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.