Common Mistakes at the Beginning of Labor

Here are some things many women do that can set them up for a high-intervention birth (vacuum/forceps, c-section) from the beginning of labor (please keep in mind that this has nothing to do with whether you want a natural or a medicated birth - absolutely nothing):

• Being induced with no medical indication - Many doctors will not induce if there is no medical reason, but many will if the woman goes even one day past her due date. They have forgotten that the due date is a rough estimate, and that the average gestation time for first-time mothers is 42 weeks. I know it's hard being pregnant for longer than you think you will be. But so long as everything is fine, labor will begin when it's best for the baby and for your body. (I've known people who have scheduled early inductions because their family was visiting and they want to have a baby to show to them).

• Going to the hospital too early - There is a balance between going to the hospital too late and the discouragement of being sent home because you aren't dilated enough to be admitted. There is wisdom in trying to stay at home as long as possible - at home you can eat, drink, and move freely. Labor progresses more quickly here than it will at the hospital (see below). And don't put too much weight on timing the contractions. The general rule of thumb is to wait until contractions are 5 minutes apart in a regular pattern before going to the hospital. I have found, through my experience and hearing the stories of other women, that the times of contractions has little to do with the amount of work being done. You can have contractions two minutes apart and still be dilated to 1 cm. Adhering to the 5-minutes-apart rule is not as helpful as using the amount of focus required from the laboring woman as a gauge.

• Staying in bed on your back - This position is the worst for laboring women. With an epidural in place you don't have much choice, and even then most hospitals encourage laboring on your side rather than on your back. The weight of the baby cuts off the oxygen supply to the uterus, decreasing contractions and possibly putting the baby at risk. Also, remaining upright causes gravity to pull the weight of the baby down against the cervix, helping it to dilate more quickly. When laboring moms walk around and move, they respond to the contractions in ways that encourage progression of labor.

• Spending too much energy when labor is easy - Many times women are so excited for the onset of labor that they stop their regular activities and concentrate very hard on contractions that are not difficult to handle. If they expend too much energy early on, they will not have the strength they need when labor gets tougher, and are setting themselves up for fatigue. If you can speak and walk through contractions, then keep going about your usual business; when it is time to pay attention, you will know.

The Best Laid Plans

A Suggestion for Birth Plans

Have you seen those really long questionnaires that are supposed to help you write your birth plan? While those can be helpful in finding out what options you may have during different stages and if complications should occur, most of what they say is not necessary to include on your birth plan.

Suppose you put a lot of thought into how you want your birth experience to go. You type up your birth plan, and it ends up being three pages long. When you're in labor, you go to the hospital and hand the nurse a copy of your birth plan. S/he might glance at it. But s/he likely won't have the time to go through it. And with so many items listed, s/he won't know what is most important to you.

One suggestion: keep it short and succinct.

My favorite way to lay out a birth plan is to divide it into the stages of labor and then put only one or two items in each section. These should be the things that are crucial to you, that apply to normal labor and birth, and things that are a departure from the hospital's normal routine. Don't put down "I would like to play music during labor" if the hospital allows it - just bring your music along and set it up when you get there.

Here's an example:

FIRST-STAGE LABOR

• I would like to be free of time limits. No artificial augmentation of labor so long as the baby and I are fine.
• I do not want any pain medication offered to me. I will request it if needed.

SECOND-STAGE LABOR

• I would like to allow the baby to descend using breathing-down techniques until the crowning takes place.
• I would like to push instinctively and not be told when or how to push.

POST BIRTH

• I would like to delay ointment in the baby's eyes for one hour after birth to allow for sight bonding.

That's it. One page long. But it's very clear and only lists the things that matter most to the mother or that depart from normal procedures. Many of the things you might want - "I'd like to breastfeed", "I'd like to take pictures" - probably do not need to be written down on your birth plan and only take up space. Keep it simple. Keep it realistic.

Also keep in mind that I'm talking about the piece of paper that will be handed to the nurses and doctor/midwife. When you're thinking about what you want and don't want, yes, be as lengthy and comprehensive as you can. But realize that your caretakers will pay more attention to a short, easy-to-read list of the most important parts, so pare down the list you give to your care providers.

This will require you to talk to your caretaker about what is and is not allowed according to hospital protocol. Writing "I want to eat and drink freely" on your birth plan won't do you a lick of good if the hospital doesn't allow laboring women food and liquids by mouth.

As far as complications (the specifics of what you want to do in case of emergency c-section, if the baby is not breathing, etc.), your options are important to understand. I would write that list and keep it separately. But know that your options will likely be limited and the hospital will make as many accomodations for you and your partner as they can.

Sick Infant
Choose as many as you would like.

• Breast feeding as possible
• Unlimited visitation for parents
• Handling the baby (holding, care of, etc.)
• If baby is transported to another facility, move us as soon as possible

This seems a bit unnecessary to write on a birth plan. You're not going to say, "If my baby is sick, I want my visitation to be limited" or "I want to stay in a separate location from my sick baby". But things like wanting the screen lowered during a c-section or having the baby stay with one parent at all times after a section, or if you have something like a lotus birth planned (I'm not holding my breath that anyone in this audience does), those things should probably be on your "complications" list.

Some people say that birth plans are silly, unimportant, and you can't plan what will happen during labor anyway. I think that, though they probably won't change the kind of labor one has, they are valuable, at the very least because they make the pregnant woman find out what matters to her. When labor begins it is too late to do research or make preferences.

Pro-o-dro-o-mal Labor

This might be one of the biggest fears of all pregnant women: slow, inefficient labor that has the potential of going on for days and days with little or no real progress. Contractions come, but they do little to dilate the cervix. The mother gets more and more exhausted and discouraged.
It's called "false labor" and "early labor" and can seem endless. Eventually - in a few hours or as long as 3 days sometimes - labor does intensify, and the cervix dilates, and the baby will be born.

Occasionally the condition of the baby might require some medical intervention. Babies might not be able to tolerate the long labor well, and augmentation with pitocin, breaking the waters to encourage labor, or even a cesarean may be necessary. Often, though, the most critical part is keeping the mother comfortable and making sure she has enough energy to continue.

"Exhaustion is the enemy of labor." How many times women have labored for a day, had their energy depleted, and asked for an epidural, just so they could get some sleep! There is no way to predict who will have prodromal labor, no way to make completely sure it won't happen. Pitocin might not be effective. And the cervix may not be dilated enough to consider breaking the bag of waters. This is a difficult time, and it feels like it lasts forever.

Here are some suggestions for prodromal labor:

• Try to relinquish control of the labor and accept what is happening. Much of what's going on is not in your control. Dismiss any ideas about what is normal or not, and accept this as part of your labor.
• Spend as little energy as possible. You will deliver a baby soon, and you will do best if you are well-rested for the hard work to come.
• Being active (walking or other light exercise) might increase contractions, but it might also just wear you down without helping labor to progress. Doing your usual routine will distract you without spending all your energy. Or, do something entertaining like going to the movies. Take care of any last-minute baby preparations, like washing or hanging baby clothes, packing your birth bag, or preparing birth announcements.
• Get plenty of sleep. Take a bath, get a massage, stay relaxed.
• Keep eating. Small, light, frequent meals will help you keep up your strength.

Coping with Fears of Labor

This full article is published here (commentary is mine).

In order to resolve fear and prepare actively for your childbirth consider the following guidelines:

• Realistic coping skills and education to the normal process of birth. (Read lots and lots of books until you get bored with the topic because you know it so well. It will help you, to understand what is actually happening in labor and birth.) Take classes that teach the normal process of birth and read books that emphasize what goes right and why, rather than focusing on what can go wrong.
• Read stories of births that went well (Ina May's Guide to Childbirth!!!), women who coped with the intensity of contractions and were supported in the labor process, by a doula and/or their partners. Allow yourself to take in the positive experiences women have to balance the messages you heard growing up. This is an important part of the healing from [other's] emotional pain around childbirth. But do not stop there.
• Use a body centered hypnosis and visualization tape for resolving your fears. Create a birth visualization on tape that you can use in preparation for labor. Address your fears, rather than run away them. (I would have thought before I gave birth that this kind of thing is really pretty hokey, but this is essentially what I did during Hypnobirthing classes, and it's what helped more than anything. Imagine beginning labor with calmness and confidence!!) Embedding a new story about birth in your nervous system must take place experientially to be effective. Doing so, will calm your mind and ready you for labor, rather than leave you a victim of your fear. This preparation allows you to replace the negative messages embedded experientially through the limbic system, which holds the emotional charge of [other's] stories about childbirth. The experiential process is critical to allowing you to separate from [other's] negative experience and be ready for your own positive labor and childbirth.
• Create a birth plan and assemble your birth team. (Get a doula! GET A DOULA!!) Allow yourself to be supported during this significant life event. Choose a birth practitioner that supports the way you want to give birth, whether you do so with an epidural or not. Consider having a doula present who is experienced in helping women cope with the normal and healthy intensity of labor. Prepare with your partner for this pivotal family life event. Some of the best anesthesia is the soothing that comes from genuine, supportive encouragement! (Absolutely true!!!)

Research shows that respect for the woman during the process of labor and childbirth, and a woman's active participation in the experience, are key contributing factors to positive feelings of self-esteem in birthing women. Addressing your fears about the birth through active education and preparation is what will allow you to enjoy the rest of your pregnancy.

* Get educated. * Face your fears. * Hire a doula.

More articles here and here.

The Unkindest Cut

The primary reason I became involved in childbirth was because I wanted to avoid a cesarean for my first delivery. Newly-pregnant women hear everyone else's birth stories, and I came to realize that most of the women around me had had c-sections, usually for their first births. The more I learned, the more I wanted to protect myself from having a surgical birth (more on this in a little bit).

And now there's news that the c-section rate in the US has climbed to almost 30% (read about it here). That's up from 24% from just a couple of years ago. So more and more women are having major surgery to deliver their children, are being sliced open with a scalpel and having their babies tugged from their wombs. One of the things the above link references is the belief that cesareans are actually safer than vaginal births. Now, I could list all the risks and difficulties from cesareans (and there are lots of them), and make another list comparing the same regarding vaginal deliveries, but that's essentially not why I chose to make c-sections my first birth battle.

I wanted to participate in my birth. I wanted to find out what it was like, to really have the experience. And I wanted to breastfeed. And I didn't want to be recovering from major surgery just as I was beginning motherhood.

Myths about cesareans:

• Cesareans are safer than vaginal birth - Actually, cesareans carry increased risks of everything from jaundice, respiratory problems in newborns, maternal death, and breastfeeding difficulties - there should be no doubt that they do cause increased harm to the mother, by their very surgical nature.
• Cesareans prevent incontinence, sexual difficulties, and pelvic damage - In truth, cesareans are far more likely to cause problems with bowel obstructions; sexual difficulties and pelvic damage are related to vaginal 'assisted' birth involving forceps or vacuums, because of the episiotomy, and are not inherent to the birth process. (ACOG support for this here.)
• Cesareans are just another birth option, and women should have choices in deciding how they want to birth - This is a misleading idea disguised as a compassionate outlook. Education shows that elective cesareans pose a hazard to women; having them available does not 'help' women at all, but puts them - unnecessarily - in harm's way. Medicine and surgery ought not be practiced with dangerous procedures being implemented through lack of education - in no other circumstance would we even consider that major surgery on this scale should be performed without medical necessity.
• It is more convenient to schedule a birth than be surprised by labor beginning spontaneously - I suppose everyone must decide what their priorities are.

I reaffirm what I said before. Doctors don't care whether you have a cesarean. They get paid more and they get to practice their surgical training, so if anything, they are likely to be predisposed towards the idea of women having cesareans rather than vaginal births. Ever heard of the famous paper in which a group of doctors gave their opinion that all births should be by c-section? Does that sound like it has women's best interests in mind?

More on Pain

Babies are the biggest things that pass through any of our orifices. Ever.

- Ina May Gaskin

I wouldn't have a root canal done without novocaine. Why would any woman give birth without an epidural?

- Husband on A Baby Story

The most common thing I hear pregnant women say is, "I'm going to try and go natural, but we'll see. I don't know how bad it will get." Fear of pain - rather than the actual amount of pain experienced during labor - seems to be the foremost reason women opt for an epidural. It's rarely because the pain is intolerable; the women are almost always afraid that it will get worse and if they don't get an epidural now, they will have lost their chance and will suffer more than they want to.

I can only speak of my own experiences here, though I have seen and heard enough accounts from other women that I believe mine are at least typical if not representative. The pain I felt during labor progressed to a point, and then the only change was that the contractions came closer together. The pain itself was not the issue; the frequency of the contractions was what bothered me, and that only psychologically, especially in my second labor. I had a trapped feeling, a sense of loss of control over my circumstances, that was far worse than the physical pain.

There are two things I want to say about pain. First, there are different kinds of pain. I have said before that I think it's more painful to stub my toe than have a baby, and I mean it sincerely. There are so many varieties of pain. Sometimes it is intolerable when I bite my lip or crash my shin into a table, but I can function relatively well through a migraine headache or menstrual cramps. And occasionally a tiny paper cut produces all-consuming agony. Some pain is harder to bear than other kinds. I think that labor is entirely bearable.

I think that when women (and from time to time, men too) think about what happens during labor, they find it hard to imagine that pushing an entire baby out of their vaginas could be anything other than traumatically painful. They think it is like pushing a bowling ball through nonelastic tissue, not realizing how much we can stretch and open up during birth:

Even though I had been attending births and respecting women's bottoms for their amazing powers for twenty years, Judy showed me something new and exciting. A first-time mother, she came to our birth center because her baby was in breech position. Several people tried to scare her into having a cesarean by warning her that her baby's head could be caught inside at birth. I told her that in my experience, her baby's large bottom was actually going to prepare the way for his head. Holding my hands in a corcle to indicate the size to which her vagina would open gradually (about the size of a large grapefruit), I told her, "You're going to get huge."

One week later, her son's bottom was just coming into view after seventeen hours of labor. Before his butt pushed directly against her perineum, her vagina enlarged and opened to an extent that astounded me. I had seen this phenomenon in women who had already had seven or eight children, but never before in a first-time mother. Judy's vagina would easily have allowed the passage of a baby considerably bigger than her seven-pound eight-ounce son without a tear.

Some days later when Judy and I were talking about her birth, I told her how surprised I had been to see how open her vagina became without direct pressure on her perineum. (I was still amazed.) Judy said, "I used that mantra you gave me."

"Mantra?" I repeated, uncertain of what she meant.

"I kept thinking while I was pushing, I'm going to get huge. I'm going to get huge!"

(This is from Ina May's Guide to Childbirth, chapter 8.)

Giving birth is not like pushing a watermelon out of your butt or having a root canal without anesthesia (incidentally I don't recommend trying either of those). Women are powerful in birth when they work with their bodies, and women's bodies can do amazing things. Birth is not meant to cause injury or be unbearable.

When I hear women describe their labors as the worst pain they ever felt, I always assume that they either had painful complications or did not know how to relax during contractions. It is also interesting to find that American women rate their labors as more painful than do women of other cultures. Indeed, every media portrayal of labor is of the woman in unbearable agony, twisting about, yelling, maybe cursing at her husband; every discussion is about how much it hurrrts. And while I don't wish to downplay the intensity of childbirth, I want to emphasize that the intensity and the pain are not equal in labor.

The greatest collective obstacle before laboring women is to face their fear of pain. Both Ina May Gaskin and Dr. Grantly Dick-Read (author of Childbirth Without Fear) have excellent perspectives on the fear-tension-pain cycle, and both of their books are part of my must-read list for pregnant women. Basically fear produces tension, and tension increases pain, which then feeds our fear, and we are headed down a frightening path. The most practical advice I can give pregnant women is to find a way to be present, to stop thinking about "What ifs" (especially "what if it gets worse?" or "what if what I'm doing, doesn't work?" or "what if this goes on for (x) hours?"), and deal with labor as it's happening right now. Don't anticipate the next contraction; get through the current one and then be happy for the break. There are more breaks during labor than there are contractions. Your focus is needed on relaxing your body, so that it can do the hard work it's doing with as little resistance as possible. For that to happen, you need to not be afraid of the process. "Embrace the water", as joyful_mommy said (that's a great analogy, by the way! Read her comment here). Use your prenatal time to deal with your fears and learn effective relaxation techniques. I can't promise pain-free labors, but having those tools will significantly reduce the pain experienced.

All About Induction

I am opposed to inducing labor. I think it's a very bad idea, especially for first-time moms. I was going to try and write as if I'm neutral about it, but I just can't do it.

Let me start my saying that there are some valid reasons for inducing labor. These include preeclampsia, placental age, and illnesses like high blood pressure and kidney disease.

Most women, though, will not have these problems. Most induction candidates are women who induce electively, for reasons like this:

• They're impatient and weary of being pregnant;
  
• They have gone one day to one week past their due date (the arbitrary cut-off point between waiting for labor and inducing, depends on the care provider);
  
• They want their baby to be smaller than he or she would be full-term;
  
• They want to have their baby at a specific, scheduled day and time.

The other most common induction group is mothers who are convinced by their doctors that it is a good idea, in the absence of any medical reason for being induced. This is simply bad practice. Mothers can be easily monitored for signs of distress or to be certain that the placenta is functioning and that all is well. There is no need to induce simply for being overdue, and being induced without medical cause opens up the route for complications, and very rarely avoids them. Mothers should carefully research their options, but arbitrary induction of labor is a route that should be avoided.

To expecting mothers: During your last weeks, you may be recommended to participate in a 'non-stress test' to ensure that the baby is responding to contractions well and that your placenta is functioning - on these days, make sure you eat a meal before you go in for the test. Not eating enough may cause you to exhibit signs of distress and illness that may be misinterpreted and end up in a completely unnecessary induction (high blood pressure, protein in the urine, lack of responsiveness of the baby, all of which will be completely resolved if you simply eat a meal). And, even though you have to pee every few minutes, drink lots of water.

As I have previously mentioned, my first baby was almost 3 weeks overdue (most women, even first-timers, don't go that long). I chose not to be induced because of one reason: I wanted to avoid a c-section. Induction is notorious for being a slippery slope, meaning that if it goes on for a while and doesn't work, the woman will likely be sectioned.

The main reason I am opposed to induction is because it leads to so many interventions and can easily culminate in a preventable c-section. Especially for first-time mothers, I believe that having major surgery is a traumatic entrance to parenthood. I had a natural birth with my first baby, and it was hard enough, getting accustomed to the new and entirely different world of motherhood; I can't imagine what additional hardships I would have had if I had also been healing from a giant surgical cut in my abdomen. Inductions are linked to an increase in the incidence of shoulder dystocia and a higher rate of instrument delivery (here). I hope for better for all mothers, and wish to help mothers avoid unnecessary trauma. Labor is much more gentle for mother and baby, and faster too, when it begins on its own.

I am also worried about the welfare of the babies. Babies born too early, even by a few days, can have trouble breathing, nursing, or sustain injuries. They are much safer in the womb until they are ready to come out and their mothers' bodies are ready to birth them.

The method of induction depends on how ready the mother's body appears to be. If the cervix is effaced and dilating, she will likely have pitocin. If the cervix is not prepared, she will probably have prostaglandin gel applied to her cervix to ripen it. Other methods are stripping or sweeping the membranes (the practitioner uses his or her fingers to manually lift the bag of waters from the lower part of the uterus, trying to stimulate contractions - labor may take a day or two to start, if it's going to at all), and breaking the bag of waters (increases the chance for infection and c-section if the woman's body doesn't start labor within a certain period of time).

Most likely, if the induction has been scheduled, a combination of these methods will be used. (Just as a side note, I found this sentence on a popular baby/pregnancy website: "Some women say that Pitocin causes more intense contractions, but if this is your first baby, you won't know the difference." You won't know if your contractions are unnaturally difficult and intense? Of course you will be able to tell! You just won't know that labor can also be gentle and manageable.)

If the mother is in a hospital and her bag of waters has been broken, she will stay until she has delivered the baby. This means that if the care provider breaks the membranes in an attempt to start labor and it doesn't give the desired results, after a period of time a cesarean will be considered necessary. With the membranes broken, the woman is at risk for infection, and once infection begins, the doctors cannot be certain that the baby is not in trouble also. Maternal fever is considered a problem for both laboring mother and the unborn baby.

If your doctor wants to induce labor by way of cytotec (also called misoprostol or prostaglandin E1, and is in pill form), refuse it and get a new doctor. At the very least don't take it. Cytotec is not approved by the FDA for use on pregnant women; it was originally intended to be used on ulcer patients. It was found to also cause strong uterine contractions. Sometimes it can cause hyperstimulation of the uterus, increasing the chances of uterine rupture and overstressing the baby. One of the problems of using cytotec is that because it is administered in pill form (either swallowed or vaginally inserted), its effects cannot be interrupted once it has been taken. I find the risks far too great for both mothers and babies, and it is unconscionable that cytotec is still being used to induce labor.

It's hard to be pregnant. It feels like forever. Towards the end, when you're as big as a house and it's hard to move around or sleep or eat or sit because your body is half baby, you really long for the relief of labor and birth, just so you can be comfortable again. Both of my babies have been overdue, and I completely understand how difficult the last weeks are.

My midwife assured me, "You will go into labor. Everything is fine, and eventually, when your baby is ready, you will go into labor." It helped to know that I was not defective, that I would not be pregnant forever. The average length of pregnancy for first-time mothers is 42 weeks. That means that some are shorter, and some are longer. Just because the pregnancy lasts 40 weeks and two days does not by itself mean something is wrong. Due dates are estimates. Women who have their labors induced are taking their babies out of the womb before the babies are ready, no matter what the reason. For some situations the risks of remaining in the womb outweigh the risks of being taken from it early. I do not believe, for the sake of mothers or their babies, that inductions should be done electively, as a matter of course, with no medical indication.

Alternatives to Epidurals

Epidurals are popular, but they are not the only means of pain relief during labor. Here are other effective methods, sorted roughly by my own preference:

• Hire a doula! Doulas know many strategies for dealing with labor. They can massage arms and legs and backs and help with breathing, movement and positioning, and emotional support. Their presence reduces the need for additional help.
• Get in the water. My doula trainer said that for fussy children and laboring moms, water always helps. Baths, showers, anything that's available, is usually helpful. Labor pools are sometimes called "wet epidurals" because of the pain relief they can provide.
• Change positions. Sometimes women find a position during labor that feels better than others. While in labor almost anything feels better than laying flat on a bed! Some women prefer to squat or sway or be on all fours, or sit on a birth ball, or a rocking chair...

Apart from getting medication injected into one's spine, there are other pharmacological approaches. I hesitate to mention them, because to me their side effects are unacceptable.
Narcotics (such as Demerol, Sublimaze, Stadol, Nubain, meperidine, Narcan; also called opioids), given by injection to the mother during labor. They do not provide complete pain relief; many people say they take the edge off the pain. They are also relatively short-lived. A quick web search found these results from a study on the effects of narcotics on newborns: "opioids are associated with neonatal respiratory depression, decreased alertness, inhibition of sucking, lower neurobehavioral scores, and a delay in effective feeding." Mothers have also reported feeling groggy, delirious, or goofy, as a result of narcotics during labor. (Note: if, when you are in labor, you are offered a shot to 'take the edge off the pain', it is a narcotic.)

Paracervical block: an injection of Lidocaine directly into the cervix, to numb the cervix and adjoining tissues during the first stage of labor. Its effects are short, but it doesn't require the presence of an anesthesiologist. Its use is associated with infant bradycardia (slow heart rate).

Though I know many women prefer medical management of labor, I feel safer with psychological and emotional support.

The Psychology of Labor

Most of what I have written about labor involves the physiological progression and can be found in any book on pregnancy. I think it is important to know what is happening and what it might feel like to be in those phases. But there is more to labor than phases. What I'm going to write about here is mostly based on my experience, and I hope it will give insight and alleviate any fears and feelings of being overwhelmed that all the information of the previous entries may have caused.

The first thing I want to say is going to sound strange. I want to tell pregnant women to not be afraid of the pain. Women in labor are not being injured. The only thing that is happening - the only thing - is that the uterus is contracting to open up the cervix. This does not cause injury; barring malposition, the only pain felt is due to the hard work of the uterus, that it is working up to and sometimes past the point of muscle fatigue that we feel when we lift weights. It feels like menstrual cramps at first because it is the same mechanism: during menstruation, our uterus contracts to get rid of the blood-rich uterine lining, so much so that the muscle rapidly uses up a lot of oxygen, causing cramps. The same thing is happening during labor.

This is why it is so important to find ways to relax during contractions. If we can relax our bodies, we are not using up oxygen anywhere extra to maintain tense muscles, and we are also not fighting against the hard work our bodies are doing. When we tense up during a contraction, we are counteracting the uterine contraction, as if we are trying to stop it from happening, and this results in serious pain.

Let me use an example from my first labor. With the help of a doula, I was doing great, not feeling the need for anything else. I had a difficult time progressing from 4 to 7 centimeters. Around the end of this time, I was getting weary of dealing with contractions, of having to stay so focused, and I decided I didn't want to do it anymore. Unfortunately I made that decision in the middle of a contraction. I panicked and tensed up, fighting against the contraction. Suddenly the manageable amount of pain I was experiencing, increased by about 100 or more, and it instantly became more than I could handle. I learned my lesson and tried hard to stay relaxed during the rest of the labor; it went back to being well within what I could take.

From that I learned that relaxation is tied to how much pain we feel during labor. With the help of my doula and several family members, I had enough support that I never even considered asking for drugs. (I remember in the few minutes after my baby was born, I had the thought, I wonder if I'll need pain medication? It took me a moment to realize, Oh my goodness, I did it already!)

Do not be afraid of the pain. The pain is temporary, it comes and goes, and you just need to get from one contraction to the next. It is well within your ability to manage, especially if you have a support person who is dedicated to making you comfortable during labor. The bodies of laboring women are doing the work all by themselves, and all the women need to do is let it happen. If you get to the point where you don't feel like you want to do this anymore, try hard to regain your composure. If you're exhausted but your contractions are still going strong, try to let it keep going; if you're overworked, have had a long labor, have been restricted from eating and drinking for a long time, or your contractions are weakening instead of progressing, you may need something like an epidural just so you can get some rest. This is not failure; this is dealing with the labor as it has happened. Labor is not intended to be a path into the depths of hell, and I hope that women never experience it as this.

I was never sure I could have a drug-free natural birth, not until it happened. I was worried during the last parts of both of my pregnancies about needing medication, mostly because I didn't know what to expect. I didn't know how much I could handle, and I didn't know what labor would be like. It was different from how I imagined. It was a much more psychological, introspective experience. Hours flew by without me being aware of how much time had passed (my first labor was 20+ hours but felt like 3-4 hours to me).

In the fantastic book Birth Reborn, Dr. Michel Odent talks about the need for laboring women to be able to get in touch with their natural instincts, that they already know what to do during labor and birth. He says that birth is in the primal realm, not the cerebral, intellectual world we usually live in, and to get in touch with that part of ourselves, we should ideally be in an environment with little or no interruption, low light, a place where we feel comfortable being uninhibited.

I want to say two things about this. First, a word about our intellects. This part of our minds, makes lists and organizes calendars, plans and arranges, and works logically and rationally through decisions. This is not the part of our minds we want to listen to during labor. Here is one example of why: It might take us fourteen hours to dilate to a 7, and our minds will tell us that we cannot endure another (quick math: one centimeter every 2 hours, means 6 more hours of labor) 6 hours of labor before the baby is born! While that is mathematically reasonable, labor does not follow that pattern. After 6 or 7 centimeters, the woman enters transition, labor speeds up, and by 7 centimeters she might have less than one hour before she is holding her baby. It should be clear that if we listen to this voice, we will be misled, feel discouraged, and might make decisions we will regret. A better gauge is something like, How am I doing? Is this bearable right now?

The second thing I wanted to address is the need for the laboring woman to feel comfortable using her coping techniques. My favorite during my first labor was low moaning - the low tone keeps the body relaxed, while making noise helped me to feel like I was doing something other than just sitting there. I could moan as loudly as I needed to, so long as I kept the tone low. Sometimes I roared and yelled, lowly of course. I can't imagine what I would have done if I hadn't been allowed to make noise or if I had been worried about disturbing other people. I believe that women should feel free to do whatever it is that helps them during labor, whether that's walking around, being completely naked, on all fours, moaning, chanting, wiggling, making horse noises, or anything else. There are so many techniques that have helped laboring women, and while pregnant women might look into those things and be familiar with them, there is a chance that they will not know what the most effective one(s) will be until they are in labor.
To read about some of those, and for lots of knowledge and confidence in the power of women in childbirth, read Ina May's Guide to Childbirth by Ina May Gaskin. This is a great book, and essential reading for pregnant women.

More about Labor

The previous entry detailed the basics. There is, of course, so much more to say about labor and birth.

Back Labor

I have never experienced back labor, but I have heard plenty of times that it is excruciating. Back labor is most often caused by the baby being in the wrong position for birth. The normal position is head down with the baby turned towards the mother's back and the baby's back facing outwards towards the mother's abdomen. If the baby is reversed - that is, with the baby's spine facing the mother's spine - the bony part of the baby's skull presses down on the mother's tender nerves, causing pain that shouldn't be there. Sometimes this can be remedied with walking and rotating the hips, or swaying on a birth ball. The pain can be partly relieved by getting on all fours and taking the pressure of the baby's head off of the mother's nerves. Counter-pressure - having an assistant press hard on the lower back - usually helps. If the baby does not rotate to the favorable anterior position, the baby will be born "sunny side up", and this might extend the pushing phase.

Epidurals

Epidurals are an extremely common form of pain relief for labor. They are typically administered between 4 and 7 centimeters of dilation. The mixture of drugs used is unique to every woman, and epidurals must be given by an anesthesiologist. The process usually takes about 45 minutes to an hour and a half to complete. The epidural is given directly to the spine. The procedure is basically as follows: an area on the mother's lower back is cleansed and a thin catheter is threaded between two spinal vertebrae into the column of fluid surrounding the spinal cord. The anesthesiologist gives a test dose to ensure the placement is correct, then tapes the catheter cord to the mother's skin. The epidural mixture is either given in doses by the anesthesiologist as needed, or it is given in a drip that can be controlled by the mother.
I am not altogether opposed to epidurals. I think they are overused, and I am stunned to hear of women who want epidurals before they have ever felt a single contraction. It seems to me that these women would be better served in facing their fears of childbirth instead of beginning motherhood in a drugged-up state. I believe that epidurals ought to be administered when the mother is overtired and her exhaustion is affecting the progress of labor, or if she suffers from back labor. I wish they were not given as a matter of course, giving women the impression that they are unable to endure labor and need drugs to help them through it. For the women for whom this is true, they should be available, but I refuse to believe that this is the case for most pregnant women.

Effectiveness of Epidurals

For most people epidurals are a very effective way to obtain pain relief during labor. The epidural numbs the mother from the top of her uterus all the way down to her feet, and often the mother will feel pressure during contractions but no pain.

Potential Risks and Side Effects

Epidurals dramatically lower the mother's blood pressure, so an IV is given at the same time to counteract this effect. Because she is numb, the mother will no longer be able to walk or change positions unassisted. Epidurals tend to slow down the progression of labor, and so they are associated with an increased use of pitocin, an artificial oxytocin used to increase the rate and strength of contractions. Occasionally the mother will not be able to feel her pelvic muscles well enough to assist with pushing the baby out (another reason to practice those Kegels!), and forceps or a vacuum extractor will be required; at worst, she will need a cesarean.The rate of complications with epidurals is estimated to be 23%. Most complications are problems with administration and are not inherent to epidurals in general. Some are life-threatening, but those of course are extremely rare. In truth no medical procedure is free of risks.One of the common complications is punctured dura, meaning the spinal cord itself may be punctured during the administration of an epidural. Spinal headaches will result, which are extremely painful and can last for a very long time - I have heard of spinal headaches persisting for as long as a year after delivery.

Some medical practitioners tell women that the epidural does not pass to the baby and therefore cannot affect the baby, which is an outright lie. Epidurals given too close to the delivery of the baby tend to depress the baby's respiratory system, requiring some level of resuscitation. Having a drowsy, uninterested baby is not ideal during the crucial first hours after birth, when bonding between mother and child is so important and can be so beautiful.

Occasionally the epidural has no effect on the mother, which means she faces both the disappointment of not being able to obtain relief and the daunting task of having to deliver a baby naturally. I believe that it is in the mother's best interest to mentally prepare herself for a labor without pain medication, even if she plans to get an epidural, just in case the epidural has no effect on her. The judicious use of epidurals can make the difference between a mildly disappointing event during an otherwise joyous occasion, and a traumatic birth experience.

Labor!

On any pregnancy website you can find a list of the signs of impending labor: spotting, nesting, crampy regular contractions, bag of waters breaking, etc. First-time moms anticipate labor beginning hourly during their last weeks of pregnancy, thinking it could happen at any moment. This is an exciting time, especially since it is nearly a universal sentiment by this stage of pregnancy that the woman is ready to be done with being pregnant and move on to the next phase. And it could happen at any time, whenever the baby is done developing, that mysterious and unknowable timetable.

Most first-timers go beyond the 40 week mark. Some, like me, go way beyond it. Tests and ultrasounds can monitor the placenta and make sure it's still functioning, since one of the risks of being overdue is that the placenta will fail - it is, after all, only a temporary organ (amazing! the body grows this wondrous organ, only to dispose of it a few months later when it is no longer needed!). I haven't seen statistics on this occurrence, but with my first baby I was 18 days overdue. Everything was fine, and I chose not to be induced. When my baby was born, she was just fine, not huge, not peely and leathery like babies who have overstayed their time in the womb - just perfect. I think a lot of women, who are tired and feel huge and just want to meet their babies, go in for inductions before their babies are ready to be born... but more on inductions later.

The truth is that unless you are one of those very rare women who has a completely painless, unfeeling labor, you will know when labor starts. You will likely have been feeling contractions all through the third trimester, but there will probably be a distinct change in sensation when the real work begins. Labor carries an intensity with it, and a regularity, that is obvious to those who experience it. From that point, the issue becomes, how much longer will it last, and how much worse will it get?

I don't believe that most people can, even through relaxation techniques, experience a painless labor. I think that relaxation is important in helping the work to progress, and in making the pain manageable, but I believe the majority of women will still have pain during labor. So long as I was relaxed, every one of my labor contractions hurt less than, say, a stubbed toe. People endure stubbed toes without getting analgesics injected into their spines; so too can people endure labor, with the proper support and understanding of what's going on, without needing medical help.

The first phase, early labor, begins with the onset of regular contractions. This is usually the easiest part, as the contractions are far apart (a few minutes) and the woman can talk and interact even while experiencing contractions. She will probably be very excited, knowing that "this is it" - but that excitement can lead to one of the most common major missteps that first-time moms are especially vulnerable to: using too much energy during this phase, when labor is easiest! The mother-to-be might decide that this is the time to clean the baby's space or cook a big dinner or even focus too deeply on the contractions when she doesn't really need to - any one of these things can lead to exhaustion. Labor probably won't feel very difficult at this point, but it is crucial that the mother get plenty of rest and not burn herself out.

The contractions will continue to get stronger and closer together. The uterus is working hard, and the sensation of cramping might turn into something that feels more painful and harder to handle. This is because the uterus, the strongest (and at this point largest) muscle in the body is being exercised, contracting and releasing, for several hours. Any muscle that is worked this much will begin to feel sore, and the same pain one gets from using an arm or leg muscle to its limits is the same as what the woman experiences - only to a larger degree. She will experience the unusual and uncomfortable sensation of moving beyond that. The uterus has a long way to go. What is happening physically is that the uterine contractions are pulling the cervix open. The cervix needs to be dilated to about 10 centimeters, or approximately the width of a human hand (this of course varies, as does the actual measurement of full dilation for each woman). When the cervix has reached 4 centimeters, the woman has entered the next phase of labor, the second stage. Contractions are typically demanding all her attention now, and usually are about 3 minutes apart and last about one minute. What this means to the woman is that she is going between contractions and rest at a rather fast pace! One minute of contractions, two minutes of rest, one minute, two minutes...it will be more challenging to stay atop the contractions. Most women cannot help but remain focused on their labor at this point, and do not want to be distracted, which is essential to getting through it.The last phase of this part of labor is transition. If women are going to panic, this is often where it happens. Here labor tends to be the most dramatic and requires the most from the woman. The good news is that it is also the shortest phase, lasting less than an hour and often only about 15 or 20 minutes, maybe 10 to 20 contractions long. The uterus is finishing its work of dilating the cervix, and contractions are hardest and closest together. Women often become overwhelmed during transition - they may decide they can no longer handle labor, or they might insult their partners or caretakers, or become nauseous and shaky. (During my first labor, transition was quite easy - it was getting from 4 centimeters dilated to 7 cm that was the tough part!)Fortunately this phase typically ends peacefully, with a period of quiet, where contractions stop completely. Sheila Kitzinger calls this the "rest and be thankful phase". With the cervix completely dilated and effaced, the body is resting in preparation for pushing the baby out. The kinds of contractions the woman endured before have ended, and the work the uterus does now to birth the baby are of a different sort and usually not painful. This restful period can last several minutes before the second stage of labor begins.

Pushing

Now the hard work begins! Up to this point, labor was characterized by endurance alone, by just getting through it, and allowing the body to do its work by not interfering. But with the second stage of labor, the woman can finally actively participate in the birth of her baby. This is the pushing stage, where the cervix is dilated and the body is ready for the passage and delivery of the baby. Even though labor may have been exhausting up to this point, a welcome surge of energy comes, and women again get excited to meet their babies.How this stage is experienced depends greatly on the woman's caretakers and environment. Some hospitals coach women through pushing, telling them how and when to push. But it is becoming more acceptable to let women push spontaneously, when they feel the urge. Most women will experience a deep primal and irresistable need to bear down as the baby descends. The uterus is still contracting, and the baby will be born whether she actively pushes it out or not, but she will probably not be able to control her desire to push. The baby makes a two-steps-forward-one-step-back progression. This is a natural way of reducing damage, to stretch out the tissues of the birth canal. Left to descend on their own, the movement of the baby down and out often prevents much damage and results in a gentler birthing than constant pushing from the moment of dilation.The head of the baby is the largest part of its body. Once it has stretched the perineal tissues to their maximum (often called the "ring of fire" because of the burning sensation this produces - to get a small idea of what this is like, place a finger at each corner of your mouth and pull hard), and is born, it will no longer retract and the baby will be born within moments. The head turns - the body is maneuvering itself down the birth canal, down the path of least resistance - and the shoulders emerge, often followed very quickly by the rest of the body. For first-time mothers, the second stage can last several hours, but for subsequent births it may be only minutes.All the hard work of labor has accomplished the most amazing thing, the birth of a baby. This time is crucial for bonding with the baby, for beginning breastfeeding, and welcoming the little one into the world.

A Second Birth

However, the woman's body isn't yet finished with its work. The third stage of labor is the expulsion of the placenta and the continuing contracting of the uterus to its prepregnancy size. The detachment and birth of the placenta is painless, and some women often do not even realize it has happened.With the detachment and delivery of the placenta and the uterus returning to its original state, labor is finally at an end, and motherhood is just beginning.

Choosing a Prenatal Care Provider

The type of care the pregnant woman wants should be reflected in who she chooses to provide her care. Unfortunately, though, not all varieties of care are found in all areas. Most women in the US go to an obstetrician for the duration of their pregnancies, and the highest number of patients admitted to hospitals in this country are women about to have a baby.

When I was pregnant for the first time, I signed up with an OB just like everyone else I knew. I picked a female because I had heard so many other women say that they felt more comfortable with female doctors, especially in this situation. Women are more sympathetic because we're all on the same side, right? I'm sure that's true for many female MDs. I can't say whether it was true for mine or not because I barely saw her. Halfway into my pregnancy, after I had done some research and decided that I wanted to try to have a natural birth, I was also considering a home birth. I spoke to another woman who had brought up the issue of home birth with our shared OB, whose reply was, "What, do you want your baby to die?"

I never went back to that OB, because I found a perfect combination of support for natural birth and quick medical attention if necessary. In a suburb of my community was a small hospital which had the ideal arrangement. The prenatal clinic was run by midwives in conjunction with OBs, but the doctors only saw the high-risk pregnant women; all "normal" (low-risk) pregnancies were directed to the midwives. The hospital had a birthing center attached, run by the midwives, and was equipped with labor pools, a doula program, and comfortable, single-patient labor rooms and a separate postpartum wing. If anything went wrong, the doctors were around the corner, and an emergency surgery room was not far. The emphasis, though, was on non-interference with the natural rhythms of labor and birth. Both of my babies were born there, the second in a warm pool of water.

This is an extremely rare arrangement. I don't believe many places like this clinic and hospital exist throughout the country. Most women will have to choose between doctors and midwives, between hospitals and home birth (or a freestanding birth center). Most of the time, that decision is between two different worlds.

My experience with obstetricians was rough, and I found mine to be cold and clinical, emphasizing the pathological side of birth. She stressed interventions (she tried to convince me to get an amniocentesis for my first pregnancy, even though I was young and wouldn't terminate even if the results showed anything) and rooted my fears that somehow birth is unnatural and needs to be carefully watched and managed. I believe that there is a place for obstetricians, and it is not with normal birth. Not many OBs have ever even seen a normal birth. Midwives specialize in this area, and their personalized support and desire to educate spreads enthusiasm instead of fear. I understand that this is an oversimplification, because of the polarization of doctors and midwives. In my current community, if a woman wants a natural birth without interventions but not a home birth, her best option is to see the only local OB who is sympathetic to this point of view. One local doula says that if you don't want a c-section here, you need to arrive at the hospital while you're pushing.

My point in telling all of this is that the person a pregnant woman chooses to give her care, does matter, especially for first-time mothers. As a society we keep believing that doctors always have our best interests in mind and always know the best things to do, and women having their first babies have been taught to be scared and to doubt their ability to handle giving birth. In some cases doctors do have expertise, but I don't believe as a whole that doctors should have so much jurisdiction in the area of normal birth. Doctors are trained to interfere, not to stand by and let nature take its course. Doctors are impatient and have schedules and many patients. They give stimulating or inhibiting drugs so that labor follows a prescribed course, an action especially dangerous for first-time mothers, who usually need more time to give birth. If a woman's OB disagrees with her about what kind of birth she wants, she will probably not get what she wants. I have very rarely seen or heard of anything that contradicts these statements.

I wish all communities had both doctors and midwives, but at least doulas can be found in most areas now. Doulas are a step towards filling the void in personalized care, but the same rule applies to them as applies to both doctors and midwives: the most important thing is that the pregnant woman feels comfortable in their presence, secure in the knowledge that her care provider will give her the kind of care she desires and will support her in her reasonable decisions.

Still more to come!