Friday, November 22, 2013

“My Baby Hasn’t Dropped Yet”!

You read about it, you wait for it to happen, and then it doesn’t!  Pregnant moms everywhere scour the internet wondering if they are going to have to be induced, or worse yet, have a cesarean. 

I get a sick feeling in the pit of my stomach when I hear how a poor mom is facing a cesarean based on the fact that her baby ‘hasn’t dropped yet’.  It’s happening so much, that it’s becoming  a common belief that this is where the evidence leads us. 

So, what does it mean when your baby ‘drops’?   When your baby drops, it means it has nestled down into your pelvis and become ‘engaged’.  When your doctor or midwife does a vaginal exam, they are not only checking for your dilation, and your effacement, they are also checking the station of your baby.  This tells them how high or low your baby is in relationship to your pelvis.  Your baby's station is measured in cm -above and below the ischial spines.  If your baby's head is even with the ischial spine, then it is considered to be "zero station", and also nicely "engaged".  Let's look at the following pictures:

My index finger is pointing to the ischial spine!

 Here is a picture of the baby's head even with the ischial spine.  It is engaged, and at "zero station":

This baby here, is not engaged at all! (some babies are lower than this, but still not considered to be engaged yet).  

The baby's station can be anywhere from -5 to +5 - measured in centimeters above or below the ischial spine.  Do a quick Google search and type in the words "pelvic station" and you will find many images that explain it much better than I'm doing here! 

For those of you out there giving birth for the second, third, or more times - please understand that your baby will most likely NOT drop until well into labor (or even pushing), and that your provider should not be doing a cesarean on you for this reason alone! 

For you first timers, it is more common for a first time mom to have her baby “drop” before the onset of labor, but she doesn’t have to feel broken if baby has decided to stay comfy higher until she is well into labor.  I’ve assisted many first time mothers whose baby was high at the onset of labor, and none of them had a cesarean because this was the problem. When my clients tell me that their baby has not dropped, I shrug my shoulders and smile.  It’s common even for first time moms, and it’s :-)   Another very interesting thing to note is your racial ancestry!  A study from  Philpott  and Castle found that African Rhodesian primigravidas did not have engagement until the late first stage of labor.  (So in other words, almost time to push before engagement)!  The Oxford Handbook of Obstetrics and Gynaecology, states that “In women of Afro-Carribean origin, engagement may only occur at the onset of labor, even in nulliparous  women due to the shape of the pelvic inlet.”  Going back over my doula notes, I did have more of my mama’s of color not have any fetal descent until late in labor, (but I also had Caucasian mother’s do the same)! 

Studies like this, suggest that there is no difference between needing a cesarean and the baby’s station.  However, there are plenty of other studies that seem to state otherwise, which is most likely why your doctor finds a cesarean the best solution in his/her practice.  A provider might see that there is an increased likelihood of having a cesarean and thinks “well, she is going to end up with a cesarean anyway, I might as well save her the trouble.”

I think that we need to consider something about these studies:  First of all most of the mothers were induced.  Induction on a good day, with baby nice and low, can lead to a cesarean in approximately 1 in 4 women.*1  So if women are being induced because baby is high, and they have a cesarean can we really blame it on the fetal station?  Secondly, if a baby is sitting high in the pelvis, it might take some time before dilation progress occurs.  Think about it; if baby doesn’t sit on the cervix, it may not open as well.  What if this takes more time than your provider would like to give?  (Studies do show that an unengaged baby may take longer).  It’s no wonder failure to progress is the leading cause for cesareans in the United States!  Finally, it is true that babies can be misaligned  (in other words the head just isn’t quite where it should be), and that this misalignment is holding the baby up.  Some providers go straight to a cesarean in this situation because they know that Pitocin can just bang baby into a bad position and that can also lead to a cesarean anyway...  This is why it’s so important to have a doula and to learn the art of optimal fetal positioning.  If you are induced, you are likely not to have a lot of time to birth your baby, and you are also not likely to be able to get into positions that would facilitate rotation and decent of your baby - so guess where that leads you? (Yes, cesarean would be the correct answer)!  The good news is that you have a choice to wait, and work on getting baby into better alignment (and more than likely neither an induction or a cesarean will NOT be necessary :-) Even if you do nothing to get baby into a better position, your body will most likely work on it anyway with or without you! 

So when is it a problem?  One study, says that it’s a problem if a mother is at 7cm dilation, and the baby has not descended yet.  According to Varney’s Midwifery Text “Lack of engagement at the onset of the second stage of labor in muliparas is abnormal”.   (Second stage is the pushing stage of labor, and muliparas - means a woman who has given birth before).  In other words, we can’t call it a problem until you *are* in labor, and you *are* pushing!   How can doctors be giving moms a cesarean for this before labor begins?  This not a medical reason for a cesarean!  A trial of labor should always be given if this is the only reason for the cesarean! 

What if we went back about 40 years when our cesarean rates were about 10%, or even 20 years ago when our cesarean rate was about 20%?  How come those women did not have to have a cesarean for such a common situation?  Did they have poorer outcomes because they didn’t do cesareans or inductions for this?  (The answer is no, our outcomes are worse now by far then they were back then). 

So what can you do, what are your options?

Your first option is to wait.  It’s boring, it’s not easy, and it’s downright uncomfortable.  (I’ve heard that cesarean recovery can be uncomfortable too, so there isn’t a perfect solution is there)?
While you are waiting, it’s time to learn some spinning baby techniques, and for this you can visit this website: .   Perhaps it’s time to consider chiropractic care that specializes in the care of pregnant women.  If your pelvis is out of alignment, your baby may not want to settle down into the pelvis.  Consider the risks of being induced, and having a cesarean.  Now think about the risks to waiting?  Which one has the shorter list of risks? 

Induction: If your provider is suggesting an induction just remember that if your body isn’t ready, you will not be likely to have a vaginal birth, no matter what your baby’s position.  But wouldn’t you rather try that then go straight for a cesarean?  I’d also like to offer this little piece of advice:  If you do decide to get induced, you might not want your waters to be broken until your baby has descended lower into your pelvis.   This can lead to ‘cord prolapse’ in about 1% and this situation requires an emergency cesarean delivery.  (Cord prolapse occurs when the waters are broken when the baby is high in the pelvis, and the cord slips down into the vagina before the baby’s head.  The baby’s head can then pinch the cord against the pelvis, which cuts off it’s blood flow and subsequently, it’s oxygen).   It is not recommend that induction be done before the 39th week, and you might even consider waiting until you are 42 weeks.  Induction of labor increases your risk of having a cesarean, so again, consider waiting it out.   May I also suggest working on baby’s position prior to the induction, and then do what you can during labor as well.  

If you go straight for a cesarean, you have to consider all the risks for you and your baby.  Subsequent pregnancies are also at risk with each cesarean you have.*5, 6

The Risks of Elective Repeat Cesareans vs. The Risks of VBAC from

I think it's time that we start using cesareans for the situations that really warrant them.  Remember, it's never too late to change providers, and for the love of doulas, get one! 

Monday, December 28, 2009

Ways to push during labor

“Okay, you’re complete! It’s time to push!”

These are the words that seem to bring changes into the birthing room. The laboring patient is usually relieved to hear these words, sometimes surprised, sometimes anxious, but most often you can catch a glimpse of a smile pass her lips when she hears these wonderful words. For some women, nobody has to tell her it’s time to push, she is already pushing! She may have been trying not to push for the last several minutes, or in some cases (hours). Sometimes there is no stopping that freight train urge and mom pushes like there’s no tomorrow! Some mom’s aren’t so sure of what is happening. She doesn’t ‘have an urge to push’, (this is due to the baby just not being low enough in the birth canal where those nerves are that say ‘push!’). There is the occasional laboring mom who never feels the urge to push (but I assure you that her baby would still be born as the uterus still presses down on it’s own).

The pushing phase is the 2nd stage of labor (the first stage is all the dilation that takes place, the second is the pushing phase, and the third stage is the delivery of the placenta). Although it’s not considered a stage of labor, there is another phase between the dilation and pushing that sometimes occurs: The resting phase.

Some women get to 10cm (or complete whatever that centimeter of dilation is), and feel no urge to push, and in fact may stop having contractions all together. These women rest or fall asleep (providing that there is no nurse or doctor yelling that it’s time to push). Sheila Kitzinger aptly calls this “the rest and be thankful phase’. This phase can be non-existent or last 30 minutes (and I’ve heard some women go up to an hour). I tell you this so you won’t feel ‘broken’ if this happens to you. It can be a normal part of labor and delivery, and you absolutely have the right to enjoy this break. As long as you and the baby are doing fine, there is no need to hurry this process, even if the doctor’s pizza is getting cold :-) There is nothing harder than trying to push when there is no urge, and worse - when there’s barely a contraction facilitating it. It’s like trying to poop when you don’t have to go! Never fear though, the hospitals have a backup plan for this resting phase: Pitocin!! Sorry mom, you can’t enjoy your resting phase today, you are broken, and we need to give you Pitocin so that we can make you contract, so that this baby can be born in a timely fashion. Argh. Just so you pregnant women out there know, you have the right to refuse any medical treatment - and this is an example of a good time to exercise this right. If the baby is doing well, and so are you, why fix what is NOT broken. If you are resting, your body probably needs that rest. What is TERRIBLY frustrating is when women refuse such treatment and then they’re told from their nurse or worse yet, their doctor, that if they refuse, their baby will DIE. Really? Without any warning? Why do studies not show this? Why is it that women with an epidural are allowed to labor down, and are sometimes told not to push for an extra long time, because the doctor is not available?

There is so much to write about the pushing stage of labor, but what I’d like to write on today is the methods of pushing. There are three basic types of pushing:
*Directed (often called “purple pushing”)
*Mother directed pushing (also called spontaneous pushing)
*Exhaled Pushing

My primary concern is with directed pushing. After a vaginal exam confirming that mom is complete, a coaching session ensues on how to push. The mother is directed to push for 10 seconds, allowed to take one breath in, and “Go back at it again, 1,2,3,4,5,6,7,8,9,10, now take another deep breath and push again..1,2,3,4,5,6,7,8,9,10". Sometimes the mother say’s things like “I don’t feel the urge to push”, or she can’t push that 3rd set of 10 seconds, and get’s scolded. Heaven forbid the woman let out noise during the pushing stage! I’ve heard it too many times “don’t make noise, hold your breath and PUSH!”. Do they tell men who are bench-pressing, or karate-chopping to stop making noise? Isn’t it normal when there is so much power going on within a woman’s body, to just make noise? Studies show that making noise can help with pain! Nurses and doctors have a trick for giving a laboring patient that gives them an urge to push. A couple of fingers in the vagina, pressing down on the rectum will make you feel like you have to push!

Directed pushing comes with a list of cons, which is why I want to write about it. Again, if mom and baby are doing fine, there is no reason to hurry this stage of labor. Directed pushing increases the risks for tearing, fetal distress (due to the lack of oxygen), blood shot eyes in the mother, a drop in her blood pressure, a drop in maternal oxygen levels, and exhaustion ensues much sooner (causing the need for episiotomies, forceps, vacuum extraction, and in some cases - cesareans). We call it “purple pushing”, or sometimes “Valsalva pushing” because it can lead to the Valsalva's Maneuver (producing the effects listed above).

Now if a woman has an epidural, she may need directed pushing, because she may not feel that urge to push, or push hard enough because of her lack of feeling. She will not have the feedback to her brain providing telling her to push harder, or slower, and this will increase her risks for tears. For the rest of this blog, unless otherwise stated , I will be talking about these pushing methods for women who are not having an epidural.

Spontaneous pushing is mother directed pushing - simply put, pushing when she feels the urge and for as long as she needs to with each contraction. Most women do not push for more than 6 seconds when pushing on their own. They may push once, twice or several times during the contraction. Baby will get more oxygen when pushing this way, and the pelvic floor has less chance of being compromised. “Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations” (

Spontaneous pushing provides more oxygen to mom and baby, decreasing fetal distress, drops in maternal blood pressure, and doesn’t necessarily make a difference in the time that it takes for the baby to be born. Some studies say that directed pushing is about 15 minutes faster, but the following study shows that there was no difference in time, but that babies had better APGAR’s when mother was spontaneously pushing:
“This pilot study focuses on the bearing-down phenomenon of the second stage of labor, within the theoretical framework of Levine's conservation principles for nursing practice. The purpose of this study is to contrast the effects of two learned approaches to parturient participation during the second stage of labor. A control group (n = 5) was taught the traditional approach to second stage bearing-down efforts: sustained breath-holding. An experimental group (n = 5) was taught to bear-down only with the involuntary urge. No differences were found in the mean duration of the second stage, phases within second stage, Apgar scores, or maternal report of effort. Perineal integrity was preserved in the experimental group. These findings suggest that involuntary bearing-down efforts are accompanied by adequate labor progress and result in less perineal trauma. Further examination of the common practice of encouraging women to bear down strenuously during the second stage, instead of responding to their involuntary urge, is recommended.”

There are several studies out there showing that there is a direct correlation between directed pushing and an increase in perineal tearing. Even the World Health Organization says that the mother should push when she feels the urge, and should not be directed unless medically necessary! So why is this still being practiced? Feel free to answer!

The final type of pushing is exhaled pushing. This is the type of pushing, that is still mother controlled (or mother directed) but without her holding her breath. Instead as she pushes, she exhales her breath. Many women instinctively do this anyway. They make noise, grunt, and do a “Schhhh” as they finish pushing. This is where they are usually told to stop making noise and hold their breaths to push. Some women simply ‘breathe’ their baby’s into the world, and it is absolutely serene to watch! This may take a bit longer for baby to come, but is really great for reducing tears. It’s can also be very difficult to do when mom’s have a really strong pushing urge. The general rule is that when baby is crowning, you should stop pushing and pant, blow or breathe so that you have plenty of time to stretch s-l-o-w-l-y. Unfortunately, when baby starts to crown, caregivers get very impatient and tell you to “push NOW, push hard, GO GO GO GO!”. Baby pops out like a cork in a champagne bottle and poor mom’s perineum tears in the process.
Again, as long as baby is doing fine, why hurry this process? I’ll be the first to admit that one reason is because IT HURTS! However, I also know how bad it hurts to heal from huge tears due to forcing baby out like a rocket. I would much rather endure a minute or two of that ring of fire, than 6 (or more) weeks of healing and pain. I’ve done it both ways, and if get pregnant again, my husband has orders to hit me over the head before baby crowns so that I don’t listen to that little devil on my shoulder saying “push! Get the pain over-with NOW!”

Positioning can also cause or reduce tears (depending on the position). Stir-ups are the worst for causing tears, in fact, any time mom is on her back, it not only makes it harder for mom to push (because she is pushing uphill against gravity), but the pressure is increased on the perineum - from the vagina to the rectum. Using a squat bar, a birth stool, laying on the side, or even a hands and knees position can help reduce tearing - especially when mom is breathing her baby out after baby begins to crown. Last but not least consider asking your birth attendant to keep their hands out of your vagina while baby is crowning. Some like to reach in and ‘help’ gently stretch mom while baby’s head is coming down, but this may actually lead to tearing. Baby’s have been born since the dawn of man, without this practice, and there really is no reason for it.

Please remember that tearing is scientifically proven to be better than having an episiotomy, and is not as painful as you might expect - especially during the birth itself. There are plenty of things you can do to heal, and manage pain afterwards, but I won’t go into that right now. Many women fear tearing so much that they would rather have a cesarean with increased risks of all kinds of things. But do remember that tearing can most often be prevented by just doing the above (spontaneous pushing, exhaled pushing and pushing upright). Some women do everything right, and they still tear, and some women do everything wrong, and they don’t tear! We are all different. I’m just giving you the odds, and I hope that someone out there benefits from this information.

Wednesday, April 1, 2009

Mucous Plug: Not for the faint of heart

OK listen up people! This blog might just make you weak in the knees, so be warned!

Since you are obviously still reading, (unless you just skipped over the previous sentence above), you are fine reading about big globs of goo. Cool! Let’s get started :-)

Let’s start with a definition of the mucous plug: The mucous plug is a collection of cervical mucous that blocks the opening of the cervix. It provides an added barrier of protection for the baby. It is super thick, (thicker than snot), and can be different shades of color. It may look creamish (varying from white to even tan) in color, and is most often tinged with dark brown, red or pink - due to new or old blood from the cervix. Think of a mixture of (and I really hate putting food and mucous plugs in the same sentence..but)...tapioca pudding and jello. More like Jello. It’s thick, I tell ya! Somebody was nice enough to put their hunk of mucous plug on the internet, and if you search in google images for ‘mucous plug’, I’m sure you will find it very quickly. I’d put it here, but I don’t want to mess with asking permission. Here is a nice picture:

Normally, during the last trimester (and even before), our bodies tend to make copious amounts of vaginal discharge. It can get bad enough that wearing a panty liner is quite helpful. This is not the mucous plug, but women get confused and worried about not being able to distinguish between the two. Some women worry they won’t know if they have lost it, and many worry when the *do* lose it!

I have something very important to tell you:

Don’t worry! Losing your mucous plug is not something that warrants a call to your doctor/midwife. (Unless you have not yet reached 36 weeks - and we’ll talk about that in a minute). You DO NOT have to wrap it up in toilet paper, or put it in a zip-lock baggie and take it up to labor and delivery for further diagnosis. Trust me, the nurses do not care to see your mucous up close and personal, and it does not mean you are IN LABOR :-)

So what does it mean when you lose your plug? Not much! It doesn’t give any indication that your cervix has changed from your last visit. It *can* mean your cervix has changed slightly, but without steady contractions, you are still not in labor. You may lose your plug hours OR EVEN WEEKS before labor begins, so it certainly no indication of when labor will begin. Because the plug is built of cervical secretions, your cervix will continue to secrete mucous, and your plug will *rebuild* itself over a day or two. That is why some women may lose their plug more than once, -and- it is super common to lose bits and pieces over time, only to find more bits and chunks later.

Some women never notice losing their plug. This is fine too! Some women do not lose it until they are well into active labor. Of course, as previously mentioned, some women start losing it weeks before labor. (Hey, we learn by repetition, and that last sentences bears repeating)!

Many are concerned with their activity level after losing their plug. They worry about risk of infection. Some ask if they can still take a bath, or have intercourse. Yes, it is fine. The baby is still protected, and unless your doctor/midwife tells you otherwise (and it’s not going to be because you have lots your plug), you can still continue with ‘normal activities’.

If you are earlier than 36 weeks' pregnant when you see blood-tinged mucus, or if you have any vaginal bleeding, you should call care giver. Better yet, have this conversation prior to 36 weeks. Ask your doctor or midwife what he/she wants you to do if you think you have lost your mucous plug before 36 weeks. Some care providers may want you to call - even after hours, and some may say to wait until morning. Depending on several factors. So let’s talk about what those factors might be:

Intercourse, vaginal exams, and an already dilated cervix may cause you to lose all or part of your plug. So, if you lose your plug after these things, it was probably do to the ‘messing’ around down there. So sometimes, your doctor will tell you not to bother calling if there has been a recent vaginal check or whatever.. BUT, sometimes they tell you to call anyway. So that is why I say, get it all straightened out before hand, so you know what to do/when to call :-) After 36 weeks, there shouldn’t be a reason to call at all. If it makes you feel better you can mention it at your next appointment :-)

That wasn’t so bad was it?

Saturday, March 28, 2009

Why take a childbirth class?

Call me a hypocrite. I’m a childbirth educator who has given birth six times and never taken a childbirth class. At least not as a pregnant person. I did have to observe some classes for my childbirth education diploma. If the truth be known, I wanted to take the hospital childbirth prep course when I was pregnant with my first baby. I hadn’t registered, and my husband wasn’t acting like he was going to have anything to do with it, but I certainly wanted to take them and probably would have. (Even if that meant going alone). If I remember correctly, the hospital wanted us to be 27-28 weeks when we started the class. I went into preterm labor at 22 weeks, and was in and out of the hospital and on strict bedrest for the duration of my pregnancy. Needless to say, I *couldn’t* take the classes. I read books on pregnancy and birth, but every time I thought or read about labor, I would start contracting! I was terrified. I was afraid that I wouldn’t even carry my baby to term (after all I couldn’t see myself as a mother, and I couldn’t picture it all in my head, so I thought it wouldn’t happen). I was afraid that if I DID get to term my baby would be deformed from all the medications I had taken to stop the labor.

In my Epidural post, I mentioned that they did not have Epidurals (at my local hospital) for laboring women when I was pregnant with my first. I was facing the unknown and I was living in fear. It would have been so nice to have a doula and a childbirth educator to help ease my fears and concerns. Not just with childbirth, but with the preterm labor stuff. I remember sometime around 32-33 weeks I was in the hospital, and it was looking like the labor wasn’t going to stop. I didn’t know what to expect of a baby at that gestational age... if it could cry, or if it would even “look” like a baby. The nurse did show take me to the nursery to see a 33 weeker. (My mother worked with the grandmother of the child, and they told us to go see the baby so I could see what my own baby would look like). The baby was perfect in every way. It LOOKED like a real baby. I don’t know what was going through my head, because I couldn’t accept that my baby would look anything close to that perfect baby. At times, I wasn’t sure my child was human at all! (Case in point, I was completely in shock seconds after I gave birth to her, because she was not only human, but beautiful and absolutely perfect).

My family was great. I did have lots of love and support from my husband and my family. I don’t think my daughter would be here today without them. But as wonderful as they were (and still are), they couldn’t help me understand what to expect in the delivery room. My mother had some of her babies under twilight sleep, gas, or spinals, so she couldn’t tell me what to expect. She did tell me (more than once) that women have been giving birth for thousands of years without drugs, and women give birth every day, and I could do it too. I don’t think I believed her. I was different. Heck, I was giving birth to an alien baby, so why should I believe anybody about the normalcy of birth? My niece sent me a wonderful letter. She told me not to worry and that she has just recently gotten a tattoo, and that hurt her much worse than when she gave birth to her daughter. I did find comfort in that. If I thought about a tattoo before that, I was certainly marking that off my list! My sister spent countless hours in long distance phone calls to me. She was a huge support person, but she was 2000 miles away. She gave birth twice without drugs, and had no doubt I could do it, but she was stronger than me. I was smaller, I was sure I couldn’t birth a baby bigger than 5 or 6 pounds. You get the picture. I was scared and I had no faith in my ability to give birth - especially vaginally.

Funny thing is that during this whole time of me fearing labor -I was contracting, and dilating and effacing! I remember a few weeks before my daughter was born, I was 4 cm and 90% effaced. My labor was half over before I even delivered. (I was 5 cm and 100% effaced the week prior to labor day).

Anyway, after her birth, I was overjoyed that I gave birth, and lived to tell about it. Not only that, I had a beautiful daughter with a thick head of dark hair rooming with me. I was so excited I could barely sleep that night!

So WHY do I feel childbirth classes are important? It’s certainly not my belief that women do not know how to birth their babies. They do! That is built into us. Our bodies know how, and they do it very well. Our brains, well, they can get in the way sometimes. But, even then, we are still very capable of having a wonderful birth. So, why do I still feel they are important?

During pregnancy we are faced with choices. Some may not even realize they *have* a choice. In either case, there are still choices every women makes. It might be her care provider, or the place of birth. It might be a procedure like pap smear or something more invasive like amniocentesis. We decide what we eat, and what we drink, and usually how we plan on parenting. (Things like breastfeeding, cloth or disposable diapers, to circumcise or not..etc) Some things we know are choices we are *free* to make, and sometimes we don’t realize we have any say in the matter. Especially if that decision has to do with something going on in the delivery room.

Do women have a choice in the way they give birth? Some things are obvious to most women, but not for everyone. For example, with my first, and even my second child, it did not occur to me that I could walk around during labor. I thought women went to the bed, and laid there for their labor. It did not occur to me that standing could make contractions feel ‘better’. I didn’t know I could walk around. After all I was attached to a machine and didn’t I have to have that on the whole time? It was not obvious to me!

You’d think I would understand something simple like getting out of bed - but nobody brought it up, and no one in my family knew anything about things like that - and the books I read obviously didn’t tell me these things either. (The one book said to relax, so I thought that meant lay down in bed). No, I would have to wait until child number 4 to understand many of ‘my choices’.

Now for someone like me (back then), it would have been extremely helpful to have taken a childbirth course.

So I’m sure you are asking: “Well, I’m pretty certain (or I KNOW) I’m going to have an epidural. Why should I take classes? “
If you take well rounded class, you will cover more than just basic childbirth. You’ll get some ideas on how to deal with pregnancy discomforts. You’ll learn about the various tests and procedures for pregnancy as well as during delivery. You’ll learn about what to expect where you are delivering, and get an idea of what will happen. How will you know if it’s real labor or false labor? Do you allow your doctor or midwife to break your water? If so, should it be done in early or late labor? Does it even matter? Would you rather tear or have an episiotomy? Do you have to have an IV? What is your option if you don’t want one? What constitutes an emergency, and how do you know if cesarean is really necessary? All of these things are nice to know before going into labor, and have nothing to do with pain control.

You’ll also learn a bit on what to expect after the birth. Women have lots of questions about this, but they still do not find it necessary to take a class that might explain it. Do you know what to look out for? What is serious enough that you need to call your doctor? What about the newborn baby? If this is your first baby, a newborn basic class is good too. Many childbirth classes talk about the newborn in one of their classes. You might learn about the tests and procedures they do on the baby, and what the results mean. You will learn what is normal, and when to call the doctor. You might know this stuff already - and if you do, skip that class if you want. I bet if you do go, you’ll still learn something you didn’t know! I know I did - even after baby number SIX!

Now what about unexpected things? If you read my blog on Epidurals, you will have read that there is a chance that your epidural will not work! Perhaps it will only work half way. Perhaps your anesthesiologist is not on call at your hospital, and you have to deal with labor for an extra hour longer than you think. Sometimes, labor just doesn’t go as planned. You might want to look into that back up plan: How to deal with labor naturally.

What if you have been in prodromal labor for a few weeks, and you have been slowly dilating and effacing (and if you don’t know these words, I suggest you take a childbirth class ;-), and you end up with a very fast and furious birth? What *IF* you end up giving birth before you get to the hospital? Yes, it is rare - but it does happen. I teach emergency childbirth in my classes, and I highly suggest that everyone look for a class that teaches some basic “how to’s”. Even if you have not been dilating, and effacing - you can still have that very rare - “I -gave- birth- in -two- hours -from- start- to- finish” births.

What about your partner? Wouldn’t it be nice if that person could learn what to expect? What is normal? What sounds you might make - (even if they are made before the epidural). How can that person help you cope? What can they do to make the contractions ‘better’? What about the very sights, sounds and smells of birth? Even if the mother has pain medication, your partner might want to see what birth looks like before your special day.

So is a childbirth class ‘worth it’?
Ask a bunch of your friends if they took childbirth classes, and if it ‘was worth it’. If they took a hospital childbirth course, you might find mixed reviews. Many will say “don’t bother”, and some will say “it was GREAT”. Ask another group about classes taken in a place OTHER than a hospital, and you will almost always get a positive review. Why? They most often have less couples per class, which means you can ask more questions. The instructor is up to date on all of the new research. Hospitals tend to use a nurse to teach classes, and they are not always up on the current research. They also tend to teach you how to be a “good patient” instead of letting you know you have certain options. Hospital childbirth classes tend to be more hit and miss. They don’t always talk about all of the things mentioned above. There are LOTS of really good hospital based childbirth classes out there. But you might have to ask around. With an out of hospital birth class, you are more likely to walk away a satisfied customer. Just do some ‘googling’ on childbirth classes. You’ll see what I mean. Hospitals: hit or miss. Private classes: almost always a really good review.

The types of classes I am referring to are “The Bradley Method”, “Birthing From Within”,” Lamaze” (and for some reason a hospital based lamaze class can be hit and miss too, so you still might be better off with an off hospital site class). There are more types of classes, and I’ll let you can find them. There are instructors, like myself, who are ‘independent’, who teach a little bit of everything - combining the best of all of the methods. Out of hospital childbirth classes are usually a bit more expensive. However, at least you know that your chances of wasting your money are a bit more slim. Like I said, most don’t regret taking this type of class. So the next time somebody says “don’t waste your money”, ask them where they took their class. If it was out of the hospital, just look for a different one :-)

More than likely, you will walk away feeling better about birth. I venture to say that most of the women out there who are saying “I’m getting an epidural”, are also afraid. They are afraid of the pain, to the point of - making sure that is what they get. Wouldn’t it be nice to at least walk in to the delivery room without as much fear? Even if you plan on an epidural, at least you know what you are asking for. You’ll understand it’s pros and cons, there won’t be any surprises should you have a side effect from it - and MOST OF ALL: You will walk in the birthing room with confidence. Give it a try, and if you want, comment on what your experience was like! I look forward to ‘hearing’ from you all :-)

Wednesday, March 18, 2009

Preterm labor:

This is a subject that I am quite familiar with, unfortunately. Let me give you quick definition: Preterm labor is defined as the start of labor between 20 and 37 weeks of pregnancy. (Before 20 weeks it's considered a miscarriage, and after 37 weeks, it is normal labor).
It will cause your cervix to dilate and efface. So - nothing to mess around with. I’ll give a quick run down of my experience and then we’ll talk about what preterm labor is, and how it is managed.

With my first baby, I had contractions starting at about 18 weeks. Since preterm labor isn’t managed until about 20 weeks, I was told to only come in if I was bleeding. I laid down and tried to stay hydrated. I had contractions quite frequently from then on, but I figured it was just normal. At 22 weeks, I was visiting with my niece (who had preterm labor with her first baby), and I was telling her about the tightenings I kept getting. She put her hand on my belly, and started timing those ‘tightenings’. She said “that’s a contraction, and they are 3 minutes apart”! She made me go to the hospital, and sure enough, I was already dilated 1cm and 80% effaced. The next 15 weeks was a rollercoaster ride with full bedrest (bathroom privileges only and a shower every other day, and it had to be a quick one!). We had several visits to the hospital when contractions would kick in despite the oral terbutaline. Those visits usually entailed a nice big dose of IV magnesium sulfate, and lots of prayer.

Let me give you an explanation of the two drugs mentioned above.
Terbutaline (brand names are Brethine, Bricanyl, or Brethaire): This drug is actually a bronchodilator (often used as a short-term asthma treatment). It works for preterm labor because it has a derivative of a hormone called epinephrine - which is released when we are under stress. (You know - the “fight or flight” hormone). Stress causes many of our muscles to contract so we can flee danger, and at the same time, it causes the smooth muscles to stop working until we are ‘safe’ again. Since the uterus is made up of smooth muscle, it relaxes. Meanwhile, the rest of you is in “freak out” mode :-)
Terbutaline can be given orally, by injection under the skin (called subcutaneous or sub-Q for short), and in some cases it can be given by a pump.

The most common side effects are:
* jitteriness
* increased heart rate
* tremors

Magnesium Sulfate: I think this stuff is evil. However, it may have kept my my first baby and possibly my second from being born too early. (I refused this stuff after my 4th pregnancy, as the oral terbutaline worked well if I took it every two hours)..

Mag/sulfate works in mysterious ways. Nobody really knows exactly why it works, but the common theory is that magnesium lowers calcium levels in uterine muscle cells. Since calcium is necessary for muscle cells to contract, this is thought to relax the uterine muscle. Seeing as how they use calcium gluconate to reverse the effects of mag sulfate, it kinda makes sense.
It is also used for those who are having problems with pre-eclampsia because it lowers blood pressure and is an anticonvulsant as well.

It is evil because: First they start you off with a bolus. This can make you sweaty, nauseous, make you throw up and feel like you are going to die. Then they level off the dosage. You can’t see, (because you can’t get your eyes to focus), you can barely swallow, your blood pressure drops (so if you have low blood pressure like I do, that’s not fun). It can even make it hard to breathe. I won’t give you the ‘serious adverse’ side effects, just as I didn’t with the Terbutaline. I will tell you that they will take regular blood draws to make sure you don’t get toxic. Let me give you an example of toxic levels:

While pregnant with my first baby I was at the hospital during one of my many stays there, with my very enjoyable (heavy sarcasm) mag sulfate. I was talking a nap (what else to do when you can’t move, and focus your eyes to even watch tv). I woke up from my nap completely confused. I was *convinced* that we were being held prisoner and nobody could get in or out of the building. My husband was in the room with me, also taking a nap. I knew the hospital had changed our names. I started calling my husband by his new name (his name is Ron, but I was calling him Nori - which NOR is just Ron backwards lol). I called.“NORI”!.. NORI! ”, but he didn’t wake up. So than I decided to call him by his old name and I yelled “RON”!. I wanted to know if I was still pregnant, because they changed our names and whatever was wrong with me. I needed help to the bathroom to pee. He helped me in there, and I plopped down on the toilet. I became very upset, and started to cry because I didn’t know my name - old or new. I finally pulled the emergency cord because I needed answers. Two nurses came in running, probably quite frightened that I was giving birth on the toilet. I was crying and said “WHAT IS MY NAME”, “WHAT IS WRONG WITH ME?” The nurse turned my mag pump off. The helped in my bed and called lab up to draw my blood. Yeah, I was at toxic levels. I couldn’t have any more mag for the rest of the day and part of the night.

Another time, I had a much smaller reaction - when my mom came into the hospital to visit me. She woke me up and started talking to me. I couldn’t understand what she was saying. I kept saying “what?” and she would repeat it.. I would ask again to repeat what she was saying, but I couldn’t make sense of any of it. It was like the words were coming in randomly, and then lost the second they came to my ears. I don’t know how long this went on until either someone went and got a nurse, or somebody went to get her. I was in tears because I couldn’t understand the very simple sentence my mom was saying. The nurse thought my mom just made me cry, and put a ‘no visitor sign on the door’, but not long after, somebody realized I was not ‘with it’, and turned the mag off again. I’m just not a big fan of mag sulfate.

In case you are wondering about my other pregnancies the short version is this:
With baby #2, I started dilating and effacing at 28 weeks.. I spent the last 4 weeks dilated to 4cm and 100% effaced. Gave birth at 36 weeks (on the dot) (the day I went off bedrest and meds)
#3- I started dilating at 28 weeks (3cm 80%) - I was 4cm and 100% effaced from at least 34 weeks. gave birth at 35 weeks (zero days) (went to ‘partial bedrest that day, and stayed on meds, but had him anyway).
#4 - I started dilating at 28 weeks 6 days -(1cm 90% and stayed there) gave birth at 36w1day. (The day I went off meds and bedrest)
#5 - I started progesterone cream at 14 weeks (the kind you get at the health food store), my doctor laughed, but told me I could continue it anyway. I started dilating at 33 weeks 2 and 80% effaced). Was 5cm and 90-95% from 36 weeks on. This was my first child that I didn’t go into labor the day I went off bedrest or meds. I delivered him at 38 weeks and 2 days. (I used the progesterone cream until I was 34 weeks).
With #6 - At 33 weeks was 4cm and 80% - at 34 weeks I was 5cm and 90%. Went of bedrest and meds, on Friday, went to hospital Friday night at 11pm.. Gave birth @7am Saturday..the day I turned 37 weeks.

Signs of preterm labor: (Keep in mind you don't have to feel all of these symptoms!)

*Contractions (tightening of the uterus) at a rate of about 6 in an hour.
*Cramping and lower back pain - especially if it comes and goes every few minutes.
*Leaking amniotic fluid from your vagina.
*A feeling like something isn't right. It can be a burp that comes every 5 minutes, or just waves of nausea that come and go.. or pressure that feels like you have to have a bowel movement..

If you have been having contractions, your doctor will give a vaginal exam to see if those contractions have been causing you to dilate or efface. If you have been dilating and/or effacing - your doctor might do one of the following things:

1) The doctor may ask you if you have had any contractions in the last hour. If no - you might be sent home, even if you have begun to dilate and or/ efface. Your doctor might also do a fFn Test (Fetal Fibronectin) to see there is a chance your body will go into labor in the next two weeks. (Note:: Not 100% accurate - is not to be given AFTER a vaginal exam or recent sexual intercourse as it can cause wrong results)

2) Your doctor may hook you up to a monitor in the office, to see if you are having contractions. This usually takes about 20 minutes. If you are having contractions, you will be sent to labor and delivery at the hospital. If you have not had contractions in this time, the doctor may send you home. Perhaps with medication to stop contractions.

3) Your doctor may send up up to the hospital's labor and delivery and have you monitored there, and give you some IV fluids as well. If you are having contractions they will give you medications to stop the contractions. They may give you an antibiotic in case there is an infection somewhere causing the labor. They might give you a steroid shot to help mature the babies lungs. When labor has stopped, and the doc is comfortable with your status, you will be sent home with instructions to come back in if symptoms return.

If you think you are experiencing preterm labor, denial will not make it go away. The sooner you find out what is happening, the better the chances of it getting stopped. Yes, it is scary, but watching a baby fight to stay alive is *much* scarier.
To all of you mothers out there going through what I have been through: You are in my prayers. I wish you all the best!

Friday, February 27, 2009

When will I go into labor?

Many women ask “when will I go into labor”? They will usually say they are so much dilated and/or so much effaced, and would like an idea of when labor day will come. I’m sure that every OB, midwife, nurse, doula and childbirth educator would love to have a scientific answer for this, because somebody would make a lot of money!!

Women like to know how far they are dilated and effaced because it give them a sense of ‘going somewhere’. But for those of you who find you are NOT dilated, or effaced, rest assured that you are not broken. I know women who walk around at 4cm and 100% effaced for a month before they go into labor, and I also know of women who were not dilated at all, and went into full blown labor and gave birth within hours.

It is because there is no magic hour or day that coincides with our dilation and effacement that having a vaginal check may not even be necessary. This especially applies to women who are term and can give birth safely at any time. I’m still up in the air on preterm labor. I do think that if a person is having preterm contractions, it might be helpful to know if they are causing dilation and effacement. It may be a difference between medications and bedrest or not. Some women dilate quite silently without hardly feeling contractions. This is also another case where vaginal checks might be helpful. However, even in both of these two cases, a vaginal check only gives us an idea of what has occurred, and is NOW. It will never tell us what is going to happen and when.

Many women believe that if they are dilated to a certain number, they will automatically be admitted to the hospital - even if they are not having contractions. There are some hospitals that won’t let you leave at a certain number, and there are others that will send home up to 5, 6 and even 7cm if you are not having contractions. Yes, I know a hospital that sent a woman home who was dilated to 7cm. She was not having contractions (or they stopped, I can’t remember). They wanted to admit her and break her water, but she refused and went home. I don’t know all the details, perhaps she even signed a waiver, I’m not sure - but my POINT is that you can be dilated quite a bit, and not go into labor right away. My other point is that not all hospitals will keep you based on your dilation, if you are NOT having contractions. Many hospitals feel quite comfortable sending a woman home who is not contracting at is 4 and even 5 cm dilated.

I have personally walked around at 4 and 5 cm dilated and 100% effaced. I have been 4cm and 100% effaced for 2, 3 and 4 weeks. I’ve been 5 cm for up to 2 weeks. Although, I was on bedrest, and medications, I still managed to stall labor enough to have baby at ‘term’. With my 5th baby, I was 4cm for a week or two. One day I started having contractions and went to the hospital. Contractions were about 9 minutes apart, and after about 3 hours they were 7 minutes apart. They checked me, and I had dilated to 5cm. Two hours later, I was still contracting about ever 5-7 minutes apart, but I had not dilated past 5cm. THEY SENT ME HOME!! With contractions! With a history of giving birth from 5 cm to 10 in 20 minutes.. (With another child I gave birth from 6cm to birth in less than 50 minutes).. I was terrified to leave the hospital, and I could have demanded to stay, but as it turned out, labor stopped two hours after I got home, and I went another 2 weeks until I gave birth...

So if you are dilated, and want to know when you will give birth, there is simply no guessing. If you are NOT dilated, there is no guessing. Neither clearly indicated going early, or going late. Perhaps you can take comfort in the fact that women all over the world are wondering when they too will go into labor. And that every woman who has ever given birth has also wondered. For those of you who think labor will never happen, I know you hate to hear it, but no woman has stayed pregnant forever. Well, except those women with the petrified babies... but that’s another story!

Monday, January 12, 2009

How bad is the pain in childirth?

How bad is childbirth?

This is a question that everyone who has ever thought of being pregnant, or is pregnant wants to know. It is also the question that nobody can describe or explain. Ask a hundred women, get a hundred answers. One woman may not have any pain at all during birth, while the next says she would have died with pain medication. Though I cannot begin to explain what childbirth feels like, I would like to write about the various reasons why women find childbirth to be different.

There are many factors involved in how a woman handles and perceives pain. We all have a certain pain tolerance, when it comes different things. Some women need a dark quiet place with prescription medications to deal with a headache, while another person may take an over the counter medication, and go about her day. We all tolerate childbirth differently. Not everyone with a low pain tolerance, finds childbirth intolerable.. Not everyone with a high tolerance to pain, finds childbirth a walk in the park either. So we know there are several other factors involved here. Tolerance is certainly ONE factor, but it is not to be the sole contributor in childbirth.

The second factor to consider is our expectations. Some women expect labor to be so horrendous, that when they actually go into labor they do one of two things:
~ They either start screaming right away for drugs because they fear what is to come
~Or they end up finding labor so much easier than they thought that they go through labor and delivery without drugs.
Alright, now I know that the two things listed above are not the ONLY scenarios, but it gives you an idea of what I’m trying to say. It’s kind of like this: My husband likes to watch movies.
He likes to critique them. Sometimes he’ll read reviews before he watches the movie. If everyone is giving it good reviews, then he has high expectations. Sometimes, he walks away very disappointed, and can’t understand why the movie was rated so high. This is a huge let down. If he has heard really bad things about a movie, and he watches it knowing not many people liked it, he might be pleasantly surprised. Sometimes it’s better to watch a movie without listening to all the reviews, and decide for yourself. Same goes with labor. Not everyone has the same tastes.

The third factor, coincides slightly with expectations. It is trust. How much does the pregnant mother *trust* herself, and her ability to give birth? More and more, women are excluding themselves from the rest of the women in all of history who gave birth. They are different. Something is wrong with their size, or their shape, or perhaps they have a medical condition that they feel changes their ability to give birth. Their baby is much too big, and their body is not capable. The list goes on. Women no longer trust birth. There are people who literally believe that it is impossible for a woman to give birth without pain medication of some kind. Lack of interest and/or misinformation has caused a huge population of women to loose this simple trust.

When there is a lack of trust, there is fear. When there is fear, there is pain. This has been scientifically proven. I’m not going to go into details here, but most childbirth classes will explain how this works. Just remember: Fear = Pain

Now we are going to discuss the various external things that can cause labor to feel differently - sometimes causing more pain. Let us take a walk into our virtual minds of a hospital room where “Angela” is laboring. Angela is laying on her back in the hospital bed being monitored. The nurse asks her to rate her pain on a scale from 1-10 (ten being the worst pain). Angela says she is at around a 6 on the pain scale. She’s not a happy camper right now. Now, rewind the movie. Let’s go back and change this movie up a little bit. Angela has come into the hospital in labor. She is standing up with her arms around her husband, friend, mother, sister or doula (you get the idea), and during a contraction, she leans into them and hangs ever so slightly while she sways her hips. After the contraction, the nurse asks her to rate her pain. Angela replies “a 3". What do you suppose changed her the ‘feel’ of her contraction? No, Angela has not had any drugs. Read on.

There are several factors involved that explain why she felt worse in bed. First of all, her support was activity involved. They are willing to go the extra mile, and do what it takes to get her through a contraction. They are supporting, and giving her full confidence in her ability to do this the way she wants..naturally. And they are willing to go through a bit of pain to help her.

Secondly, she is standing up and leaning forward through the contractions. Science shows us that when a woman has a contraction, her uterus tilts forward. When a woman lays on her back, the uterus has to fight gravity to tilt forward, so it has to work harder. The uterus is a muscle, and we all know that the harder you work your muscles, the more pain you feel. The uterus is certainly a very strong muscle, and can withstand a lot of hard work. But why put undo stress on it if it can be avoided? The more work it has to do, the harder the feel of the contractions. The moral of this story? Help your uterus do it’s push ups! Stand up, and lean forward.

There are more benefits for standing through labor. All the nerves to the uterus lie in the lower back. These are the ones that tell you when you feel pain. When a woman avoids lying on her back, there is no direct pressure to those nerves, so she feels less pain! Another reason that standing up helps ease the pain of a contraction is oxygen. We know that when we are running, or exercising, oxygen plays in important key to keeping the muscles from being in pain. When you become out of breath, the muscles start to spasm. We know that when we have pushed it too hard, we need to stop, catch our breath, and let our muscles relax. When Angela was laying in bed, her uterus was squishing up more into her chest cavity. Her diaphragm was being squished more, and so it was harder to get all the oxygen she needed to supply her uterine muscle. When standing, Angela’s uterus was able to have more room. This also gave her diaphragm and lungs a tiny bit more space too. More oxygen was able to get to her uterus, and that helped ease the pain a little bit.

Although position is a huge factor in how a woman feels each contraction, there are still many more. A woman needs to feel safe, secure, and cared for (or supported). Her breathing, and how well she can relax makes a huge difference. Are there medications involved? Things that make her feel uncomfortable (monitors, IV’s, etc)? Is she allowed to use a tub, or a shower for pain relief? Is someone rubbing her back and giving counter pressure? How about belly lifting? Applying hot or warm compresses to her belly or back? Can she eat and drink during labor? These things can make natural birth so much more bearable! I could give you more detail on how these other things help during labor, and I could also give you all the information about how our body provides awesome pain releasing endorphins 10x more powerful than morphine, but I’ll save that for your childbirth teacher to tell you.

We cannot strip a woman of every available method of reducing pain, put her in a hospital bed, on her back, and expect her to cope with labor! We cannot have the attitude that this is painful and the pain can’t be reduced by any other means (other than drugs). We need to open our minds to the fact that birth without medications is always better for both mom and baby. We need to start supporting the idea that birth is something ‘do-able’ just as every women in the world did, before the inventions of narcotics and epidurals. Mothers: You can do this!!!