Labour could be spontaneous, induced or avoided.  Each of these possibilities will form a different pathway.  To understand more on these pathways read: The Flows of Modern Birthing

The spontaneous pathway may see us ‘home as long as possible’ or even birthing unassisted in a fast birth. This labour begins in its own time. There are opportunities to shift onto the assisted pathway at different decision points. Perhaps birth is ‘slow’, or you become very tired or unwell, or the baby may become unwell. Only you can decide if or when a shift occurs.

The assisted pathway begins with induction. When a labour begins with induction, this means we will be monitored and observed more, may be on a limited timeframe, and will be in the hospital. Vaginal exams are needed to determine the type of induction, and will be offered to assess progress. Labour may progress quickly without further intervention or may require more interventions. There are options to shift onto the caesarean pathway, and whilst your vaginal birth may still be spontaneous, it will also be more restrictive, and as a higher likelihood of needing assistance.

The caesarean pathway before labour can be expected (perhaps called planned, elective, or scheduled) or emergent. If expected, you have time to prepare. A Maternal Assisted or more involved option may appeal to you, you may like to discuss skin-to-skin in theatre, and who can be present, and even a ‘lotus’ approach to the placenta where the cord remains intact. Considering the emergency can help reduce stress if we find ourselves in this circumstance.

Induction is fast becoming a standard way to manage maternity.  Knowing why it is being offered and under what circumstances you would consider it will help if you reach this particular decision point.   If you have been waiting for labour to start naturally, shifting to induced labour may be a difficult decision.  The decision to shift OR NOT to the induced pathway is up to the birthing woman.  The pressure to shift may become increasingly difficult, so know your whys, if and when.  For some, this decision may come down to physiological or pathological information, for others, it may be logistics (a FIFO partner, work pressures, or hospital policies) or a combination of both.  There is no one way.

Both Sara Wickham and Rachel Reed have books about induction that can help you to make this decision.

These blog posts on Birthmap.life may also be insightful for you

To induce or not to induce; is impatience the question?

Timing of Birth

Once labour has begun, it will unfold differently for every birth.  Many factors will influence our labour, and taking a childbirth education class can help you understand these and prepare.  Birth is not just a physiological event.  It is also psychological.  We are undertaking a journey, it is transformative and can bring up past experiences that may impede us and enhance us.  There is an element of surrender to this transformation, which needs us to feel safe and supported rather than observed or rushed.  There is No One Way – what feels safe and nourishing for one woman, may not for another.  Explore your options here:

Make preparations for a fast Birth Pathway (without medical assistance) and know that You Can.
Roadside Birth

Five Reasons to Prepare for Unassisted Birth

Make preparations for a long, slow pathway.  Here the pressure of intervention will loom; perhaps you will welcome them, perhaps not….know your whys, if and when.  Know about the ‘birthing pool test’  and how it can help you determine if your path is best shifted to caesarean or assisted vaginal.

There are four types of CSection, each with different considerations:

• Before Labour – non emergency
• Before Labour – emergency

• In Labour – non emergency
• In Labour – emergency

Preparing for Caesarean

In Australia, the ‘standard’ procedures post birth that require a decision from the parents are:
Vitamin K (injected or orally)
Heb B Vaccine
‘Heel Prick Test’

It is also very important to have preparation in case of separation of mother and baby.

Called the ‘third stage’, this is the birth of the placenta.
Discussing the scenarios for this stage during pregnancy will reveal routines and definitions that will help you express your decisions in ways that can not be misinterpreted.  Your hospital may consider ‘delayed cord clamping;’ to be one minute.  You must discuss this during pregnancy if this is not what you want.   This stage can be very quick and feel very intrusive.  Many people will be in the room, and unless you declare otherwise, you will be managed (receive an injection of synthetic oxytocin).
 Read about this on Rachel Reed’s blog

Did you know you can keep it?  Find out more about The Placenta

On the spontaneous (no interventions) pathway, this can look like a waterbirth, a birth on your knees or standing, on all fours: whatever position feels good for you at the time.  Perhaps you would like to be the first to touch your baby (catch the baby), or perhaps your partner will be.  Perhaps you’d like it to be the care provider.
Worry not if the cord is around the baby’s neck: the somersault maneuver will help.  Usually, the cord is long enough to allow the baby to be in your arms; there is no need to clamp or cut the cord.

What about the cord?

On the assisted pathway, when birth has been induced, there is more observation and monitoring.  ALL PROCEDURES are a decision point: non-emergency interventions can not be done without your consent.   Your birth may begin with induction but no need for further intervention.  However, this pathway has increased likelihood of interventions.  If the induction is slow to start, synthetic oxytocin may be used to induce contractions via a drip.  These induced contracts can be very intense and often lead to an epidural.  This means a drip in each arm (one for the synthetic oxytocin, one for hydration), the epidural in your back (this is a thin tube inserted, and you can control the dosage) and a catheter into your bladder to drain your urine.  You will also be continuously monitored.  This is a ‘package deal’, so when consenting to one intervention, be sure to understand the full package.

The Flows of Modern Birthing

This Birth may be after induced labour, or after shifting onto the assisted pathway after spontaneous labour.  This birth is most likely to be on a bed; you can be on your side, pull yourself into a squat or be on your knees in some circumstances.  You may, however, be very tired and glad to be on your back.  If you have had an epidural, you will likely be coached to push.  This comes with an increased risk of tearing or an episiotomy.  Episiotomy requires a decision from you (it can only be done if you consent, so if you don’t want it: say no).  An ‘assisted delivery’ may also occur.  This uses either forceps or vacuum suction to hasten the birth.  This may be offered if the CTG monitoring of the baby indicates a need for haste, or indeed it may be impatience on the behalf of a care provider.  There is an increased risk of third or fourth-degree tear with assisted delivery, which can have long-term impacts on the mother.

This is a critical decision point in labour.  Perhaps  the birthing pool test helps you determine, perhaps you have set a time limit, or base it on other factors.   This is a point where your labour has become medicalised, and you can decide if a caesarean or the vaginal pathway is best for you and your baby.  There will come a point where this option is no longer available, and either an emergency caesarean will happen or an assisted delivery.

Choosing to have a caesarean over an augmented birth will be a decision made in the moment.  Taking the time during pregnancy to understand the risks and benefits of each option allows you to remain calm and make an informed decision at the time.

Michel Odent argues that in some cases, it is better to opt for an ‘in-labour non-emergency caesarean’ over augmenting a slow labour. If labour seems ‘stalled’ or progress is deemed slow, Odent suggests that the birthing woman should be offered a quiet bath for two hours to determine the best option. If, after that time, she has made no progress, the chances that she will end up with an in labour emergency caesarean or an assisted birth is very high. At this point, the woman can decide to opt for an ‘in-labour non-emergency caesarean’. In this case, the baby is fine and there is no urgency. You may be able to opt for a ‘gentle approach’.  

On the assisted pathway, the birth of the placenta will be ‘managed’.  This means you will receive an injection of synthetic oxytocin to expel the placenta.   Read about this on Rachel Reed’s blog
In addition to this, you need to be clear about your options. 

Your baby may need to be removed, so the cord may be cut immediately.

If you have had a long labour, with IV fluids and epidural, your baby may be slower to breastfeed and ‘lose too much weight’ in the days after birth.  Maternal IV Fluids and Weight Loss in Newborns

Your hospital may consider ‘delayed cord clamping;’ to be one minute.  You must discuss this during pregnancy if this is not what you want. You may be able to have a long time, if you and baby are well, and you may be able to have skin-to-skin.

This stage can be very quick and feel very intrusive.  Many people will be in the room.