

The amount of fluid that flows out can go from a few drops to a few tablespoonfuls. Stimulating a female’s G-Spot may be a way to help her ejaculate. This will vary from person to person. For more on female orgasms, see that page. For gynecology information, see Gyn Stuff.

The Vagina

Your vagina; get to know it better.
The vagina is the opening that is located directly below the urethral opening (where you pee from). The opening is called an orifice, as are other openings in your body. Directly outside of the vaginal opening are the labia minor, the smooth inner lips of the vulva. Outside of the inner lips are the labia majora, the fleshier outer lips that are typically covered in hair. Females tend to know less about their genitals than males because they cannot see them as easily - fairly obvious. There is nothing wrong with using a mirror and taking a look at what is “down there”. It’s easy to see if you put a mirror between your legs and look, especially if you are trying to insert a tampon for the first time. (See Sexual FAQs 15 for that information).

The clitoris is a sensitive organ and it's function is to provide sexual pleasure. It is a hard round 'button' at the top of the vulva. It’s often so concealed that it may only to viewed when the lips of the vagina are separated. It is structurally connected to the labia minora or inner lips of the vagina. The visible glans of the clitoris, which is hooded by a prepuce -- (formed by the meeting of the labia minora) -- is only the outward and visible part of a much more extensive structure of erectile tissue. The clitoral structure surrounds and extends into the vagina. The structure contains erectile tissue, very similar to the male penis, so when a women gets sexually aroused, it engorges with blood. The clitoris is densely packed with nerve endings, while similar in number to the penis, they are much more concentrated and closer together.

The role of the clitoris in orgasm has been the subject of heated controversy for years. There is even controversy as to its pronunciation, whether it should be 'clitt-oris' or 'cli-toris'. Dictionaries vary and some list both as correct. However, this infers to some that this variation may cause hesitation in referring to this organ openly while speaking to others, (even to your health care provider). The anatomy of the clitoris was first described in 1559 by Renaldus Columbus of Padua, who claimed that previous anatomists had overlooked the very existence of “so pretty a thing”.

When a woman is sexually aroused, the vagina begins to produce lubrication to aid in penetration. Your bartholin glands produce that lubrication. Most vaginas are only four inches in length. At the top of the vagina is what kind of feels like a semi-hard round ball. This is your cervix, the 'neck' of your uterus. In the middle of the cervix is a small round opening, called the os, that leads to the uterus. The os is the small opening through which menstrual blood flows from the uterus into the vagina. This is the same small opening that expands during childbirth. This is also where cells for a pap smear will be taken to make sure they are healthy. Many females have very sensitive cervixes, some do not.


Keep in mind that the vagina is a 'potential' space. The walls of the vagina are normally in contact with each other. In other words, they are touching unless something is inserted between them; contrary to what most anatomy illustrations like the one here illustrates. This drawing looks like the vagina is an 'open' canal. It is not. The vaginal opening is normally closed. It’s important to realize that the vagina isn't a hole or cavity inside the body. When something enters the vagina, the body must make room for it, no matter how small or large it may be.

How to care for your vagina?
The vaginal walls are continually producing secretions necessary to provide lubrication, to cleanse the vagina, and to maintain the proper acidity to prevent infection. You will notice during different part of your menstrual cycle that your vaginal discharge will vary, (see Menstrual Cycle for more on that). The vagina tends to be fairly acidic (sperm tend to be more of a base or alkaline). The vagina is a naturally self-cleansing body part, so douching isn't necessary to keep the vagina clean. Some women chose to use a vinegar and water douche after the end of their period, but this is not necessary. Women who like to douche, however, should do so with products that are unscented. It is not normal to have a vagina that smells like a field of flowers and can you imagine the chemicals used to create that "fragrance"... not good for you at all. If you have a 'strange' odor from you vagina, see a gynecologist!

Wash your vagina when you shower or bath with a gentle soap or cleansing bar. Don't over-do-it or you can irritate the sensitive lining and it is not a pleasant feeling, but it will heal. I’m sure you’ve seen many TV ads for products that claim to care for your vagina, most are not necessary, unless you have a vaginal infection.

The vagina is sometimes referred to as the 'front door to life', one day you may even deliver a baby through it. Hard to believe that a baby can fit through that canal, but it can stretch (and tear) and they do. Of course, let’s not forget that the vagina is where you have vaginal sexual intercourse or oral sex (cunnilingus). For information on the the infamous “G-Spot”, see that article.

Mammary Glands

Vagina. Functionally, the mammary glands produce milk; structurally, they are modified sweat glands. Mammary glands, which are located in the breast overlying the pectoralis major muscles, are present in both sexes, but usually are functional only in the female.

Externally, each breast has a raised nipple, which is surrounded by a circular pigmented area called the areola. The nipples are sensitive to touch, due to the fact that they contain smooth muscle that contracts and causes them to become erect in response to stimulation.

Internally, the adult female breast contains 15 to 20 lobes of glandular tissue that radiate around the nipple. The lobes are separated by connective tissue and adipose tissue. The connective tissue helps support the breast. Some bands of connective tissue, called suspensory (Cooper's) ligaments, extend through the breast from the skin to the underlying muscles. The amount and distribution of the adipose tissue determines the size and shape of the breast. Each lobe consists of lobules that contain the glandular units. A lactiferous duct collects the milk from the lobules within each lobe and carries it to the nipple. Just before the nipple the lactiferous duct enlarges to form a lactiferous sinus (ampulla), which serves as a reservoir for milk. After the sinus, the duct again narrows and each duct opens independently on the surface of the nipple.

Mammary gland function is regulated by hormones. At puberty, increasing levels of estrogen stimulate the development of glandular tissue in the female breast. Estrogen also causes the breast to increase in size through the accumulation of adipose tissue. Progesterone stimulates the development of the duct system. During pregnancy these hormones enhance further development of the mammary glands. Prolactin from the anterior pituitary stimulates the production of milk within the glandular tissue, and oxytocin causes the ejection of milk from the glands.

Female Sexual Response and Hormone Control

Vagina. The female sexual response includes arousal and orgasm, but there is no ejaculation. A woman may become pregnant without having an orgasm.

Follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone have major roles in regulating the functions of the female reproductive system.

At puberty, when the ovaries and uterus are mature enough to respond to hormonal stimulation, certain stimuli cause the hypothalamus to start secreting gonadotrophin-releasing hormone. This hormone enters the blood and goes to the anterior pituitary gland where it stimulates the secretion of follicle-stimulating hormone and luteinizing hormone. These hormones, in turn, affect the ovaries and uterus and the monthly cycles begin. A woman's reproductive cycles last from menarche to menopause.

The monthly ovarian cycle begins with the follicle development during the follicular phase, continues with ovulation during the ovulatory phase, and concludes with the development and regression of the corpus luteum during the luteal phase.

The uterine cycle takes place simultaneously with the ovarian cycle. The uterine cycle begins with menstruation during the menstrual phase, continues with repair of the endometrium during the proliferative phase, and ends with the growth of glands and blood vessels during the secretory phase.

Menopause occurs when a woman's reproductive cycles stop. This period is marked by decreased levels of ovarian hormones and increased levels of pituitary follicle-stimulating hormone and luteinizing hormone. The changing hormone levels are responsible for the symptoms associated with menopause.

Female Reproductive System

The organs of the female reproductive system produce and sustain the female sex cells (egg cells or ova), transport these cells to a site where they may be fertilized by sperm, provide a favorable environment for the developing fetus, move the fetus to the outside at the end of the development period, and produce the female sex hormones. The female reproductive system includes the ovaries, Fallopian tubes, uterus, vagina, accessory glands, and external genital organs. For more details see:

Female Genital Tract

Fallopian tubes
There are two uterine tubes, also called Fallopian tubes or oviducts, one associated with each ovary. The end of the tube near the ovary expands to form a funnel-shaped infundibulum, which is surrounded by fingerlike extensions called fimbriae. Because there is no direct connection between the infundibulum and the ovary, the oocyte enters the peritoneal cavity before it enters the Fallopian tube. At the time of ovulation, the fimbriae increase their activity and create currents in the peritoneal fluid that help propel the oocyte into the Fallopian tube. Once inside the Fallopian tube, the oocyte is moved along by the rhythmic beating of cilia on the epithelial lining and by peristaltic action of the smooth muscle in the wall of the tube. The journey through the Fallopian tube takes about 7 days. Because the oocyte is fertile for only 24 to 48 hours, fertilization usually occurs in the Fallopian tube.

Uterus
The uterus is a muscular organ that receives the fertilized oocyte and provides an appropriate environment for the developing fetus. Before the first pregnancy, the uterus is about the size and shape of a pear, with the narrow portion directed inferiorly. After childbirth, the uterus is usually larger, then regresses after menopause.

The uterus is lined with the endometrium. The stratum functionale of the endometrium sloughs off during menstruation. The deeper stratum basale provides the foundation for rebuilding the stratum functionale.

Vagina
The vagina is a fibromuscular tube, about 10 cm long, that extends from the cervix of the uterus to the outside. It is located between the rectum and the urinary bladder. Because the vagina is tilted posteriorly as it ascends and the cervix is tilted anteriorly, the cervix projects into the vagina at nearly a right angle. The vagina serves as a passageway for menstrual flow, receives the erect penis during intercourse, and is the birth canal during childbirth.

Vagina

Vagina. A portion of the female reproductive tract, running from the cervix of the uterus to the exterior of the body. Tube-like in shape, it receives the erect penis during sexual intercourse. The muscular walls of the vagina enable it to dilate massively to allow the passage of a baby during birth.

Uterus

Vagina. Also known as the womb, a hollow muscular organ located near the pelvis of female mammals. The uterus protects and nourishes the growing fetus until birth.

The upper part of the uterus is broad and branches out on each side into the Fallopian tubes. The lower part of the uterus narrows into the cervix, which leads to the vagina.
The wall of the uterus has two layers of tissue. The inner layer, or lining, is the endometrium. It is to this inner, mucous membrane to which the egg attaches after fertilization. The outer layer of the uterus is muscle tissue called the myometrium.

In women of childbearing age, the lining of the uterus grows and thickens each month to prepare for pregnancy. If a woman does not become pregnant, the thick, bloody lining flows out of the body through the vagina. This flow is called menstruation.

Cervix

Vagina. A small, cylindrical organ, several centimeters long and less than 2.5 cm in diameter, which comprises the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina. Running through the cervix is a canal, through which sperm can pass from the vagina into the uterus and through which blood passes during menstruation. The cervical canal, which forms part of the birth canal during childbirth, dilates (expands) widely to allow passage of a baby.

The bulk of the cervix consists if fibrous tissue with some smooth muscle. This tissue makes the cervix into a form of sphincter (circular muscle) and allows for the great adaptability in its size and shape rquired during pregnancy and childbirth.

Female Reproductive Tract Disection

The Cervix

Where the cervix and vagina meet

Inside the cervix

Childbirth

Definition

Childbirth is formally divided by the medical field into three stages. The first stage is labor, which has three phases: early, active, and transitional. The first stage ends with complete dilatation (opening) of the cervix. The second stage is delivery, which involves pushing and the actual birth of the baby. The third stage is delivery of the placenta or afterbirth.

Description
A full-term pregnancy is considered to be 280 days, nine calendar months or ten lunar months calculated from the first day of the last menstrual period. This is a fairly arbitrary number that may, in fact, vary with genetic differences and depends on a normal menstrual cycle, which varies considerably from woman to woman. The average actual length from conception to birth is estimated as 267 days. Childbirth is a natural process,

Childbirth in stage 2. The baby's head is crowning and about to emerge from the vagina.
(Illustration by Hans & Cassidy.)
and it, too, varies among women. Despite what the obstetrical texts say about what to expect, there are many variations that make each woman's experience hers alone. The whole process averages about 14 hours for first-time mothers and about eight hours for mothers in their subsequent pregnancies.
Labor can be described in terms of a series of stages.

First stage of labor
During the first stage of labor, the cervix dilates (opens) from 0 to 10 centimeters (cm). This stage has an early, or latent, phase, an active phase, and a transitional phase. The latent phase usually lasts the longest and is the least intense phase of labor. This phase is characterized by dilatation (opening) of the cervix to 3–4 cm along with the thinning out of the cervix (effacement). It can take place over a period of days without being noticed or over a period of two to six hours with distinctive contractions. Most women are relatively comfortable during the latent phase, and walking around is encouraged, since it naturally stimulates the process.

With the initiation of labor, the muscular wall of the uterus begins to contract causing the cervix to open (dilatation) and thin out (efface). For a first-time mother the cervix must completely efface before dilatation continues. Effacement is reported in percentages as 50 percent or 100 percent, which is completely thinned out. The amniotic sac may or may not break during labor, and the birth attendant may rupture the bag with an amnio-hook, which looks a little like a large crochet hook. There is no pain involved with the breaking the bag of waters, although the contractions may intensify. During a contraction, the infant experiences pressure that pushes it against the cervix to assist with the dilatation. During this first phase, a woman's contractions typically increase in frequency and duration. Periodic vaginal exams are performed by the physician or nurse to determine progress. As pain and discomfort increase, however, the woman may be tempted to request pain medication. The administration of pain medication or anesthetics should be delayed until the active phase of labor begins, at which point the medication will not act to slow down or stop the labor.

The active phase of labor is usually shorter than the first, lasting an average of two to four hours. The contractions are more intense and accomplishing more in less time. They may be three to four minutes apart lasting 40–60 seconds even though the pattern may not be regular. During the active phase, dilatation continues to 7 cm. Relaxing between contractions is essential for coping because these contractions are more intense. Breathing exercises learned in childbirth classes can help the woman cope with the discomfort experienced during this phase. Pain medication offered at this point consists of either a short-term medication, such as Nubain or Stadol, or long-term such as epidural anesthesia.

The transitional phase continues dilation 7–10 cm. It is the most exhausting and demanding phase of labor. The contractions become very strong, are two to three minutes apart, and last 60–90 seconds. It may feel as if the contractions never stop, and there is no time to relax between them. Dilatation of the final 3 cm to 10 cm takes, on average, 15 minutes to an hour. Strong rectal pressure, with or without an urge to push or move the bowels, may cause the woman to grunt involuntarily. If it is a natural labor and delivery, the laboring woman at this phase becomes very inwardly focused and can lose control. It is important to breathe with her through contractions as this keeps her attention on what she needs to do.

Second stage of labor
Up to this point, the woman may feels as if her participation is small, because all she has done is breathe. Active involvement can now begin along with some emotional relief that it is almost over. Without anesthesia, there is often an overwhelming urge to push, and the mother gets a second wind. The baby's head is through the cervix and on its way down the birth canal. The uterine contractions get stronger, and the infant passes along the vagina helped by contractions of the uterus and the mother's pushing. If an epidural anesthetic is being used, many practitioners recommend decreasing the dosage so the mother has better control of her pushing. Research has shown, however, that the contractions will continue to push the baby down the birth canal without mother's help. If a woman is numb from an epidural, she cannot push effectively, and it is usually better to let the contractions work alone. This is called "laboring down."

When the top of the baby's head appears at the opening of the vagina, the birth is nearing completion. First

A newborn baby sits crying on the mother's stomach.
(© Jules Perrier/Corbis.)
the head passes under the pubic bone. It fills the lower vagina and stretches the perineum (the tissues between the vagina and the rectum). This position is called "crowning," since only the crown of the head is visible. When the entire head is out, the shoulders follow. The attending practitioner suctions the baby's mouth and nose to ease the baby's first breath. The rest of the baby usually slips out easily, and the umbilical cord is cut.

Episiotomy
Many practitioners argue that it is better to cut the perineum than to let it tear. This cut is called an episiotomy. In reality, it is more difficult to repair a straight cut than a small tear in much the same way it is harder to put together a puzzle with straight edges; it is more difficult to match evenly and can result in vaginal discomfort once healed. Instead, the perineum can be massaged and gently stretched to prevent tearing as the baby's head crowns. There is also less pain associated with a tear than an episiotomy. If the woman has not had an epidural or pudendal block, she will get a local anesthetic to numb the area for repair.

Third stage
In the final stage of labor, the placenta is expelled by the continuing uterine contractions. The placenta is pancake shaped and about 10 cm (25 cm) in diameter. During pregnancy, it is attached to the wall of the uterus and served to exchange needed nourishment from the mother to the fetus and simultaneously to remove waste products from the fetus. Generally, there is a rise in the uterus due to a contraction and a gush of blood as the placenta is expelled. The placenta should be examined to make sure it is intact. Retained placenta can cause severe uterine bleeding after delivery, and it must be removed.

Breech presentation
Approximately 4 percent of babies present in the breech position when labor begins. In this presentation, the baby's bottom is the presenting part instead of the head, which is called a vertex presentation. Using a technique called a version, an obstetrician may attempt to turn the baby to a head down position. This is only successful approximately half the time, and there are possible complications with the procedure, such as umbilical cord entanglement and separation of the placenta. However, some practitioners are very successful with versions, and it does make a vaginal delivery safer.

The risks of vaginal delivery with breech presentation are much higher than with a head-first (vertex) presentation. The mother and attending practitioner need to weigh the risks to make a decision on whether to deliver via a cesarean section or attempt a vaginal birth. The degree of risk depends to a great extent on which one of the three types of breech presentations it is. In a frank breech the baby's legs are folded up against its body. This is the most common breech presentation and the safest for vaginal delivery. The others include complete breech, in which the baby's legs are crossed under and in front of the body, and footling breech, in which one leg or both legs are positioned to enter the birth canal. Neither of these is considered safe enough for a vaginal delivery.

Even with a complete breech, there are other factors to consider for a vaginal birth. An ultrasound examination should be done to determine that the baby's head is not too large and that it is tilted forward (flexed) rather than back (hyperextended). Fetal monitoring and close observation of the progress of labor are also important. A slowing of labor or any indication of difficulty in the body passing through the pelvis should be an indication that it is safer to consider a cesarean section.

Forceps delivery
Although not used as much in the early 2000s as in earlier times, forceps can be used if the baby's head is very low in the birth canal. Also, if there is some sudden change in the maternal-fetal status, the doctor may opt for a forceps delivery if it would be faster than a cesarean section. Forceps are spoon-shaped devices that can be placed around the baby's head while the doctor gently pulls the baby out of the vagina.

Before placing the forceps around the baby's head, pain medication or anesthesia may be given to the mother. The doctor may use a catheter to empty the mother's bladder and may clean the perineal area with soapy water. Often an episiotomy is done before a forceps birth, although tears can still occur. The use of forceps can cause vaginal lacerations in the mother.

Half of the forceps are slid into the vagina and around the side of the baby's head to gently grasp the head. When both forceps are in place, the doctor pulls on them to help the baby through the birth canal during a uterine contraction. The frequency of forceps delivery varies from one hospital to the next, depending on the experience of staff and the types of anesthesia offered at the hospital. Some obstetricians accept the need for a forceps delivery as a way to avoid cesarean birth while other obstetrical services do not use forceps at all. Complications from forceps deliveries can occur, such as nerve damage or temporary bruises to the baby's face. When used by an experienced physician, forceps can save the life of a baby in distress.

Vacuum-assisted birth
This method of delivering a baby was developed as a gentler alternative to forceps. Similar to forceps deliveries, vacuum-assisted births can only be used with a fully dilated cervix and a well-descended head. In this procedure, a device called a vacuum extractor is used by placing a large rubber or plastic cup against the baby's head. A pump then creates suction that gently pulls on the cup to ease the baby out the birth canal. The force of the suction may cause a bruise or swelling on the baby's head, but it resolves in a day or two.

The vacuum extractor is less likely to injure the mother than forceps, and it allows more space for the baby to pass through the pelvis. There can be problems in maintaining the suction during the vacuum-assisted birth, however, so forceps might be a better choice if the delivery needs to be expedited.

Cesarean sections
A cesarean section, also called a c-section, is a surgical procedure in which an incision is made through a woman's abdomen and uterus to deliver her baby. This procedure is performed whenever abnormal conditions complicate labor and vaginal delivery that threaten the life or health of the mother or the baby. The procedure is performed in the United States on nearly one in every four women resulting in more than 900,000 babies each year being delivered by c-section. The procedure is often used in women who have had a previous c-section, but if the incision on the uterus is not vertical, the woman can try a vaginal birth after cesarean (VBAC).

Dysfunctional labor is commonly caused by one of the three following conditions: maternal structural abnormalities; abnormal fetal presentations; failure to progress. Non-reassuring fetal heart rate tracings represent a condition in which the fetus may not be tolerating labor and oxygen deprivation can occur. Other conditions which might indicate a need for c-section include: vaginal herpes, hypertension (high blood pressure), and uncontrolled diabetes in the mother.

Causes and symptoms
Childbirth usually begins spontaneously, but it may be started by artificial means if the pregnancy continues past 41 weeks gestation. There are three signs that labor may be starting: rhythmical contractions of the uterus; leaking of the bag of waters (amniotic sac); and bloody show. The importance of the sign of contractions is in the rhythm and not the contractions. True labor contractions may start once every ten or 15 minutes or even at longer intervals, but gradually the interval decreases until they come every three to four minutes. The most important thing a woman can do at this phase is to remain relaxed. The bag of waters may leak slowly or may suddenly burst, and there is a gush of fluid. There is no pain when the water breaks, although it may be startling. If contractions are not ongoing prior to this, they are likely to start soon after. If they do not, it may be necessary to stimulate labor as the womb is now open to possible infection. The bloody show is a slight discharge of blood and mucus. It usually occurs after the cervix has started to dilate slightly and the mucus plug that keeps the cervix sealed from potential pathogens becomes dislodged.

Diagnosis
The diagnosis of true labor can only be determined by a vaginal exam to determine if the cervix has changed in dilatation (opening). True labor is determined by whether the contractions are, in fact, changing the cervix. If a woman is experiencing contractions and makes no cervical change, then this is false labor. Dilatation is measured in centimeters and it goes from zero to ten centimeters, which is complete dilatation. Although the woman having the contractions may feel like she is really experiencing labor, true labor is determined by cervical change. Many women may experience Braxton-Hicks contractions (practice contractions) in preparation for true labor, and these can become uncomfortable at times, which prevents the woman from resting. A warm bath or warm drink may help her to relax and sleep. Inevitably she will wake up in true labor with effective contractions. Palpating contractions as they occur can assist in determining whether they are strong. A very strong contraction cannot be indented and will feel as hard as the forehead. A moderate contraction will palpate like the feel of the chin and an easy contraction feels like the end of the nose. If the contractions can be indented, they probably do not constitute true labor.

Electronic fetal monitoring
Electronic fetal monitoring (EFM) involves the use of an electronic fetal heart rate (FHR) monitor to record the baby's heart rate. The FHR is picked up by means of an ultrasound transducer and the movement of the heart valves. Elastic belts are used to hold sensors against the pregnant woman's abdomen. The sensors are connected to the monitor and detect the baby's heart rate as well as the uterine contractions. The monitor then records the FHR and the contractions as a pattern on a strip of paper, called a tracing. Electronic fetal monitoring is frequently used during labor to assess fetal well-being. EFM can be used either externally or internally. Internal monitoring does not use ultrasound, is more accurate than electronic monitoring, and provides continuous monitoring for the high-risk mother. An internal monitor requires that the bag of waters be broken and that the woman is at least two to three centimeters dilated. It is used in high-risk situations or when it is difficult to obtain an accurate FHR tracing.

Telemetry monitoring has been available since the early 1990s but is not used in many hospitals as of 2004. Telemetry uses radio waves transmitted from an instrument on the mother's thigh, which allows the mother to remain mobile. It provides continuous monitoring and does not require the patient to be in bed continuously.

Besides EFM and telemetry, which is usually continuous, there is intermittent monitoring using a hand-held Doppler to assess the FHR. This method gives the mother freedom of movement during labor. Prior to electronic gadgetry a special stethoscope was used, called a fetoscope, which is rarely seen as of 2004 because it requires more skill to use. Research on the use of intermittent monitoring and continuous monitoring found no difference in fetal outcomes with intermittent monitoring. The use of continuous monitoring does result in a higher c-section rate partly because the tracing can be misinterpreted or because the mother usually requires more interventions when she cannot be mobile.

Treatment
Many women choose some type of pain relief during childbirth, ranging from relaxation and imagery to drugs. The specific choice may depend on what is available, the woman's preferences, her doctor's recommendations, and how the labor is proceeding. All drugs have some risks and some advantages.

Regional anesthetics
Regional anesthetics include epidurals and spinals. With this procedure, medication is injected into the space surrounding the spinal nerves. Depending on the type of medications used, this type of anesthesia can block nerve signals, causing temporary pain relief or a loss of sensation from the waist down. An epidural or spinal block can provide complete pain relief during cesarean birth.

An epidural is placed with the woman lying on her side or sitting up in bed with the back rounded to allow more space between the vertebrae. Her back is scrubbed with antiseptic, and a local anesthetic is injected in the skin to numb the site. The needle is inserted between two vertebrae and through the tough tissue in front of the spinal column. A catheter is put in place that allows continuous doses of anesthetic to be given.

This type of anesthesia provides complete pain relief and can help conserve a woman's energy, since she can relax or even sleep during labor. This type of anesthesia does require an IV and fetal monitor. It may be harder for a woman to bear down when it comes time to push, although the amount of anesthesia can be adjusted as this stage nears.

Spinal anesthesia operates on the same principle as epidural anesthesia and is used primarily in cases of c-section delivery. It is administered in the same way as an epidural, but the catheter is not left in place following the surgery. The amount of anesthetic injected is large, since it must be injected at one time. Spinals provide quick and strong anesthesia and allow for major abdominal surgery with almost no pain.

NarcoticsShort-acting narcotics can ease pain and not interfere with a woman's ability to push. However, they can cause sedation, dizziness, nausea, and vomiting. Narcotics cross the placenta and can affect the baby.
Natural childbirth and preparation for childbirth

There are several methods available to prepare for childbirth. The one selected often depends on what is available through the healthcare provider. Overall, family involvement is receiving increased attention by the healthcare systems, and the majority of hospitals now offer birthing rooms and maternity centers to accommodate the entire family.

Lamaze, or Lamaze-Pavlov, is the most commonly used method in the United States as of 2004. It became the first popular natural childbirth method in the 1960s. Various breathing techniques, cleansing breath, panting and blowing, are used for different phases together with the use of a focal point to enable the laboring woman to maintain control. A partner helps by coaching the mother throughout the birthing process.

KEY TERMS
Amniotic sac—The membranous sac that contains the fetus and the amniotic fluid during pregnancy.

Breech birth—Birth of a baby bottom-first, instead of the usual head-first delivery. This can add to labor and delivery problems because the baby's bottom doesn't mold a passage through the birth canal as well as does the head.

Cervix—A small, cylindrical structure about an inch or so long and less than an inch around that makes up the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina.

Embryo—In humans, the developing individual from the time of implantation to about the end of the second month after conception. From the third month to the point of delivery, the individual is called a fetus.

Gestation—The period from conception to birth, during which the developing fetus is carried in the uterus.

Perineum—The area between the opening of the vagina and the anus in a woman, or the area between the scrotum and the anus in a man.

Placenta—The organ that provides oxygen and nutrition from the mother to the unborn baby during pregnancy. The placenta is attached to the wall of the uterus and leads to the unborn baby via the umbilical cord.

Vertex—The top of the head or highest point of the skull.
The Read method, named for Dr. Grantly Dick-Read (who published his book Childbirth Without Fear in 1944) involves primarily remaining relaxed and breathing normally. Dr. Dick-Read promoted this method in the 1930s to help mothers deal with apprehension and tension associated with childbirth. He emphasized the practice of tensing and relaxing muscles so that complete relaxation occurs between contractions in labor. This action also serves to promote good oxygenation to the muscles.

The Bradley method is called father-coached childbirth, because it focuses on the father serving as the coach throughout the process. It encourages normal activities during the first stages of labor without interventions and focuses on breathing and relaxation.

HypnoBirthing is becoming increasingly popular in the United States in the early 2000s and has proven to be quite effective. Based upon the work of Grantly Dick-Read, it teaches the mother to understand and release the fear-tension-pain syndrome, which so often is the cause of pain and discomfort during labor. When people are afraid, their bodies divert blood and oxygen from non-essential defense organs to large muscle groups in their extremities. Unfortunately, the body considers the uterus to be a non-essential organ. HypnoBirthing explores the myth that pain is a necessary accompaniment to a normal birthing. When a laboring woman's mind is free of fear, the muscles in her body, including her uterine muscles, relax, thus facilitating an easier, stress-free birth. In many cases, first stage labor shortens, which diminishes fatigue during labor leaving the mother stronger for pushing. The founder of HypnoBirthing, Marie Mongan, promotes the philosophy that eliminating fear allows the woman's body to work like it is supposed to.

The LeBoyer method stresses a relaxed delivery in a quiet, dimly lit room. It strives to avoid overstimulation of the baby and to foster mother-child bonding by placing the baby on the mother's abdomen and having the mother massage him or her immediately after the birth. This is followed by the father giving the baby a warm bath.

See also Apgar testing; Electronic fetal monitoring; Cesarean section.
Resources
BOOKS
Murkoff, H. I., et al. What to Expect When You're Expecting, 3rd ed. New York: Workman Publishing, 2002.
Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.
Simkin, Penny, et al. The Labor Progress Handbook. Ann Arbor, MI: Blackwell Publishing, 2000.
Simkin, Penny. Pregnancy, Childbirth, and the Newborn, Revised and Updated: The Complete Guide. Minnetonka, MN: Meadowbrook Press, 2001.

ORGANIZATIONS
American Academy of Husband-Coached Childbirth. PO Box 5224, Sherman Oaks, CA 91413–5224. Web site: http://.
Childbirth Enhancement Foundation. 1004 George Avenue, Rockledge, Fl 32955. Web site: http://.
HypnoBirthing Institute. PO Box 810, Epsom, NH 03234. Web site: http://.
International Association of Parents and Professionals for Safe Alternatives in Childbirth. Rte. 1, Box 646, Marble Hill, MO 63764. Web site: http://.
International Childbirth Education Association. PO Box 20048, Minneapolis, MN 55420. Web site: http://.
Lamaze International. 2025 M Street, Suite 800, Washington DC 20036–3309. Web site: http://.
Linda K. Bennington, MSN, CNS