Friday, April 17, 2015

Functioning with Depression

Sometimes when I feel vaguely under the weather, I don't really connect all the random "not-quite-right" feelings into one, "Oh, I'm sick!" revelation right away. "Why am I so tired?" I wonder. "I feel thirstier than usual. What's with that?" "I'm kind of cold." And then someone mentions a virus going around, or another member of my family comes down with something, and it'll click. "I must have a cold!" And then the next day or a few days down the line, the stuffy nose, sneezing, cough, and other hallmarks of the cold will begin, as if by realizing I might have contracted a virus, giving it a name, brings it to life.

But it's only once I've decided, "Yep, I'm sick" and allow the symptoms to crash over me, to rest and up my fluids and behave accordingly, that I can then continue on to recover from that minor illness.

A similar experience happened this week, but it's not a cold I realized I have.

It's depression.

And it took about two months for me to link all my various, vaguely unpleasant symptoms, put them all into a box, and label that box "Depression," but once I did, it made total sense.

I've been seeing a therapist for several months now. I wasn't sure what I needed when I first made the phone call and set up the first appointment, but I knew I needed "something." Someone to talk to, someone to help me make sense of what was going through my mind. I wanted to be a better parent. I wanted to understand myself better. And she has helped me with a lot of those questions.

Then why, I wondered, after starting to feel so much better about life and myself and my parenting, why is it so hard for me lately to just be that person?

Why am I so tired? I mean, sure, the baby doesn't sleep extremely well, but it isn't worse than it's ever been, and it's gotten marginally better, and yet I feel so tired all the time.

Why am I eating all the time? I can't get enough sugar. All I want is pasta and bread and snacks and treats, six times a day.

Why can't I just focus on one task and get my work done? I'll sit down to do 20 minutes of work, and three hours later I'm still working on it. Sure, Facebook is engrossing, and Candy Crush is fun, and, yes, the kids keep distracting me and pulling me away. But even with all of that, why does it take all day to do one simple task?

Why am I so irritable? Every little thing any of my kids does just sets me off on an epic rant. I'm cursing more (I try to hold back the worst of it when I'm around my kids, but I've been letting quite a few more of those words slip through than usual). I yell at the drop of a hat. I don't like it.

Why do simple tasks seem so monumental? I have to do laundry. Ugh. Getting it out of the dryer is so annoying. I'll do it tomorrow. Cooking dinner? Forget it. I'll just make pasta. I have to put a check in an envelope and walk all the way to the end of the driveway to mail it? I'll take it out later.

Why is it suddenly so hard for me to run, when I've been running for six months now? I felt so sluggish, slow, like I had no stamina. I turned to hiking up the hill behind my house and staring out at the ocean instead of doing my interval training and working up to a 5K like I had planned.

Why do I feel so detached? Nothing is interesting enough to bother with. Yeah, I have an idea for a story or novel, but it's too much trouble to actually sit down and write anything. I'd like to read that book, but it's so long and big and heavy. I guess we could go to the park, but it sure seems like a lot of effort to get everyone into the car and all. Go to the beach? Nah.

The thing is, I'm functional. I do eventually get work done. I get the dishes washed and the laundry folded and put away. I go out and run/walk three times a week. I make lunch and dinner for the kids and do the shopping. I pick them up from school and get them to Hebrew school on time. I pay the bills and have been keeping up with the budget. I even took on a little extra work and am getting that done, too, albeit more slowly than I'd like.

That's where depression is so sneaky. It takes up residence in the back of your head and plays with your mind, manipulating your emotions and your memory so you don't connect the dots. There's no stuffy nose or vomiting or localized pain to signal exactly what's going on. There's no telltale rash or high fever to broadcast to you and everyone around you that you're sick.

But you are sick.

Depression is an illness. It's a physical problem just like appendicitis or diabetes. And just like those more obvious diseases, in most cases it is treatable. For some people, psychotherapy alone is enough to help them out of the fog of depression and on the way to normal function. For others, medication helps the brain manage hormones appropriately and regain the chemical balance that lets them recover.

I had my suspicions about two weeks ago, that maybe all of this discomfort was related. When my therapist suggested getting a psychiatric evaluation and discuss medications with a psychiatrist, suddenly I was able to throw all those symptoms into a box and put on that label. And even just doing that has helped me feel better. Just putting a name to it, understanding that this isn't the real me. This is an illness. This is the disease talking. I can manage a disease. I can understand it. And I can control myself better knowing that there isn't something horribly wrong with me as a person, but maybe I need a little help finding myself under this pile of symptoms.

It's so, so important to be able to recognize the signs and symptoms of depression. Depression can be mild, but it can still rule your life in a way you're not aware of. When depression is severe, immediate help is vital, but a mild depression can drag on for months without any obvious manifestations except maybe a little irritability, a little sluggishness, a little, "Huh, I'm feeling kind of...not quite me," and you don't have to let yourself feel that way.

It's only once you identify the symptoms, attach the label, and put it all together that you can begin to find your way out. You may not even realize how poorly you were feeling until you start to feel better.

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Please note that many common antidepressant and anti-anxiety medications are compatible with breastfeeding. Talk with your prescribing physician about options that will work for your situation.

Wednesday, April 8, 2015

Finding the "Yes" on Passover

This week is Passover. It started with the first seder last Friday evening and ends this Saturday after sundown. In the meantime, we, as Jews, are prohibited from eating any kind of leavened bread, along with other restrictions, which is both more complicated and simpler than it sounds.

It does mean a huge disruption to our routine, a change in the way we handle and plan meals, and me saying "no" to many requests for various snacks and favorite dinners.

My kids' spring break from school happens to coincide exactly with Passover this year, which is quite rare. There is often some overlap, but to have the entire holiday off from school is a luxury. Removing the need to pack school lunches from the already complicated week surely helps.

My husband and I want our kids to form happy memories associated with Passover. Rather than dreading it every year because they can't have pasta, rice, sandwiches, peanut butter, and pancakes, we want them to look forward to macaroons, special desserts, the excitement of the seder meals, and other treats.



But the reality is that kids are far more likely to remember the nos than the yeses. They won't remember that we gave them dessert every night and sometimes after lunch, too. They won't remember that we handed out macaroons randomly throughout the day and had bottles of Dr. Brown's Cream Soda on the table at dinner.

What they'll remember is that they couldn't have chips. They couldn't go out to eat. They couldn't have their hot dog in a bun or their meatballs over spaghetti. There's no pizza, no mac and cheese, and we're trying to make them eat way more vegetables than we normally do (because there's nothing else to eat!). And the only vegetables they're guaranteed to eat, peas and corn, are prohibited on Passover.

It's only a week (well, eight days, really). As adults, we know how short a week really is. We're adaptable. We understand the "why" and the "how." We can get creative. We know how hard we're working to provide a fun and interesting time for the kids, to provide good food and meet their needs. But to them, it feels like all we're doing is saying no.

For the first few days, we thought we could manage on just meat, potatoes, and eggs, but it quickly became clear to me that the kids needed something else. They needed some kind of snacky, non-healthy treat. I took them to a supermarket with a decent-sized kosher-for-Passover selection (45 minutes from our house), and we picked out some treats and easy lunch items to ease the "no" aspect. We had chicken franks for lunch today, to their delight. I also found fish sticks that are potato-crusted instead of breaded, which will be great for lunch tomorrow. We got kosher-for-Passover pasta, which is made from tapioca and potato starch and was surprisingly pasta-like in both taste and texture. I bought turkey lunch meat and some packaged snack items. I came home with much happier kids.

Parenting is always a delicate balance of meeting needs, acknowledging wants, and trying to explain that sometimes things are just the way they are. It's looking for opportunities to say Yes when it feels like all you do is say No. It's teaching and learning, giving and taking. None of this is more clear than on Passover.

Tuesday, March 10, 2015

Reflections on Being a Work-At-Home Mom

When I we first made the decision that I would work from home while our kids are young, I had all sorts of fantasies about how I would spend my time.

If I was at home, that meant I could chaperon field trips for school, volunteer in the kids' classrooms, attend daytime events and conferences at school, do activities with the kids like going to the zoo or crafts or gardening or baking, stay on top of household chores and cooking, run errands during the day, be available for homework help and supervision, not have to worry about finding childcare during school breaks and sick days, and save money on babysitting and childcare.

Now that I've been in the work-at-home (WAH) game for eight years (!!), I have mixed feelings about it.

Some of my hopes and dreams for this arrangement have certainly proven true. We have needed far less day care and general child care than we would have if I worked full time. However, I have found that I've needed to make use of babysitters and preschool some of the time, both for my kids' sake and my own. It's hard to get work done with kids in the house, especially when they're toddlers! I tell anyone considering going the WAH route: you WILL need some childcare, so work that into your budget!

Now that I have two elementary school-aged kids, all my plans to help out in the classroom and attend field trips are totally out the window. I discovered that I simply don't want to do those things, even though I theoretically could. Having two little ones still at home with me is part of the problem, because I can't really have them in the classroom with me, but even if I could obtain care for them, or even if they're welcome at a particular event, I tend to avoid volunteering. I also do need some hours at home to get my work done.

I have in the past made an effort to go out with the kids to the park, or take them out for lunch, or set up playdates with their friends on occasion, especially during school breaks. But, I find that I am very set in the routine of working at home. I like to work during the daytime hours as much as possible so I don't have to stay up late working after they're in bed, so I avoid multi-hour outings at mid-day, which is my most productive work time.

I don't like doing crafts. I do like to cook and bake, and I have started including my older two in those endeavors. Baking, especially, offers great lessons on measuring and math, and they seem to enjoy the process. Cooking is a very valuable skill, and they may as well start learning it now!

I do like to run errands during the weekdays. Stores tend to be less crowded, and if it gets done mid-day on Wednesday, then we have weekends free for other things. I do laundry during the day, too, which is super convenient.

Most importantly, though, I am home. If my son gets sick at school and needs me to come get him, I can. If there's a half-day, or conferences, or an early dismissal at school, I'm here and can easily go pick them up. I don't have to scramble for childcare if there's a blip in the schedule, like week-long conferences or the odd day off. I pick them up from school every day and can supervise homework. I can do doctor's appointments during the day or immediately after school, leaving early morning and evening appointments open for parents who have longer work days. I can and do attend their class plays and book fairs and other events.

The biggest downside to being a work-at-home, as opposed to stay-at-home, parent is that my kids don't really get the attention they would get from me if I were not working. Similarly being a work-at-home, as opposed to work-out-of-the-home, parent means my kids are hanging around the house doing nothing instead of being engaged at daycare! It's a bit of a stuck-in-the-middle feeling.

When you work at home, naptime is precious!


If I take time away from my desk to be with the kids, I feel guilty that I'm neglecting my work. I feel pulled toward my computer so I can get more done, bill more hours, earn that paycheck. But if I am sitting at my desk working, I feel guilty that my kids are in another room trying to entertain themselves. I am impatient with them when they interrupt me for needs and wants, and I don't like having to ignore them for stretches at a time so I can finish up my work. It's very difficult to find a balance.

I love my job and the flexibility it offers so that I can be home. But I know that the fantasy I had, of being available to my kids, just isn't the reality I'm living. I'm in a funny in-between place, and it's hard to define my role.

Being at home means I get to see moments like this, when the toddler found a hat and just had to wear it!

I do tend to believe, though, is that my kids will remember that I was there. They'll remember being picked up by (or coming home to) Mommy every afternoon. They'll remember being cared for by me. They'll know I was doing my best to give them what they need while meeting my own needs and the needs of the family as a whole. I do sometimes wish I had a regular office job and they were all in school or daycare all day. I do sometimes wish I didn't have to work at all and I could be a full-time stay-at-home mom. But I think either way I would be in some way less happy than I am now, in this funny in-between place.

Tuesday, March 3, 2015

What Can I Do If I See Car Seat Misuse?

I'm nosy about car seats. I like to know what seats people have. I like to watch them buckle their kids, or unbuckle them, or watch the kids buckle themselves. I like to offer help when a friend is purchasing or installing a new seat.




But when I see misuse out on the street, or in a parking lot at a store, or at school, I'm at a loss. I know those kids aren't as safe as they could be, but they're not MY kids. They're not even my friends' kids, where I might be able to make a gentle suggestion in passing. I am not confrontational by nature, and I am sure that the words of a complete stranger in the Safeway parking lot would not convince someone to change their habits anyway.

There are venues where education and knowledge are possible, however.

Social Media

Share articles, videos, and images about proper car seat use and encourage friends to share them as well. If you do spot misuse in a friend's picture, send a friendly private message (no shaming, no public retribution).

Here's an idea for a gentle message you might send: "Hey, your baby is getting so big and is sooooo cute. I love the little hat he's wearing in the picture you posted! I have that exact car seat, and I had trouble figuring out how the straps should go. I went to a professional car seat installer and got the scoop. I'm not sure if you realize that the straps are supposed to be BELOW the baby's shoulders! My baby kept squirming and getting his arms out until I adjusted the straps. Also, if you tighten the straps until you can't pinch them, then it'll hold him in the seat better. They showed me that if you put the chest clip right up at his armpits, then the straps stay on his shoulders. I can't wait to see more pics of your sweet little one! Let me know if you have any other questions!"

This is likely to be fairly inoffensive, and if you "blame" your observations and information on a professional, then it's not you criticizing, it's you sharing information that you didn't have and that you found useful (even if that isn't precisely true). You may also want to include a link to a neutral third party's article or video (The Car Seat Lady is a great resource, or, of course, this very blog!). Again, the advice isn't coming from you! Just like you might say, "My doctor told us...", saying that a car seat expert told you something will probably have more power and feel less judgmental than if you jump in and say, "Hey, you're doing it wrong!"



Day Cares and Schools

My mom is a preschool teacher and often helps kids in and out of cars in the carpool line. She sees rampant misuse and isn't afraid to speak to parents about how they might improve their car seat use. As a fellow parent, you may not have that ability, but here are some ideas for ways to address misuse among other parents at your kids' schools.

Speak with the Teacher

In some schools, the teachers may not have any authority or may not be permitted to speak to parents about car seat safety. The school may not want to take on the liability for poor advice or risk angering parents with unsolicited information. However, it may be possible to share with the teacher an article or video or website that she or he can distribute to the other parents in your child's class universally, as a interesting bit of information or an issue of safety right alongside fire prevention, first aid, and stranger danger. This way, no parent is singled out, and all parents get good information. You can't control whether the parents read the articles and watch the videos, and you can't control whether they take any of it to heart and make changes, but at least you know you took some action.

Speak with the Administration

Taking things one step further up the line, you can speak to the school administration about school-wide car seat safety. If the administration is open to the idea, you might suggest having the school host a "Car Safety Day" where parents can have a CPST check their seats in the school parking lot. After all, schools often have police offers and fire fighters come to do presentations about safety. Isn't car safety equally important? (After all, car accidents are one of the leading causes of death and injury to young children!)

You may also be able to suggest that the administration to issue a newsletter or memo or include an article about car seat safety in their regular bulletin.

Direct Confrontation

If you have any rapport with the fellow parent you're concerned about, you may be able to confront them directly. As in the social media example above, though, try to be kind, nonjudgmental, and helpful. "Hey, can I show you something about your car seat?" will obviously go over much better than, "Your kid is buckled wrong." Whether you choose the direct confrontation method is dependent on your own personality, the relationship you have with the other parent, and the type of person that parent is. You may be pleasantly surprised to find that he or she is open to your information, or you may find that they shut down. If you truly don't trust this person's car seat safety commitment, then, at the least, don't let your child ride in their car.



Out in Public

I unfortunately see a lot of misuse in stores and parking lots where the fellow parent is a total stranger. I have never personally approached anyone to comment on their car seat use, but there have been times where I've been tempted. If you can establish some kind of friendly contact with the person before mentioning their car seat, your information is likely to go over better. If you feel obligated to convey the information regardless, be aware that the other parent may ignore you, become angry, or argue back.

I had an experience a few years ago with a woman when I stopped into the bank to make a deposit. This experience - as the one being "advised," not the one doling out tips - gave me a lot of insight into how it feels to be approached by a stranger out of the blue.

If I were the one making a safety mistake - willingly or not - how would I want to be approached? Probably in a similar way to methods I've listed above. I'd want the person to be friendly, "on my side," and nonjudgmental. I'd want to feel that that person genuinely had my kids' safety at heart and not merely a need to feel like a superior parent. I'd want a chance to respond, ask questions, and make my case. And I'd want to leave the encounter smiling, not fuming.

Start off with a simple greeting. A smile and a friendly "hello" are always a better opener than, "You shouldn't." Use "I" statements: "I noticed..." "I was concerned..." Most importantly, don't accuse or judge! Parenting is not a competition. You are not a better parent because you know something about car seats that someone else doesn't.

I think it's important to understand that a random encounter with a stranger is probably not going to change anyone's mind. But if you give them the information and they have it confirmed by other sources, at least you planted the seed.


Do you have suggestions for addressing car seat misuse in various venues? Have you successfully approached or been approached by someone about a safety issue? In what context? Please share your experiences and your tips here in the comments or on the Facebook page!

Thursday, February 19, 2015

Vaccines Keep Our Kids Safe

The measles outbreak traced to Disneyland this winter has created a great resurgence in the "vaccinate or do not vaccinate" debates that surface relatively often in parenting discussions. The media has been covering different angles, from encouraging everyone to get their shots to heart-rending stories of children purportedly injured by a vaccine. It's a hot topic.

I did an Ask-Me Monday video on vaccines a couple of months ago, coincidentally just before the Disneyland outbreak. (See it here.) Predictably, people who are against vaccines sought out my video so that they could pick a fight. I chose to engage calmly, state my opinions, and be done with it. I know that throwing facts at people doesn't change their minds. Indeed, there have been studies on this very topic, and the more you argue, the more people dig in their heels.



The vibe I get from parents who are genuinely concerned and thoughtfully considering whether they should consent to having their children vaccinated - as opposed to being solidly in the "anti-vaxxer" camp - is that they are trying to keep their children safe. They hear stories of children who suffered brain damage, organ damage, or death from a rare reaction or complication of receiving a vaccine. They don't want to take the risk for their own children. The word "autism" gets tossed around. We see link after link to blog posts and opinion pieces about how we're all being duped by the pharmaceutical companies, how there's a great conspiracy in the FDA and the CDC to force all of us to be injected with poison, and how a child was perfectly healthy and typical before they got the DTaP or the MMR shot, and afterward showed signs of brain damage or a blood disorder or had uncontrollable seizures.

Well, obviously we don't want to become involved with or duped by government conspiracies! And don't you know that there's formaldehyde in those shots?!

What no one bothers to say when making these arguments is that there's another side. There's the parents whose newborn babies were exposed to measles or whooping cough because of an unvaccinated child in their community. There are the children who contract these diseases and become severely ill and spend weeks or months in the hospital. There are the babies who die a slow, horrible death wracked by rib-cracking coughs until they turn blue from lack of oxygen and suffocate in their own mucus. There are the children left paralyzed by polio or suffer encephalitis from measles. There are the women who lose pregnancies because of rubella infection.

Underneath all the sob stories and "what if's" are parents who are just trying to figure out what is best for their own children. How do we protect our kids and our families? What should we be afraid of? What are the real risks?

I'm going to take this discussion outside of vaccines to look at a bigger picture. There is risk in everything we do every day. Indeed, one of the riskiest things we do every day with ourselves and our children is drive our cars. Did you know that car accidents are one of the leading causes of death and injury for children? Car accidents. But I bet most of you put your kids in the car almost daily. I know I do. School and daycare drop-offs and pickups, shopping, errands, visiting friends, grabbing a bite to eat, playdates, road trips, vacations, all sorts of reasons to get in the car.

And do you, each and every time you get in the car, double check that your kids are in appropriate child restraints, installed and buckled correctly? Do you take your car in for regular maintenance? Are your brakes and tires in good repair? Do you have a hands-free device for your cell phone, or do you put your cell phone away while you drive so as to avoid distractions? Do you glance in your mirrors and check your blind spot every time you change lanes?



So, what if we decide the risk of driving is too high and we stay home? There's a risk of earthquakes or windstorms. In the winter, ice could bring a tree branch down on your house. If you live in tornado country, you could end up trapped under the rubble of your home. If you live in the hurricane zone, another Katrina could turn your life upside down. You could forget about the pot of soup on the stove and set your house on fire. You could slip in the bathroom and hit your head on the toilet and knock yourself out.

Things can happen anywhere. And we can't live our lives in fear. It's impossible to account for every possible scenario. It's impossible to be completely, 100% safe, all the time.

So, we do the best we can with the information we have. We weigh the risks and benefits as we understand them. And if doing something has risk and not doing something also has risk, it is very hard to choose. But if the goal is to keep our kids as safe as possible, it's important to do what we can to minimize risk in all situations. Like buckling them correctly in a properly installed, appropriate car seat when on the road, and having them wear a helmet when they ride a bike, and putting a fence around the pool.

When it comes to medical procedures, and vaccines specifically, certainly, it is much easier not to do something. The passive route feels less risky. If I don't give my baby this injection, then it can't hurt him!

It's important, then to consider the other half of the equation. If you don't give your child this injection and he contracts measles, say, through contact with a tourist at Disneyland, then measles can hurt him. And not just him. Measles can affect him, and his siblings, and his cousins, and his friends, and his friends' families, and their friends, and at some point, someone will die. Maybe it won't be your kid. Maybe your kid will miss two weeks of school and recover and that's the end of it, and you'll be relieved that everything is fine. But maybe some other baby down the line of contagion isn't so lucky.

And if you do give your child that injection, and you go to Disneyland and come in contact with a tourist who is carrying measles, and your child doesn't get measles, well, then clearly you made the right choice in getting that shot!

It's not simple. And yet, it is. Because if we look at the research, at the documented risks, at the statistics, it becomes clear that the risk of contracting a disease, and the risks of complications from that disease, are higher than the risks associated with the vaccine. If we look past the sob stories and the fear-mongering and the impassioned pleas, if we look at the cold, hard facts, at the science, it's purely, radically simple.

Vaccinations work.

Protect your children and all of the people your children come in contact with every day.

Get vaccinated.

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Statistics:

Complications of measles:
http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#complications
Note: 30% of measles cases experience some complication, such as diarrhea, ear infection, or pneumonia. Pneumonia is the leading cause of death from complications of measles. The risk of death from measles is 0.2%, or 2 in 1000.

Adverse reactions to MMR Vaccine:
http://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#adverse
Note: 5 to 15% of susceptible persons may develop a high fever but be otherwise asymptomatic. As for serious complications, 1 in 30,000 may develop thrombocytopenia (a blood disorder in which blood does not clot), but the risk of thrombocytopenia due to measles infection is much higher than the risk of thrombocytopenia due to the measles vaccine. Other risks are so rare as to almost be incalculable.

Yes, it is possible to have an adverse reaction to a vaccine. It's important to acknowledge that. But it is far, far more likely to have complications from the disease itself.

Thursday, February 5, 2015

Childbirth Choices Series Part VI: Labor and Delivery

This is the sixth and final article in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

Previous articles in this series:

Part I: I've Just Found out I'm Pregnant; Now What?Part II: Meeting Your Care ProviderPart III: Do I Need a Doula?Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!


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Welcome to the sixth and final installment of the "Childbirth Choices Series"! You've made it! Your pregnancy is nearing the end; you're finally going to meet your baby after nine long months. But first there's that pesky labor and delivery thing to get through. While your care throughout your pregnancy can and will affect your health and your baby's health, it's the birth experience itself that is likely to leave the most lasting impression on your and your child, both physically and emotionally. The experience of birth is profound for most women, no matter how your baby is born, and being informed and educated about the process and your options in advance will help you achieve the healthiest possible outcome, whatever that looks like to you.

This article is admittedly quite long. There's a lot of important stuff to know about labor and birth. Feel free to scroll down to find sections of interest to you, or simply read straight through to get the whole story at once.

What is a Birth Plan? Do I Need One?

Your care provider may ask you if you have a birth plan, or you may come across the term in your own reading and research. A birth plan is simply a written record of the way you hope your birth will play out and your preferences when certain decisions have to be made. It can be as simple as, "Get the baby out" to as complicated as a several-page document outlining every possible scenario and what your choices are in any given situation. You don't have to write a birth plan at all. It is not a legal or binding document. But it can be helpful to write down your desires in advance, or at least think them through, so that you have an idea of what you want before you're in the immediate excitement of labor itself. It can also be helpful to clearly express your preferences to your care provider in advance to make sure he or she is going to be supportive of your desires. See my article on birth plans for more information and an idea of what you might want to include in yours. You can also search the internet for fill-in-the-blank birth plans that may help you consider options you may not have thought about. Be aware that sometimes crazy things happen or things go way askew and you may have to toss the birth plan for the health of mother and/or baby, but knowing your options and rights is still better than going in blind.

Find out Your Baby's Position

A subject that is not discussed enough in preparation for birth is your baby's position in the womb. Most people know that it's best if the baby is head down for delivery. If a baby is not head down, that is called "breech" presentation. There are several possible breech positions. In some of these positions, such as transverse breech, where the baby is horizontal across your body, it is not possible to safely deliver vaginally and your provider will schedule a c-section to deliver your baby. In others, most notably "frank breech," which is when the baby's bottom is pointed toward the cervix, with the legs folded up, it may be possible to deliver vaginally if your provider is trained in the process. If your baby is breech as your estimated due date approaches, discuss your delivery options with your CP!

While most people know that the baby should be head-down at delivery, there are other positioning issues that I want to bring up. The best scenario is if your baby is head down with his or her face toward your back, with the chin tucked down toward the chest. This is called "occiput anterior (OA)" (the back of the head toward the front of the mother). The occiput is the narrowest part of the head, and it is easiest to push a baby out if that part of the head comes first! This is not to say that it is impossible to deliver vaginally if your baby is "occiput posterior (OP)" (the back of the head toward the back of the mother), but it will be more difficult. If your baby is OP, labor may stall, last longer, or not progress at all, and even if you get all the way to the pushing stage, it may be more difficult for the baby to get through the birth canal and you may experience more tearing of the perineum or vaginal canal. You may also experience back labor, which is when contractions are felt in the lower back. This is typically more painful and difficult to manage than more standard contractions, which are felt in the lower part of the abdomen. Plenty of babies are born posterior with no major complications, but for the smoothest possible birth, occiput anterior is ideal. 

While your care provider will certainly discuss with you whether your baby is head-down, he or she may not mention or even know whether the baby is posterior or anterior. Some providers can tell by touch, while others can take a peek with an ultrasound machine. If you are concerned, you can try to figure it out for yourself! Check out the website www.spinningbabies.com for more information about positioning and exercises you can do before and during labor to help your baby settle into an optimal position for delivery.

Being mobile toward the end of your pregnancy and during labor is very beneficial for promoting healthy positioning and a smooth delivery.

How Do I Know if I'm in Labor?

This is the big question, of course! Most women do end up in spontaneous labor, meaning your body starts labor without help from medications or interventions. The experience of labor will vary from woman to woman and even pregnancy to pregnancy, but it does follow a basic pattern for most people.

In about 15% of pregnancies, the bag of waters will break before any labor contractions begin. Despite what you see in many sitcoms, however, most women do begin having contractions before their water breaks. If your water breaks and contractions do not start within 12 to 24 hours, call your care provider to find out what you should do. If your water has broken, do not put anything in your vagina or take a bath or do anything else that may introduce bacteria into the vaginal canal, as this puts you and your baby at risk of infection.

Some other signs that labor may begin soon:
  • The loss of your mucus plug: Over the course of the final weeks of your pregnancy, you may notice gobs of mucus when you use the toilet. The mucus plug has closed up the cervix during your pregnancy to prevent foreign substances and infectious agents from entering the uterus. This has to fall out before your baby can be born.
  • The "bloody show": You may see mucus streaked with blood in your underwear or in the toilet. This usually indicates that labor will begin within the next few hours or days.
  • Your baby "dropping": You may notice that your baby is sitting much lower in your abdomen than in the previous weeks. For some women, this happens several weeks before labor, but others may experience this in the hours leading up to labor. This also depends on whether it is your first pregnancy. Babies tend to drop earlier in a first pregnancy than in subsequent ones.
  • "Nesting": You may feel a burst of energy and the sudden desire to clean, bake, or organize. You may feel agitated and the need to take care of things, especially things related to the baby, such as washing all the baby's clothes or rearranging the nursery.
  • Loose bowels: Often your body starts getting ready for labor by emptying your bowels, and you may experience diarrhea-like symptoms or very loose bowels and intestinal cramping.
But labor hasn't really begun until you're having contractions! You have probably already been experiencing strong but typically not painful contractions called Braxton-Hicks contractions. Labor contractions are stronger and more painful than Braxton-Hicks contractions and are more regular. Early labor contractions may feel like very strong period cramps. Many women in the last stages of pregnancy report that they feel much like they do in the days leading up to their period starting. These contractions differ from Braxton-Hicks in that they will not stop with activity, rest, or fluids. Your provider will probably tell you to call when your contractions are lasting about one minute (timed from when it starts to when it is over) and occur about every five minutes (timed from the beginning of one to the beginning of the next). There are several apps you can download for your smartphone that can help you time and record your contractions, if you're nervous about keeping track of it yourself. If you begin to experience regular contractions, try drinking two full glasses of water and taking a 15 to 30-minute walk and then lying down on your left side for a little while to rest. If the contractions continue or become more intense, you are likely in labor, and the walking and hydration will be great for helping labor along. If they subside, you may be experiencing what is called "prodromal" or "false" labor. If the contractions do die down or become less intense and frequent, take the opportunity to get some rest. Labor will come soon enough, and it's hard work! 

In the early stages of labor, your contractions will be painful but probably manageable. That is, you will still be able to walk and talk through them. You may try taking a hot shower or a long walk to cope with the early contractions. Don't over-exert yourself, and stay hydrated. Eat if you're hungry. Many women lose their appetite or even feel nauseated as labor progresses. Move in ways that feel good, lie down or sit down in positions that feel more comfortable and relieve some of the pressure. If you have a yoga ball, bouncing on that can be soothing as well. Having someone massage your lower back can feel great. Try getting on your hands and knees or into the yoga position called Child's Pose. Squatting helps to open the pelvis and allows the baby to move downward toward the cervix.

What Does a Contraction Feel Like?

It's difficult to describe a contraction if you've never experienced one, but I'd hate to say, "You'll know it when you feel it" and leave it at that! Milder contractions may feel similar to period cramps or intestinal cramping. You may feel like you need to go to the bathroom urgently, but when you go to the toilet, nothing comes out. As contractions build in intensity, you will feel a tightening in your lower abdomen. Usually, the pain starts in the lower part of the abdomen, and then as the uterus tightens, radiates upward through your belly. It may feel like you are clenching your stomach muscles, but you can't make them unclench. If you place your hand on your abdomen, you should be able to feel your uterus contract and then release as the contraction passes.

At the height of a strong contraction, you may find it difficult to breathe, talk, or walk. It may help to moan or hum during the contraction to help keep yourself focused. Screaming or yelling is usually less effective, but if you feel the need to yell or scream, you have my permission to do so! You may also want to grip something - a popular choice is your partner's hand!

When Do I Call My Provider?

Your care provider will give you an information sheet with instructions on when and who to call if you think something is wrong or you suspect you are in labor. The typical recommendation is to call when your contractions are lasting for one minute and coming every five minutes for at least an hour. When your contractions are strong enough that you have to stop whatever you're doing and can't talk during one, it's probably time to call! However, some women's labors don't follow this exact pattern, so if you strongly feel you are in labor or have any questions, don't hesitate to call. Your CP will listen to your concerns and give you advice on what to do. If it's after hours, you may be instructed to call the hospital (if that's where you're delivering) labor and delivery unit directly to speak to the triage nurse there. She can also give you some tips on how to tell if you are in labor or whether you should come on in to the hospital. It's usually good to call ahead just in case, so they can prepare a room for you and assign you a nurse.

When Do I Go to the Hospital, and What Will Happen When I Get There?

This section assumes you are delivering at a hospital, which is true for about 99% of births in the United States. 

The earlier in your labor you are when you arrive at the hospital, the higher the likelihood of interventions. For most first-time mothers, labor lasts many hours, and you don't have to go to the hospital as soon as labor starts. Some women do experience very quick labors (defined as under three hours), but it is unusual. Staying at home, in a comfortable and familiar place, can help you relax, manage early labor on your own, and allow you the freedom to move around, rest, eat and drink, shower, take a bath (as long as your bag of waters is intact), go shopping, or whatever seems like a good idea! If you have hired a doula, she can come to your house to be with you while you labor and can help you decide when it's a good time to go to the hospital.

If you are at all high risk and have been told to be at the hospital at the earliest signs of labor, then please heed that advice!

Some women are more comfortable being at the hospital. If that is the case for you, be aware that many hospitals won't admit you to L&D until you're clearly in active labor, usually at 3 to 4cm dilation. 

When you arrive, they will have you undress and put on a hospital gown and will hook you up to two monitors - one that measures the baby's heartbeat and one that measures your uterine contractions. These are attached to elastic bands that are wrapped around your belly. With these, they can "watch" the baby to make sure he or she is tolerating labor and they can see how often and how strong your contractions are. A nurse will check your cervical dilation by inserting her gloved fingers into your vagina. If your labor is not far along, they may suggest that you go home and allow labor to progress for a while. If your contractions are strong and regular and your cervix is dilating, you will be admitted.

They will probably take one last urine specimen and do a blood test. They may ask to insert an IV, or at least a hep lock or saline lock, which would allow them to attach an IV bag at some point in the future without having to insert the tube during a crisis. If you are Group B Strep positive, they will use the IV to administer antibiotics. You can also receive fluids via IV to prevent dehydration. The IV can be used to give you Pitocin or narcotic medication. You are within your rights to refuse an IV if you feel it interferes with your birth plan, or you may find it reassuring to have an IV ready to go in case it is needed.

They'll also have you do some paperwork. You probably filled out some kind of preregistration for the hospital so they'll have some information about you on file already. You will probably have to fill out some more forms when you get there, including insurance information, emergency contacts, and admission notes such as your religious preferences, food service needs, and so on. They'll get your medical history and information about this and previous (if any) pregnancies. You will also be asked to sign certain consent forms for medical treatment, which may include consent to use medications in labor and consent to c-section if the provider deems it necessary. Read through what you're signing, or ask to have it explained to you. It is important that you understand what you are agreeing to!

The Stages of Labor

Labor is typically divided into three general stages.

Stage One is the process of your cervix dilating, which is what we generally call "labor." It begins with the first phase, which is the early hours of labor as your cervix begins to dilate, until you reach about 4cm. Next is active labor, where your cervical dilation will speed up, contractions will become more intense and possibly more frequent, and your cervix will dilate to about 8 or 9cm. This second phase can take many hours in a first-time labor. The third phase is when you reach full dilation and enter transition.

Transition is when you switch from laboring to open the cervix to laboring to actually get the baby out. Transition can involve symptoms such as shaking, nausea and vomiting, screaming and yelling and thrashing about, shouting obscenities or cursing at your partner or your birth team, sweating, and other somewhat disturbing reactions. These are all normal and will be familiar to a competent birth team, though they may be frightening to you! Transition usually happens quickly, and brings you to the second stage of labor.

Stage Two is actually pushing out the baby. You will feel a strong need to push, which may feel like having a large bowel movement. Your provider or nurse may want to do a cervical check to ensure that you are fully dilated before you begin to push so as to avoid the cervix swelling up and preventing the baby's exit. Some babies come down slowly as you push, while others slide right out. The length and difficulty of the pushing stage can be affected by your position as well. If you are mobile, pushing in a squatting position or on hands and knees may be more effective for you than lying reclined on the hospital bed with your legs up. Once the baby is out, you go into the final stage.

Stage Three is the process of shrinking the uterus down and expelling the placenta. This usually happens without too much additional effort on your part, although you may need to push slightly or allow some uterine massage. Once you have delivered the placenta, labor is over, and the postpartum period begins. 

Let's talk a little bit about some of the decisions you'll need to make during labor.

Fetal Monitoring

You will most likely be asked to wear fetal monitors for most or all of the time that you are laboring in the hospital. In a home birth, your midwife will listen to the baby's heartbeat regularly but not continuously. In a hospital, the monitors strapped to your abdomen will feed information about the baby's heartbeat and your contractions directly to the nurse's station so that your nurse can see what's happening at all times, even when she is out of the room. A sudden deceleration of the baby's heartbeat (if the baby's heart rate suddenly slows down or stops) can indicate fetal distress and may mean there is an emergency situation. Typically this is caused by the umbilical cord becoming compressed or twisted. These decelerations can often be managed by changing your position to untwist or free the cord and by taking in extra oxygen through a mask to ensure the baby is getting enough as well. 

"Continuous fetal monitoring" means that you wear the monitors the entire time you are in labor. Many hospitals and providers require this. If it is not required, you may want to request "intermittent monitoring", which means that you will wear the monitors for 20 minutes every hour to check on the baby but will otherwise be mobile. This will allow you to walk around, change positions, use the bathroom, or take a shower (if available). Continuous monitoring limits your movement. If you receive an epidural, you will be immobile anyway and will probably require continuous monitoring.

Sometimes your provider will ask to use internal fetal monitoring. This is uncommon and involves inserting a wire through the cervix and attaching a monitor directly to the baby's head. This is used when a reliable reading is not possible with an external monitor. Internal fetal monitoring carries many risks that rarely outweigh the benefits. Ask your provider why he or she is recommending this course of action and if it is necessary for your health or the safety of your baby.

Non-Medical Pain Relief

Learning some strategies for managing the pain of labor without medications is valuable. Even if you are certain that you will request medications at some point, delaying these medications is typically associated with healthier outcomes. I discussed some of these techniques above and will go into more detail here.

Breathing: It may sound silly, but controlled breathing during a contraction can help you tolerate the pain and then release the tension once the contraction is over. Blowing air out will force you to inhale deeply and ensure that you continue to breathe regularly, rather than holding your breath and increasing the stress you are putting on your body. Think about what you do when you stub your toe. You rub it and breathe rapidly and loudly to try to dispel some of the pain. In the same way, breathing - and concentrating on the breathing rather than the pain - can help you get through the contraction and prepare you for the next one. It's helpful to try to relax as much as possible between contractions.

Movement: Find a position or movement that makes the contraction as comfortable as possible. This may mean standing up and swaying, bouncing on a yoga ball, kneeling beside the bed, squatting, getting up on your hands and knees, getting into Child's Pose, lying on one side or the other, leaning against a wall, or some combination or variation. It's okay to sit up, lie down, stand up, kneel, dance, walk, squat, lean, hug your partner, or whatever feels good. You don't have to spend your entire labor lying flat on your back. Indeed, you shouldn't!

Warm Bath or Shower: Warm water can be soothing, and sitting in a warm bath or standing in a stream of warm water in the shower may help dull the sensation of pain and help you relax. You may use your bath or shower at home, and if you have the option to use one at the hospital or birthing center, you may be interested in taking advantage of it.

Massage and Counterpressure: Especially if you are experiencing back labor, having someone massage your back or even use tennis balls to provide counterpressure during a contraction can lessen the pain of the contraction. A massage between contractions can help you relax as well.

If you have a doula, she may have other tools at her disposal to assist you, such as essential oils, aromatherapy, massage techniques, and equipment that she specializes in using.

Medical Pain Relief

There are basically three types of medical pain relief you may be offered.

Gas: While common in other countries, few hospitals and care providers in the United States offer nitrous oxide (like what you might get at the dentist) to help you relax during labor. It is becoming slightly more common, however, and you may be interested to ask your provider if gas and air is available to you.

IV Narcotics: Your care provider may offer you narcotic pain relief via your IV. Ask which specific medications are in the narcotic mix they offer. There are pros and cons to using narcotic pain relief. It can be an effective short-term option to help manage contractions without getting an epidural. The effects of one dose last about 60 to 90 minutes, and the dose can then be repeated if desired. It may be a welcome break from the pain and you may feel dreamy, happy, high or sleepy while the medication is in effect. The risk of taking the narcotics is that the baby will receive some of the drug through the umbilical cord, and if you deliver the baby while the medications are still in your system, your baby may be sleepy or lethargic at birth, which is not desirable. If you would like to try the narcotic pain relief, it's best to get it early enough in labor that it will wear off before you deliver.

Epidural: The epidural is an extremely common method of eliminating the pain of labor. The majority of hospital births in the United States involve an epidural. It is very effective at blocking the pain while allowing the contractions to continue so that you can, in theory, painlessly (though not effortlessly) birth your baby. But the epidural is fraught with controversy, and rightfully so. I'm going to spend some time here discussing epidurals, because I believe it's important to make an informed choice, and many providers gloss over some of the risks.

First, what is an epidural? An epidural is an injection of medication into the space just inside the spinal column, outside the dura, which is a layer of tissue that surrounds the spinal fluid. An anesthesiologist will insert a needle between two of your vertebrae and into the epidural space. The needle will be attached to a tube which will be fed a short way into the epidural space, and then the needle will be pulled out. The tube will be supply anesthetic medication directly into the epidural space continuously for as long as you want pain relief (typically until labor is over). The medication works by blocking pain signals to the brain. You will probably still feel the pressure of the contractions, but they should not register as painful.

In order to administer the epidural, you will be asked to sit up on the edge of the bed and hunch your back in a C shape. This allows the anesthesiologist to feel for the space in which he or she needs to insert the needle. You will need to hold as still as possible during the procedure, which is difficult while having contractions, but an experienced anesthesiologist understands this and should be quick. Once the tube is in place, the anesthesiologist will tape it down so that you can lie back without worrying about dislodging the tubing. The medication will begin to flow and can take up to 15 minutes to take effect. You will need a urinary catheter because the epidural will make you unable to pee on your own. They will adjust the medication as necessary so that you feel no pain but can ideally still move your legs and feel the urge to push when the time comes.

There are documented direct risks of epidural, most of which are small or fairly easily managed. The most significant risk is that of a drop in maternal blood pressure. Your blood pressure will be monitored, and if it drops too low, you will be given fluids via IV to raise your blood pressure back to a safe level. If your blood pressure drops, blood flow to the placenta may be reduced, which would cause distress to the baby. It is important to monitor maternal blood pressure and fetal heartbeat to ensure that both mother and baby are safe. 

A second small risk is that of epidural headache, which is quite rare and occurs if the dura is accidentally punctured during insertion of the epidural needle. The headache will usually clear within a week or two.

Tenderness or bruising at the insertion site may occur and will heal on its own.

My concerns with epidurals have more to do with the indirect or secondary risks. While research shows very low risk to mother or baby with epidural and does not show a correlation between epidural and c-section, there are secondary effects or consequences of epidural that you should be aware of.

I have stressed above that being mobile in labor can be very important for your comfort and to assist the baby in his or her descent through the birth canal. Once you have an epidural, you will be confined to your hospital bed, lying reclined on your back. For some women, this can slow or even stall labor. Additionally, you will have to push in this position, with your legs up in stirrups or held up by your or birth attendants' hands. This position is not ideal for pushing out a baby, because you are working against gravity and your pelvis cannot open as wide as in other positions. Depending on the size of your baby's head and the position of your baby, it may be more difficult or take longer to push out the baby. Indeed, epidural is associated with a lengthened pushing stage. You may risk increased tearing or require an episiotomy or other intervention such as forceps or vacuum extraction when delivering in this position, which I will discuss in more detail below. If the epidural is particularly strong, or you react strongly to the medication, you may find it difficult to push effectively, which will also lengthen the pushing stage.

A lengthened labor and poor position may lead to a suggestion of augmenting your labor with Pitocin to speed things up, which carries its own set of risks. I will discuss Pitocin in more detail below.  

If the epidural causes your blood pressure to drop, which is fairly common, you will be given extra fluids via IV to bring your blood pressure back up. If your labor is long, you could receive upwards of 5000cc (that's five liters) of fluids. All this extra fluid has to go somewhere. Some of it will go to the baby, which may artificially inflate the birth weight. After birth, the baby will quickly shed this extra weight, leading to concerns about whether the baby is getting enough to eat. The rest of the fluids will go to your hands, feet, and breasts, which will cause swelling until you can pee out the excess fluids. This swelling of the breasts, especially, can make it difficult for your baby to latch and remove milk, delaying the increase in milk production that should occur by the third day postpartum and possibly having long-term effects on your milk supply. There are techniques to mitigate this problem, most notably "reverse pressure softening," which you should be aware of if you choose to have an epidural and require extra fluids.

Finally, while the epidural medication is not likely to affect the baby strongly, some babies born to mothers who chose an epidural do appear more lethargic, sleepy, or less responsive compared to babies born without medications. This sleepiness or lethargy may make it difficult to initiate breastfeeding and keep the baby awake to receive feedings during the first several hours or days of life. As the medications work their way out of the baby's system, your baby should perk up and be fine. I think it's important to be aware of the ways in which epidural can impact early breastfeeding, as many women do wish to breastfeed and are not informed of these potential difficulties or how to manage them.

While for some women, epidural does slow labor, possibly due to inactivity, immobility, or position, others find that they are unable to release the stress caused by the pain of the contractions, and once they receive an epidural and can relax, their labor progresses more steadily. If you feel exhausted, overwhelmed, or frightened, getting an epidural may be a good choice for you. Keep in mind the possible complications or risks, but you should feel comfortable choosing one if you feel it is the right decision for you.

Augmentation of Labor/Pitocin

If labor is slow to start, starts and stops, or is not progressing as quickly as your provider would like, it may be suggested that your labor be "augmented" with Pitocin. Pitocin is a synthetic form of the hormone oxytocin, which is naturally produced in the brain. Oxytocin is released during sex, prolonged physical touch, breastfeeding, and labor. During labor, it specifically stimulates uterine contractions. Giving synthetic oxytocin (Pitocin) through your IV can help to increase the frequency and strength of your contractions. Doing so may also help get labor started if an induction of labor is deemed necessary.

The effect of Pitocin is increased contractions. The contractions tend to be stronger, more painful, and more frequent than non-augmented labor. This can be effective for opening your cervix and moving labor along, but it can also be intense and difficult. Many women opt for an epidural after receiving Pitocin.

There are risks to Pitocin which your provider may or may not discuss with you. 

Pitocin use is associated with higher risk of uterine rupture. (For this reason, it is often not recommended for VBAC, although it may be administered in low doses in certain cases.) It is also associated with postpartum hemorrhage due to hyperstimulation of the uterus. For the baby, Pitocin increases the risk of jaundice, and may contribute to fetal distress in labor due to the strength and frequency of the contractions. Fetal distress may lead to emergency c-section. As mentioned previously, even if a laboring mother had intended to give birth without pain medication, she may opt for an epidural after being given Pitocin because of the increased intensity of the contractions. (This is not to say that it's impossible to give birth without pain relief if you're given Pitocin, only that some women find it more difficult to bear.) In this case, the additional risks of epidural would apply.

It can be difficult to know whether a Pitocin augmentation is truly necessary. You'll need to consider whether your labor is progressing at all (Are you having regular, strong contractions? Is your cervix dilating, even slowly?), whether you've tried other means to encourage labor to progress (Have you taken walks, tried nipple stimulation, changing positions?), and how long you've already been in labor (Have you been having regular contractions for three or four days now? Are you exhausted? Is your baby tolerating labor?). Many doctors will begin to pressure you to speed up your labor after you have been at the hospital for over 12 hours, either because they need the bed emptied or because they genuinely believe that labor shouldn't last that long. However, many women experience healthy labors and births that last considerably longer than 12 hours, so this is an artificial limit that you are not obligated to meet! This is why I and many other normal birth advocates strongly recommend that you stay at home during the early hours of labor and let your labor progress naturally for as long as possible so that you don't end up on the hospital time table.

There may be emergent reasons for needing to birth your baby quickly, such as the onset of fever or distress that require immediate delivery vaginally or an emergency c-section. Pitocin can be very helpful in such a situation so that you can avoid major surgery, if desired.

Being aware of the risks and benefits of the use of Pitocin before you go into labor can help you decide if you will consent to using it if the option is presented.

Breaking of Waters

Your care provider may offer to move your labor along by breaking your bag of waters manually if it has not broken on its own. There is no way to predict at what point the amniotic sack will rupture. Some women (about 15%, as stated above) experience a rupturing of membranes before labor begins. For others, the water breaks somewhere in the middle of the labor. For some, the water breaks just before or during transition. And in rare cases, the baby is actually born inside an intact amniotic sac - called being born in the caul, and the sac must be broken after the baby is birthed or as he crowns!

It is believed that rupturing the membranes can speed up labor and increase the frequency and strength of contractions without the use of medication. It is not clear if artificial rupturing of membranes in fact decreases the length of labor, however. It has become so routine to break the waters that many providers may suggest it simply as a matter of course, believing that there is no great risk to doing so.

Because it is so routine, you may decide to allow the procedure - a simple and painless one which involves the care provider inserting a hook into your vagina and through the cervix to tear a hole in the sac. You may also wish to consider some of the risks or consequences associated with your waters being broken before deciding whether to allow artificial rupturing of membranes.

Once the membranes are ruptured, the baby is no longer protected from infection. If your waters break and the baby is not born within about 48 hours, there is an increased risk of infection that may require a NICU stay and IV antibiotics for both mother and baby. If you are GBS+, the risk is greater, as there is a chance of bacteria entering the birth canal and endangering the baby. Once your waters are broken, you should avoid excessive vaginal exams (such as to check dilation).

Another risk of ruptured membranes is that contractions tend to become more painful without the cushion of the bag of waters. The baby may also be affected by the increased pressure of the contractions. The consequence of increased pain is, of course, that you may opt for epidural pain relief. If the baby is affected by the increased pressure of each contraction, he or she may experience distress, which could lead to an emergency c-section.

Of course, since many women do experience a natural rupturing of membranes, the risk is probably fairly low, and it is up to you whether to consent to the procedure if it is offered.

Pushing the Baby Out

Yes, at some point you will actually have to get the baby out. That is the goal of labor, of course! In a vaginal birth, you will reach a point at which you are told to "go ahead and push." This happens when you get through transition and your cervix is fully dilated, measured at 10cm by an internal vaginal exam. In a birth that doesn't require any intervention, the pushing stage can last as little as a few minutes to as long as three or more hours.

Unless you have a very strong epidural, you will likely feel your body telling you to push. With each contraction, you'll take a big breath, hold it, and concentrate on pushing down and out, almost like when you're trying to poop when you're constipated. You'll feel pressure in your perineum or rear that feels much like the need to go to the bathroom. You'll push for as long as you can, usually about 10 seconds or so, and then take another breath and push again, typically two or three pushes per contraction. Rest in between contractions and catch your breath for the next round!

If you are mobile, it may help to push in a position other than lying on your back. If you get up and squat, or turn around and kneel, or get on hands and knees, you may be able to open your pelvis more and give the baby more room to come down. Plus, if you're more upright, gravity will help the baby come down with less effort from you.

A good provider will massage your perineum and help to stretch it as you push. The more your perineum can stretch, the less damage will be done by the baby coming through.

Because the action of pushing is similar to the action of having a bowel movement, many women do poop on the table. I promise that you will very likely not even notice that you have done so, because you'll be concentrating so on the baby. But, there's no need to be embarrassed about it. It happens all the time, and providers and nurses are used to it and will simply clear it away, wipe you off, and continue to cheer you on as you push.

The pushing stage is hard, whether it's minutes short or hours long. This is when having a good cheering section around you is vital. Your partner (if applicable), your delivery nurse, your provider, and your doula (if you have one) will tell you how well you're doing, will encourage you to push a little harder, will offer whatever kind of support you need. Strong support can make a huge difference in your will to keep pushing. You may experience thoughts of wanting to quit and demand a c-section just to get it over with. You may feel resentful that no one is helping you with this part, that you have to do it all yourself. You may change your mind and decide you don't want to have a baby after all! It's amazing the tricks the mind can play when you're exhausted, amped up from adrenaline, and have crazy hormones coursing through your body.

Keep your goal in mind: That baby will come out. You can do it. You will do it. If you need to take a short rest break, as long as the baby's vitals are stable, you can opt to not push for one or two contractions. But it usually feels better to push than not once you're in the pushing stage! Plus, I promise, you'll feel almost immediately better once the baby is OUT.

Your provider will check for the baby's head as you push and may announce the baby's "station." The station just means where along the birth canal the baby's head is. Negative station numbers mean the baby is still inside the uterus and hasn't passed through the cervix. Station 0 means that the head is at the cervix. Positive station numbers mark the progress down the birth canal. As long as the baby is making progress, you will be encouraged to keep pushing. You may hear your provider or a nurse tell you to "bear down." This just means to push downward as hard as you can. Try to direct your pushing down and out and not up into your face. You can burst capillaries in your eyes and cheeks if you push your breath outward in your face, and it's a less effective push than if you can focus downward toward your abdomen and vagina.

Within minutes or within hours, your baby's head will finally emerge into the world. Your provider may ask you not to push for a moment if there is a need to suction fluids from the baby's nose and mouth or to uwrap the umbilical cord from around the baby if the baby has gotten tangled. Or, your provider may help the baby rotate his or her shoulders to better fit through. Then you will give another good push to get the rest of the body out. Hearing the baby's first cry is exhilarating!

What Happens Immediately after the Baby Comes Out?

There will still be a little more work to be done once the baby is out. You have to expel the placenta. You may request "delayed cord cutting," which means that you wish to wait until the umbilical cord stops pulsing, usually two to five minutes, before cutting the baby off from your blood supply. Research suggests that this extra burst of maternal blood boosts the baby's iron stores and can make for a healthier baby in the first several months of life. There is no risk to waiting to cut the cord unless there is an emergency situation that requires that your baby be taken from you for help from a NICU team.

Within a few minutes of the birth, you will feel the need to push once more, and the placenta will slide out. Your provider may assist in this step by gently tugging on the umbilical cord. The placenta will be checked to make sure it is intact. If any piece of the placenta is retained in your uterus, it can lead to postpartum hemorrhage, infection, delay in milk production, and other complications and may require surgery to remove. It is important to ensure that you have completely expelled the placenta!

If you have requested immediate skin-to-skin, you may want to wait until your baby is wiped off with a towel and diapered, or you may want to hold the baby as soon as he or she emerges. That's up to you! Put your baby on your chest between your breasts, and your nurse will put blankets over both of you to keep you both warm. Introduce the baby to the breast, which may require assistance from your doula, partner, and/or nurse (as applicable). Your baby should be fairly alert in the first hour or two after birth and actively seek out the breast. Help your baby find the nipple and latch on. The sucking will release additional oxytocin to help your uterus to shrink, stemming the flow of postpartum bleeding. That first dose of colostrum will help prime your baby's digestive system, help him or her start moving out the meconium that has coated the intestines in the womb, and give you something to focus on and help you start bonding with your baby.

The neonatal team (usually a nurse and occasionally a pediatrician as well) will want to weigh your baby, measure his or her length and the size of his or her head. They will also suggest putting antibiotic ointment on the baby's eyes and giving the baby a vitamin K shot. I won't go into all of these procedures here, but I do recommend you do some reading about the purpose of these medications. You may request to wait for weighing and measuring until the baby has taken a break from the initial breastfeeding, or you may wish to have it done right away and then take the baby back to breastfeed (if you're planning to breastfeed). They will also ask if you'd like your baby bathed. You may choose to delay the bath or you may like to have your baby bathed immediately. Research does suggest that holding off on the bath for 12 to 24 hours can help your baby maintain body temperature and has other benefits as well, such as protecting the baby's delicate skin.

If there was any damage to your perineum or vulva during the baby's exit - either tearing or an intentional cut, called an episiotomy (see below) - your provider will assess the need for stitches. If you have an epidural, they will keep the medication flowing while they stitch you up. If not, they will offer a local anesthetic. In my experience, you are often fairly numb from all the stretching anyway, but a local may still be welcome, depending on how much stitching you need.

Your provider, your labor nurse, and/or your doula will massage your uterus to encourage it to spring closed, near to its prepregnancy size and shape. It takes a few weeks to completely return to normal, but this initial shrinkage is very important to prevent hemorrhage. This will probably be painful. They may also show you how to massage it yourself and instruct you to do so periodically over the next several days. If there are any concerns about postpartum hemorrhage, they may also recommend a dose of Pitocin to help the uterus contract.

Episiotomy

An episiotomy is a deliberate cut to the perineum made by your provider during delivery. The perineum is the area of skin and muscle between your vaginal opening and your anus, and it needs to stretch to allow the baby to come through the birth canal. Episiotomy was once a routine procedure. It was believed to cause less damage and heal faster and more cleanly than the natural tearing that might occur during a normal delivery. Evidence has shown this not to be the case, and episiotomy is considerably less common now than in decades past. Tearing of the tissues can be minimized by perineal massage and warm compresses, by being in a comfortable and optimal position while pushing, and by allowing the baby to descend slowly so that the tissues can stretch. There may still be tearing, especially if this is your first vaginal delivery, but these tears can be repaired with stitches after the delivery.

However, your provider may still suggest an episiotomy under certain circumstances. If your baby is malpositioned - that is, not in an optimal position for delivery - your tissues may need to stretch and tear more to allow your baby's exit, or you may simply not be able to push the baby out easily. An episiotomy in this case may help to widen the vaginal canal to allow the baby's exit. In other cases, the perineum is tough and will not stretch as much as needed, and your provider may feel that a tear would be more traumatic than a small cut. Finally, if your baby is in distress and needs to be delivered quickly, an episiotomy can help speed delivery by providing more space for the baby to emerge.

Risks of episiotomy include infection, more painful recovery, and difficulty sitting, defecating, and urinating for a few days or weeks after delivery. There is also a risk of cutting too deeply and causing severe damage to the perineum, or that the episiotomy will tear further as the baby emerges. Your provider should make the smallest possible cut to allow the baby to pass through.

Discuss the risks and benefits of episiotomy with your provider before your delivery, if possible, so that you can make an informed decision if one is suggested or offered.

If an episiotomy is warranted and you do not have an epidural, your provider will inject a local anesthetic so that you don't feel the actual cut. After your baby is born, your provider will then stitch up the episiotomy and/or other tearing.

You will be given instructions on caring for your episiotomy or tears to prevent infection, speed healing, and reduce pain.

Assisted Delivery

Sometimes, despite your best efforts and the support of your birth team, it becomes clear that the second stage (pushing stage) of your labor is not progressing well, or that the baby needs to be delivered quickly for his or her safety or for yours. In these cases, an assisted delivery may be deemed appropriate.

There are two instruments that may be used to assist you in delivering your baby vaginally. These are the vacuum extractor and forceps. Your provider may prefer one to the other, but they serve the same purpose: to allow your provider to help pull the baby out as you push.

Vacuum Extraction

One method to assist you in birthing your baby is the use of vacuum extraction. In this procedure, your care provider will attach a cup to the top of your baby's head using a vacuum pump. Then, as you push, the provider will tug on the cup to try to help pull the baby out.

Use of the vacuum has some risk, including injury to the baby's scalp or skull and injury to the mother's vagina or perineum. It may cause swelling of the baby's scalp where the cup attaches. The risks associated with vacuum assisted delivery are relatively minor, but if you are able to deliver your baby without assistance, it is safer for you to do so.

Forceps


Forceps have been around to assist birthing women for hundreds of years. They look roughly like large salad tongs. The care provider inserts the forceps into the vagina and grasps the baby's head on either side, then gently pulls on the baby's head as the mother pushes. In this way, much like with vacuum assistance (above), the provider can help the mother deliver the baby.

Risks of forceps use include minor bruising or cuts to the baby's head (which will heal on their own), additional tearing of the mother's vagina or perineum, and, more rarely, nerve damage to the baby's face (which will heal). If forceps are used properly, the risks associated are relatively minor. However, as with vacuum-assisted delivery, if you are able to push the baby out on your own, it is safer for you to do so.

Emergency Situations

I am including this partial list of possible emergency situations so that if something does occur during your labor, you will have some understanding of what's going on. This is not meant to frighten you or dissuade you from giving birth in the location and manner you feel most comfortable. These situations are rare, and if attended to quickly, generally mother and baby come out healthy and safe.

While most women go in, give birth, and everything is fine, emergency situations do arise that will require quick responses from your care team. "Fetal distress" is a catch-all term for evidence that the baby is not tolerating labor for whatever reason. Typically, the baby's heart rate slows down or speeds up to dangerous levels, as noticed on the fetal heart monitor or during a routine listen with a stethoscope or Doppler machine. If the heart rate doesn't recover to the normal range within a few minutes, it may be declared an emergency.

Emergencies can happen for a variety of reasons. For example, the umbilical cord may be too short, or the baby may be tangled in the cord, or the position of the baby may mean he or she is putting pressure on the cord and blocking blood flow. In rare cases, the cord may actually be twisted or tied in a knot. In many of these cases, the baby may not be able to drop into the birth canal and emerge vaginally, and a c-section is necessary to safely deliver the baby. Sometimes, repositioning the mother can help take pressure off the cord and resolve the situation with no further intervention.

Another emergency situation is cord prolapse, which is when the umbilical cord emerges from the cervix before the baby crowns. This is a definite emergency, because it is impossible for the baby to be born vaginally without cutting off his or her own blood supply. This situation necessitates an emergency c-section.

Placental abruption is when the placenta detaches from the uterine wall before the baby is born. This is also an emergency situation because once the placenta detaches, the baby can no longer receive oxygen and nutrients from the mother. The baby must be delivered immediately.

Shoulder dystocia is a rare condition in which the baby's shoulders get stuck in the birth canal. If not resolved quickly, this can be very dangerous. However, a trained birth team will be able to jump to action to free the baby, which may require breaking the baby's collarbone and pulling him out.

Meconium in the amniotic fluid is a situation that may warrant attention from a NICU team. Meconium is a sticky substance that coats the intestinal tract of the baby while in the womb. If the baby has a bowel movement in utero, which can occur either because the baby was in distress or sometimes when you are well past your estimated due date, it is possible for the baby aspirate the meconium into his throat and lungs. Because it is sticky, it is difficult to expel, and this can cause respiratory distress once the umbilical cord is cut and the baby needs to start breathing on his own. If meconium is found in the amniotic fluid when the sac is ruptured, a NICU team will be on call for the delivery.

Uterine rupture is when the wall of the uterus partially or completely opens. This is an emergency situation requiring immediate surgery. Usually, mother and baby are perfectly fine once the crisis has passed, and often the mother's fertility can be saved as well if action is taken quickly. Sometimes uterine rupture can have more catastrophic results, unfortunately. The good news is that uterine rupture is very rare. It is slightly more common in women who have had one or more cesarean sections or more than five pregnancies, but the risk is small even in these cases.

Fever/Infection in the mother may warrant emergency action by the delivery team. If the mother develops a fever during labor, it may indicate that she has an infection that requires immediate attention. Infection in the mother during labor may put the baby at risk as well, and infection or fever can be very dangerous for a newborn, whose immune system is not developed yet.

C-Section

Conspicuously absent from the discussion above is the other way to give birth, cesarean section, or surgical birth. You should know what a c-section is and what the risks are if you are thinking about choosing a cesarean birth. You should also know the circumstances under which a c-section may be suggested or required so that you can make informed decisions if the situation should arise.

A c-section may be planned, non-emergency but unscheduled, or emergency. A planned c-section is when it is known in advance that a surgical birth is necessary or desired. You and your doctor will choose a date no earlier than your 39th week of pregnancy (unless other circumstances require an early birth). A scheduled c-section is associated with the lowest risks for the mother, compared with unscheduled and emergency c-sections, but there are risks to both mother and baby with cesarean section, and unless otherwise indicated, typically a vaginal birth is safest.

A non-emergency but unscheduled c-section occurs when you had planned on a vaginal birth, but it becomes clear during labor that you will not be able to deliver vaginally, or you and your provider determine together that you do not wish to labor any longer. You and your provider may decide that the baby's position or your physiology simply will not allow the baby to completely emerge through the birth canal. There are other situations that may arise as well. For example, you may have tried an induction that did not result in sustained labor. Or, perhaps you are well past your estimated due date and have not gone into labor, or your amniotic sac has ruptured (your water broke) but labor is not starting on its own.

Under these circumstances, your provider may suggest delivering the baby via cesarean section. Even if you had not planned to have a c-section prior to this point, a c-section under these circumstances is not considered "emergency" as long as mother and baby are not in distress. A non-emergency c-section allows time to administer a spinal block (if the mother does not already have an epidural) so that the mother can remain awake and alert during the delivery. It allows the family and provider to prepare for a surgical birth. The risks of complications in a non-emergency c-section are lower than those associated with an emergency c-section.

An emergency c-section will be ordered if a situation arises in which the health or life of mother or baby are suddenly in danger. I detailed some possible emergency situations above. If one of these should occur, you will be quickly transported to the nearest operating room and prepped for surgery. If you already have an epidural, they will continue those medications to prevent you from feeling the pain of the surgery. If you do not, depending on the seriousness of the emergency, your doctors may be required to use general anesthesia to render you unconscious so the surgery can be performed quickly and safely. 

How is a C-Section Performed?

In a cesarean section, the surgeon (your obstetrician or an obstetrician on call at the hospital) cuts through the abdomen with a scalpel, makes an incision in the uterine wall, retracts (pulls back) the sides of the incision, suctions out the amniotic fluid, disengages the baby from the pelvis (if necessary), and delivers the baby head-first through the incision. When the head is out, the fluids are suctioned from the baby's mouth and nose to clear the lungs and airway, then the rest of the body is pulled free of the incision, and the umbilical cord is cut. The placenta is removed and examined to ensure it is intact. Then the uterus is sutured and the abdominal incision is closed up. The entire procedure typically takes about 45 to 60 minutes, with the first 5 to 10 minutes being delivery of the baby.

Depending on the practices of your particular doctor and hospital, it may be possible to hold your newborn on your chest during the second phase of the surgery, and even breastfeed him or her if desired. This is becoming more common and is something you may want to discuss with your provider prior to the surgery, if there is time. You may also want to research "family centered cesarean," in which the birth environment is set up to be as comforting and warm as possible for mother and baby. You may even be able to request to watch your baby's birth (if you want!). If possible, discuss cesarean section scenarios with your provider so that your wishes and needs can be heard and respected during the process. A c-section need not be traumatic or emotionally sterile just because it is not a "traditional" birth.

Risks of C-Section

The most common risk to the mother is post-surgical infection. Other risks for the mother include severe blood loss, reaction to anesthesia, and blood clots. Risks to the baby include lung or breathing problems and birth injury (such as being cut by the scalpel). Risks to the baby of a planned (scheduled) cesarean, as opposed to one that occurs during labor, also include premature delivery, which can carry many complications of its own. It should be noted that a planned cesarean does appear carry fewer risks to the mother than an emergency c-section.

There are also long-term risks of c-section, or multiple c-sections. These include increased risk of future placenta previa (which is when the placenta is blocking the cervix), future placenta accreta (which is when the placenta is too deeply attached in the uterine wall and cannot be expelled), uterine rupture, and risk of future emergency hysterectomy during birth. These risks increase exponentially with each additional c-section.

I want to stress here that in most cases, it is possible to have a vaginal delivery in a subsequent pregnancy even after one or two cesarean deliveries (vaginal birth after cesarean, VBAC). You can browse the "VBAC" tag on this blog for more on than, and investigate www.vbacfacts.com for great information about VBAC.

The Immediate Postpartum Time

I won't go into great detail about this in this series, since the focus is on pregnancy and birth. See this article for some tips for your postpartum hospital stay. During the first hours and days after your baby is born, you will spend time resting, learning to feed and care for your baby, and simply bonding. Spend time skin-to-skin with your baby (whether you're breastfeeding or not), enjoy being waited on, and get as much information from the doctors, midwifes, and nurses as you can. If you and your baby are healthy and you had a vaginal birth, you may be able to go home within 24 to 48 hours of the birth. In a c-section birth, you will stay three to four days to ensure you are healing properly.

Conclusion

Despite the length of this article and the Childbirth Choices Series, I cannot possibly have covered every question or every scenario you may encounter. I hope that I have given you some guidance, information you did not already have, and helped to organize your thoughts so that you can make evidence-based and informed choices as you navigate your way through pregnancy and childbirth. Do not be afraid to ask questions of your care provider, research on your own, and talk to friends who have had babies. You'll find a myriad of experiences, a plethora of opinions, but from all of this you should be able to figure out what you want out of the birth of your child.

I encourage you to browse the pregnancy and birth-related tags on this blog to learn more and to visit www.improvingbirth.org for evidenced-based articles on childbirth-related topics.