Tuesday, January 28, 2014

Childbirth Choices Series Part V: It's Almost Time to Have a Baby!

This is the fifth 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.

More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?

Part IV: What Will Happen at My Prenatal Appointments?
Part VI: Labor and Delivery


It's finally here! You've finally reached the end of your pregnancy! You're 38, 39, 40 weeks (or even 41) weeks along. You're anxious to meet your baby. This section will address what's going on with your body at the end of pregnancy and some things to think about as you go into labor.

Nearing and Passing Your Due Date

As described in an earlier article, your "due date" is really just an estimate of when your baby will be born, based on your last menstrual period. A normal, full-term pregnancy can run anywhere from 38 to 43 weeks, and the 40-week estimate is just a convenient mid-point of that range from which to measure the pregnancy. Many factors, both natural and artificial, can influence when you give birth, and scientists and researchers have yet to determine the exact mechanism or sequence of events that tells your body to start the labor process.

By the end of the pregnancy, though, you're likely feeling very uncomfortable. You're big, ponderous, experiencing aches and pains, having difficulty sleeping at night, having heartburn, needing to pee frequently, noticing swelling in your fingers, hands, ankles, and feet; you're short of breath and possibly even feeling strong, if not painful, contractions of the uterus. You're ready for this pregnancy to be over and to start life with your new baby.

Remember that every day that your baby grows inside you is good for his lifelong health. Take things day by day, and remember that you will eventually have this baby!

What Your Body and Baby Are Doing

At the end of your pregnancy, your body and baby are getting ready for labor and delivery. From early in your pregnancy, you were experiencing mild contractions called Braxton Hicks contractions. These contractions help to "warm up" the uterus and strengthen the muscle to eventually push out that baby. As you near the end of your pregnancy, these contractions will increase in frequency and intensity but will generally not be painful.

You may also experience early labor, or prodromal labor, also called "false labor." These are regular contractions that may be mildly to noticeably painful that continue for several hours and then stop without building in frequency or intensity. Prodromal labor may begin several weeks before your estimated due date. Many women call their provider or even go to the hospital thinking they are in labor, only to find out that the cervix is not dilating or that an hour of rest makes the contractions stop. If you experience painful, regular contractions, try lying down and resting for a while, drinking water, or even going for a walk. If the contractions slow down or stop after a while, you were probably experiencing prodromal labor. If they continue to increase in intensity and frequency, there's a good chance you are in the early stages of active labor. It can be very hard to know for sure, even if you've been through childbirth before, so don't be embarrassed to call your provider to find out what you should do.

Your baby should "drop" into the pelvis in the late stages of your pregnancy. This may happen a few weeks before your are due, or it may happen just days or hours before labor begins. You'll notice that the weight of your uterus seems to be lower in your abdomen than it has been, and the shape of your belly may change. You may be able to breathe more easily, and your symptoms of heartburn and pressure in your chest may ease. You will feel more pressure in your pelvis, more urgency to pee, and possibly increased constipation or hemorrhoids.

Your baby is packing on weight at the end of your pregnancy, at a rate of about half a pound a week! Ideally, she is settling into a good position for delivery, with the narrowest part of her head, the occiput, pointing toward your cervix. You can help her along by being upright and active, walking, stretching, and moving your body in ways that feel good. Unless you are on bedrest for health reasons or are experiencing unusual symptoms that make physical activity particularly painful, the end of your pregnancy is not a time to convalesce (that comes after you give birth!).

Going Post-Dates

As you near your estimated due date, your provider may discuss with you how far "post-dates" or "overdue" he or she is comfortable allowing you to remain pregnant, and what to do if labor does not start spontaneously by a certain date. Remember that the average first pregnancy goes beyond 41 weeks, and that the "due date" really is only an estimate. Your provider may express concerns about the health of your placenta or the size of your baby and may request that you have a non-stress test (NST). We talked about NSTs in the previous article.

There are two main issues with a pregnancy continuing on into the 42nd week. You may raise these concerns with your provider, or she will likely bring them up with you if you do go past 40 weeks. The first concern is that your placenta may begin to age or calcify, which would be dangerous for your baby. The health of the placenta can be checked by ultrasound, but as long as your baby's heart rate is good and he is moving normally, you probably don't have a lot to worry about. The other concern is that the baby may "poop" in the womb, or release meconium. The problem with that is that he may aspirate the meconium into his throat or lungs before or during delivery. Meconium is very sticky and can cause breathing problems if inhaled.

Because of the risks associated with these possibilities, some providers are not comfortable with a pregnancy going much more than 10 days "overdue." She or he may offer an induction or ask that you schedule a c-section. Remember that there are many risks associated with an artificial induction of labor and with c-section that are not found in a normal, spontaneous labor. You may like the idea of knowing when your baby will be born, but you should also be aware of these risks.

The biggest risk of an artificial induction of labor is emergency c-section. If the induction of labor does not work, or if your cervix does not dilate fully, and especially if your waters are broken, it may be necessary to get the baby out some other way. Pitocin can cause the baby to go into distress, which would also typically require an emergency c-section. There is also the chance that your due date was incorrectly estimated or that your baby really did need those extra days or weeks to grow and that inducing labor means that he comes too early, leading to lifelong health problems due to his brain or lungs not being fully developed.

Your provider may also mention your baby's size as a reason for wanting to induce. The size of the baby rarely has any bearing on whether it is possible to give birth vaginally. Remember, too, that ultrasound estimates and measurements of your uterus are just guesses that can be off by up to 1.5 to 2 pounds. "Large baby" alone does not have to be a reason for early induction or scheduled c-section.

It is important to investigate the risks of interfering with the natural process of labor before making your decision. Don't be afraid to ask questions of your provider regarding his or her reason for wanting to induce or schedule a c-section and the risks to you and your baby both of waiting for labor to start spontaneously and of induction and c-section.

This article discusses what a c-section is and some of the risks associated with c-section.

Inducing Labor

Many women become impatient to give birth and will look for any trick to get their bodies to go into labor. Some of the "natural" (non-medical) ways you might attempt are:
  • Sexual intercourse: Having sex releases the hormone oxytocin, which is the same hormone that stimulates uterine contractions. In addition, semen contains prostoglandins, which can help ripen the cervix. Do not have sexual intercourse if your water has broken or if your provider has asked you to refrain from sexual activity for any reason.
  • Walking: Taking long walks is good for you throughout your pregnancy, and especially at the end. Walking helps the baby get into an optimal position for delivery - head down, with his face to your back - and settles him into the pelvis. The pressure of his head against your cervix as you walk may also help the cervix to begin ripening. If you can manage it, walking up stairs or steep hills can be very effective at moving labor along if you think you're in the early stages, and it's excellent exercise in any case. Otherwise, simply strolling along to music on your iPod or conversation with your partner is good for you. Make sure you stay hydrated, as dehydration can be dangerous for you and your baby during labor. Check with your provider if you are concerned about what level of physical activity is safe for you at these late stages of your pregnancy.
  • Acupuncture/acupressure: Some women say that getting acupuncture or an acupressure massage helps stimulate pressure points that encourage labor. 
  • Massage: Stress can inhibit labor, so anything you can do to help you relax is good. Specifically, prenatal massage can also help open up the pelvis and loosen your muscles, as well as relieving pregnancy-related body pains such as back pain.
  • Nipple stimulation: As with sexual intercourse, stimulating your nipples releases oxytocin, which may trigger uterine contractions. You can self-stimulate, have your partner do it, or use a breast pump for 20 minutes at a time.
  • Castor oil: Taking a teaspoon of castor oil triggers an "emptying" of your digestive tract (read: possibly painful cramping and diarrhea). It is thought that this may stimulate uterine contractions as well. It is often considered a "last resort" because this effect is uncomfortable and unpleasant.
  • Various natural/herbal remedies: There are many herbal preparations that you take orally or insert into your vagina that may or may not help jump-start labor as well. Because herbal remedies are not regulated by the FDA, please make sure you are obtaining your preparations from a reputable source and that you are using them according to directions.
  • Various foods and drinks: I've heard many tales of eating a particular food or drinking something specific that may help bring on labor. Who knows if any of this is true, but it probably doesn't hurt to eat something you like if it has that possibility attached, right?
If your body is not ready to go into labor, or your baby is not quite ready to be born, these methods may not work. However, if you are on the brink, or are in early labor, trying one or more of these options may help to speed things along or get things moving in the right direction. At the very least, it may help you psychologically to know that you are doing something relatively noninvasive to make labor start.

In the previous article, I talked about some of the ways your provider might attempt to get labor started without medications, such as stripping your membranes. 

If you are full term (at least 39 weeks, according to the newest recommendations from the American College of Obstetricians and Gynecologists), your provider may offer to have you come in to the hospital for a medical induction. An induction before your body is ready for labor, and especially if this is your first pregnancy, is risky, because your body may simply not respond well to the induction. Many labor inductions result in an emergency or unnecessary c-section that may have been avoided if labor was allowed to start spontaneously. However, if you must be induced for a medical reason (such as preeclampsia), or you elect to be induced because of severe discomfort, a medical induction is fairly straightforward.

Depending on your circumstances, whether there has been any cervical ripening or dilation, and the urgency of the induction, your induction may start with a drug to ripen your cervix, which is inserted into your vagina and left there for 12 to 24 hours. Sometimes this alone can start labor, if you are nearly ready. Alternatively, your provider may use a special device that physically opens the cervix over the course of about 12 hours. Once some cervical ripening has occurred, you will likely be started on a Pitocin IV. 

Pitocin is a synthetic version of the hormone oxytocin. Oxytocin is produced in the brain under several different circumstances, such as sex, breastfeeding, and labor. During childbirth, oxytocin specifically stimulates uterine contractions. Synthetic oxytocin - Pitocin - will also stimulate uterine contractions and is administered via IV. Pitocin-induced contractions may be more intense, stronger, and more painful than the contractions your body would naturally experience from the oxytocin your brain produces. 

Once labor begins, an induced labor will likely follow a similar, if accelerated, pattern to a spontaneous labor, if all is going well. We'll talk about labor and delivery in Part VI, so stay tuned!

Risks and Benefits of Induction

Let's talk briefly about the risks and benefits of having your labor medically induced.

There are occasions where it may be necessary or preferable to have your baby before labor starts spontaneously:

  • In cases where the mother's life is at risk due to a pregnancy-related complication such as preeclampsia or PUPPPs, giving birth is often the best option, especially if you are near your due date. Giving birth usually resolves the issue almost immediately, so a medical induction or c-section may be preferable to continuing to risk the mother's health or life by allowing the pregnancy to progress.
  • In cases where the mother is suffering from a pregnancy-related condition such as hyperemesis, induction at the first viable opportunity (37+ weeks) may be an option to relieve the mother's suffering. If you think you can stick it out for a few more days or another week or two, it is likely better for the baby to do so, assuming the condition is controlled and the mother's health is stable. However, you may discuss with your provider the earliest reasonable date for having the baby if you are unwilling to wait for spontaneous labor.
  • There are certain conditions of pregnancy in which the health of the baby is actually more endangered by continuing the pregnancy than by inducing labor or doing a c-section. One example of this is cholestasis of pregnancy, in which the risk to the baby increases after 37 weeks.
  • In cases of general extreme discomfort or gestational diabetes, early induction of labor may be preferable to allowing the pregnancy to continue because of pain or extreme weight gain for the mother or danger to her health. In less clear-cut cases, the risks and benefits must be weighed fully, and you should discuss with your provider the best set of options for you and your baby. Especially in cases of GD, your provider may wish to induce early due to "large baby." These types of inductions often fail and result in emergency c-section, and, as stated above, "large baby" is not, by itself, a good reason for early induction.
  • Some women and their providers consider the convenience of knowing when the baby will be born to be a benefit of medical induction or scheduled c-section. If you have childcare or job issues, if your provider may be unavailable after a certain date, or if you or your partner need to figure out maternity/paternity leave or there are other schedule complications such as a military deployment or the need for a family member to arrive to help with the birth or other children, scheduling the childbirth may be an attractive option. In this case, when there are no actual health issues to consider, weighing the risks against the convenience of knowing the birth date is very important. Some providers will be more reluctant than others to encourage a scheduled c-section or induction under these circumstances, but it is ultimately your choice to make. You should consider the short- and long-term risks for you and your child of waiting versus artificial induction or scheduled c-section.
While there may be risks to waiting for spontaneous labor, typically there are greater risks to an early induction (except in certain cases like some of those described above). There are risks both to mother and baby of using Pitocin to start labor and to giving birth before your body or baby are ready.

The list here is not comprehensive but will give you some things to consider as you weigh your options.
  • Premature or late preterm delivery. Scheduling an induction for your due date or a few days before your due date may result in a baby who was not quite ready to be born. For example, if your estimated due date was off by even a week (you think you are 39 weeks but you're actually 38), and your pregnancy would have continued another week or two beyond that date (to 41 or 42 weeks), inducing labor at 39 weeks may result in a baby who is actually 3 weeks premature. This is called a late-preterm baby, and late-preterm babies may have lifelong health risks or short-term problems as a result of being born just a little too early. These problems may include learning disabilities, lung and breathing issues, susceptibility to illness, NICU stay, difficulty breastfeeding, developmental delays, and low birth weight.
  • Postpartum hemorrhage. Pitocin use is associated with postpartum hemorrhage due to the hyperstimulation of the uterus.
  • Fetal distress in labor. Pitocin contractions are intense and often faster and stronger than natural labor contractions. These intense contractions may compress the umbilical cord or cause other stress to the baby, causing a sharp increase or decrease in fetal heart rate, which may lead to an emergency situation requiring a c-section or other interventions.
  • Increased need for pain medication in labor. Pitocin-induced contractions may be more painful and intense than natural labor contractions, which may sway a mother who is unsure about using medicinal pain relief options toward opting for them. The most common option is the epidural, which limits your movement during labor and may have other risks associated with it, including a drop in maternal blood pressure, lethargic baby, and slowed labor progress. We'll talk more about epidurals and other pain relief options in the next article.
  • Increased risk of c-section. If an induction "fails," i.e., labor does not progress or the baby goes into distress, a c-section may be necessary. The risk of c-section is much higher in an induced labor than in a spontaneous one, often due to malpresentation (when the baby is not in an optimal position for delivery) or distress (due to the Pitocin).
The final article in this series will talk about labor itself, what to expect as you go into labor, and the decisions you may be faced with once in labor.

More articles in this series:Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?

Part VI: Labor and Delivery

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