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

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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.

Benefits:
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.

Risks:

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.

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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

Childbirth Choices Series Part II: Meeting Your Care Provider

This is the second 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 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!
Part VI: Labor and Delivery

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So, let's talk about that first meeting with a potential care provider. What are you looking for in a care provider? How do you know if this person is the one you'll want to see throughout your pregnancy? How do you know this is the person you want to help you deliver your baby?

Your first meeting can be a simple "meet and greet" appointment even before you're pregnant, just to get a feel for the practice, his or her personality, how the office is run, and other general impressions, as well as a chance to ask specific questions relative to your situation. Your first meeting might be early in your pregnancy, when you're still looking for someone to help you through the rest of this process. Or, you might have a care provider you've been seeing for your GYN care, and this is your first prenatal appointment. Keep in mind that often the first prenatal appointment isn't until you're 8 or 9 weeks along, so there will be some time for you to think about your concerns and questions you might want to ask. Your pregnancy will  be pretty well established by the time you have your first regular prenatal appointment.

Depending on whether this is a meet-and-greet or a prenatal appointment, the atmosphere of the meeting may be different. I'll start with the universals, things you'll probably want to ask or judge your impressions of no matter what. I'll then move on to a typical "first appointment" scenario.

What kind of provider are you looking for?

We discussed in the previous article the three basic options for a maternity care provider (CP). These were a certified nurse-midwife (CNM), a licensed midwife (LM/CPM), or the most common choice, an obstetrician (OB). Now I want to look at the type of person or personality you might be looking for. 

We all have different expectations when it comes to someone who will be providing us with medical care. Some may prefer a certain clinical distance: you don't want your CP to be your friend, you want your CP to be professional, reserved, authoritative, and objective. Others prefer a warmer or friendlier relationship: you want someone you connect with on a personal level, someone you'd like to go out for coffee with. Still others might like a mix of the two: someone you feel meshes with your personality, sense of humor, and style, but who still maintains a comfortable distance. Remember that this person will become fairly intimately involved with your most private and sensitive of areas, so you want to make sure that you are personally comfortable with him or her, however that comfort is manifested for you. You should think about what kind of personality you're looking for as you prepare for your first meeting so that you can assess whether this person meets that need. Since you'll be seeing this person fairly regularly for the next several months, you don't want to dread your appointments because you don't "like" him or her!

Male or female?

While most midwives are women (probably over 99%), there are about the same number of male obstetricians as female. Female doctors are increasingly joining the field of obstetrics, and many patients prefer a female obstetrician, for various reasons.

I have been equally happy (and in some cases equally dissatisfied) with male and female CP's over my four pregnancies. Several of the most celebrated obstetricians in the natural birth community in my local area are male. I don't think you can make any kind of sweeping generalizations about male or female practitioners being "better." It's really about your personal preference.

Why a woman?

Some women are simply more comfortable being unclothed in front of another woman. This is quite understandable. You may also feel that a woman will have more empathy for your situation, especially one who has given birth herself. You may feel a certain sisterhood with her, or feel that her personal experience is to her benefit as a practitioner. You may feel more comfortable discussing intimate problems with a woman, because you feel she may have "been there" herself, or that she will understand why it's difficult for you to talk about. There's a peer relationship you can have with a woman that you can't necessarily have with a man.

Why a man?

Some women feel that a male practitioner will have a more objective view of the process. Having not experienced childbirth or other "woman problems" directly may mean that he will view your situation with a clinical eye not clouded by feelings. You may feel he is better able to distance himself from the emotions of the situation in order to give you the best objective advice. Indeed, does a cardiologist have to have had heart surgery to perform it? Does a pediatrician need to have children to take good care of yours?

What if I don't have a preference?

Some women don't have a gender preference for their CP. Sometimes, you're just looking for the best fit, the person who is best at the job at hand and who meshes best with your expectations. You may feel going in that you couldn't possibly be examined by a man but then find that the woman you choose is not as empathetic as you hoped. Or, you may think that you prefer the objectivity a man will likely provide, only to find that his approach is too clinical and you prefer a warmer touch. There's no way to generalize. Midwives and doctors are human, too, and their practice is colored by their training, their background, their personal experiences, and their personal biases. That's why it's prudent to have an open mind when interviewing or meeting with your practitioner.

Group Practice or Individual?

We talked about the different advantages of a group practice versus an individual practice in the previous article as well. 

If you're going with a group practice, it's a good idea to try to make appointments with each of the available providers throughout your pregnancy so that you'll get a chance to meet everybody. In a group practice, you would hope that there's a unifying philosophy among the members of the practice. However, each doctor or midwife in the practice may have a different style and will certainly have a different personality, and you may find you simply "like" some of them better than others. It's up to you to decide whether you can be comfortable with whoever ends up attending your delivery. I was with a group practice in my first pregnancy, and I definitely found I preferred two of the doctors over the other two. Toward the end, we scheduled all of the appointments with our "favorite" doctor, but he didn't end up being on call for the delivery. But, we were comfortable enough with the level of knowledge and competence, as well as the personalities, of each of the four doctors that we were willing to "take what we got" when it came time to have the baby. 

With an individual practicing on his or her own, a major concern will be whether this is the person who will attend your birth. Some individual practitioners cannot guarantee that they will be available or on call when you go into labor, while others make it a point to be there. This is something you'll definitely want to find out early on! If your doctor or midwife can't be there for the delivery, then whoever is on call at the hospital or birth center will be there for your birth.

What do I want to know?

Okay, so what questions should you be asking, and what information should you be sure to acquire? Well, there are a few things you'll definitely need to know. 

• Where will I deliver my baby? What hospital or birthing center does this CP deliver at? (For a home birth, this is obviously not a relevant question.) 
• Who will deliver my baby? This goes back to the on-call situation: are you the one who will be there when I call to say I'm in labor, or is there no guarantee? If you are not available, who can I expect to see? Do you have arrangements with another practice to work with you for backup, or am I stuck with whoever is on call? How much of an effort do you make to be there personally?
• What is your cesarean section rate? This question applies to OB's, since midwives can't perform c-sections. Midwives in birth centers and the home-birth setting will instead have a "transfer rate" - that is, how often the patients in their care need to transfer to the hospital for emergency care. This is something you will want to find out if possible. Knowing if your OB has a relatively high c-section rate (the national average is about 32%, which most experts agree is too high) or a relatively low one may help you decide if you feel you are in capable hands. An OB with a lower rate is probably more "hands off" in the birth process, more inclined to let things happen naturally. An OB with a higher rate may be more likely to err on the side of caution if there are any concerns during the labor process. Remember that OB's who handle more high-risk cases will likely have higher c-section rates by virtue of their type of practice and not necessarily because of their philosophies.
• What kinds of recommendations do you make for managing the pain of labor? This is going to be a big question. What you're trying to find out is, how likely is this person to immediately turn to medical interventions such as epidurals and IV narcotics before or instead of trying non-medicinal methods of labor relief, such as breathing, changing positions, shower or bath, and relaxation techniques. Is this a CP who is more likely to let labor progress on its own, or is he or she going to recommend interventions early on? How do you as the patient feel about that? Are you more interested in "letting nature take its course," or do you feel strongly that you want an epidural the second you walk into the hospital? Are you more comfortable with laboring in more hands-off environment, or are you nervous about laboring without monitoring and assistance? These are very, very important questions for you to consider as you progress through your pregnancy, and we will definitely be addressing the issues of interventions, medications, and monitoring in a future article in this series. How your CP answers this question will help you understand how he or she views the birth process and how you as the mother will be treated.
• What is your (or the hospital's) policy on continuous fetal monitoring? Continuous fetal monitoring (CFM) means that you would wear a fetal heart monitor strapped to your belly at all times. This is a tool that we will discuss in more detail in a future article. You may want to know if you will be required to wear this monitor at all times, as it may limit your mobility and ability to change positions or use alternative pain relief options such as a shower/bath, and CFM has some unexpected risks, such as increasing your chance of emergency c-section. You may want to follow up on this question by asking if intermittent monitoring is an option. In this scenario, you'd wear the monitor for 20 minutes every hour and otherwise be disconnected and free to move about, if you want.
• What is your policy on eating and drinking during labor? What is your (or the hospital's) policy on the use of an IV? Labor can be long and uses a lot of your energy. Many CPs and/or hospitals will not permit a laboring woman to eat or drink during labor in case she requires an emergency c-section and emergency anesthesia. You will want to know if you'll be allowed to bring food and drink with you to fuel your labor. Often, if your provider or birth location has a policy against eating and drinking during labor, they will require you to be on an IV for fluids at all times to prevent dehydration in you and the baby. They may also prefer to have an IV ready in case any medications such as antibiotics or Pitocin are deemed necessary.
• How do you feel about my having a doula? Even if you don't plan to hire a doula (and we'll talk about doulas in a later article, too, never fear!), you may want to know whether your CP is open to your having a labor coach or additional support in the room with you. A "doula" may also simply be a friend or family member who is there to encourage and support you as you labor. Most CPs, birth centers, and hospitals are amenable to the presence of a labor support person other than the baby's father or a close family member, but some are not. Knowing your CP's attitude on this subject may be informative for you.

These questions should help you gauge your potential provider's approach to labor and birth so that you can determine if these ideals are in line with your own. We will be getting into considerably more detail about many of these topics in future articles, to help you gauge your own birth preferences, as well!

Your First Prenatal Appointment

This is a description of what typically goes on during a first prenatal appointment, especially in a more traditional setting, just to give you an idea of what to expect.

You'll first be asked to fill out some paperwork about your general health history and gynecological history specifically, especially previous pregnancies and births, if applicable. Your provider may have these forms mailed to you in advance of your appointment so you can arrive with them already completed, or you may be asked to fill them out when you arrive. You'll probably need addresses and phone numbers to use for emergency contacts, how to contact you and your partner at work, your insurance information, and so on. You may also want to have on hand information about previous GYN care providers and be prepared to have your records transferred if you are moving to a new provider. It's important that your provider has a picture of your medical history so that they can care for you appropriately. Conditions such as diabetes, hypertension, thyroid issues, psychological disorders, and various GYN problems will likely be relevant to your treatment during pregnancy and delivery and possibly postpartum as well.

You'll probably be asked to provide a urine sample (by peeing in a cup), which will be quickly tested for protein and glucose content. The presence of protein in your urine could signal kidney problems, which would need to be evaluated. Glucose in the urine may indicate diabetes or the potential for diabetes, which would need to be managed.

You'll then be taken to the exam room. Your provider will most likely want to perform a full gynecological exam. For this, you'll be asked to take off all of your clothes, and you'll probably be given either a hospital gown or a paper vest and towel to put around yourself. (From personal experience, I recommend keeping your socks on if you're wearing socks - sometimes the room is cold, or the stirrups are uncomfortable on bare feet.) The care provider will examine your breasts and genitals and do a quick internal vaginal examination with gloved fingers and possibly a speculum to check your cervix and feel for your uterus and ovaries. If you have had a gynecological exam before, this should all be familiar to you.

Many care providers will then perform a transvaginal ultrasound to "see" the pregnancy. An ultrasound machine measures the way high frequency sound waves bounce off various structures in your body and creates a live picture on a computer screen of the tissues, organs, and bones the sound waves encounter. The provider can manipulate this picture to focus on the organs of interest, in this case your ovaries and uterus, and to view the growing fetus. You may be familiar with a traditional ultrasound machine, which uses a wand and some gel on your abdomen. For this type of ultrasound machine to get a clear picture, you generally need to have a full bladder. A transvaginal ultrasound, by contrast, uses a wand that is covered by a lubricated condom and inserted into your vagina. It does not require a full bladder to get a clear picture of your uterus, cervix, ovaries, and the baby. The provider will use the ultrasound machine to take measurements of the fetus and look at the heartbeat as well as to check the placement of the pregnancy to make sure everything looks healthy. Based on the measurements on the ultrasound, your CP can get a pretty good idea of how many weeks and days the baby has been growing, and from there determine whether your estimated due date, based on your last menstrual period, is accurate or if an adjustment needs to be made. If the estimate from your ultrasound and your last menstrual period are within a few days of each other, your due date will probably not be changed. If there is a larger difference, they may want to change the date based on the baby's actual growth.

If you are not comfortable with the idea of an ultrasound in general, or a transvaginal ultrasound specifically, you should bring up your concerns with your provider. It is your right as the patient to refuse any procedures you feel are unnecessary or carry unreasonable risk to yourself or your baby. Though it is a useful tool, an ultrasound is not necessary to date or assess the pregnancy. You should feel comfortable asking your provider what the purpose of the procedure is and whether and why he or she feels it is important. While you may not be able to hear the baby's heartbeat using external methods (such as a Doppler machine or stethoscope) at eight or nine weeks, by about 12 weeks it is possible to hear the heartbeat using noninvasive methods, and you may be more comfortable simply waiting to use a less intrusive method to hear the heartbeat. On the other hand, you may be excited to get to see your baby so soon (no, you can't see the gender this early!), and seeing the little heart fluttering on the screen is very reassuring.

You will also be given information about certain blood tests your CP recommends. These will include general blood tests such as checking your blood type, measuring your iron stores, thyroid function, and white blood cell count. Your CP will also likely recommend that you be tested for antibodies to certain diseases such as chicken pox, measles, rubella, and other viruses that may be dangerous to a growing fetus. If you have had any of these diseases in the past, or you have been vaccinated against them, there should be nothing for you to worry about. There is a blood test, as well, to look for certain chromosomal abnormalities in the fetus, specifically Down syndrome. Your CP will ask if you would like to receive this testing and give you information about how it works and what they look for.

Your CP will also discuss with you whether you want genetic testing to find out if you are a carrier of any known genetic diseases such as cystic fibrosis, sickle cell anemia, or Tay Sachs (depending on your ethnicity and risk of being a carrier). If you are a carrier of a genetic disease and the father of the baby is as well, there is typically a one in four chance that your baby will have that disease. You may want to know whether your baby is at risk of having one of these terrible genetic disorders. Some people choose to be tested for this before deciding to have a baby, but often you don't know about them until you are pregnant. If anything is found, you can receive genetic counseling to help you decide what to do and how to handle future pregnancies.

Remember, again, that you have the right as the patient to refuse any tests or procedures you are not comfortable with. For example, if you don't think that knowing the results of a genetic test would change your desire to carry your pregnancy to term, then you may want to decline the testing. On the other hand, knowing about a potential disability or disease may be important to you, even if you still plan to carry the pregnancy to term, so that you can be prepared with services and support when the baby is born. You probably want to discuss this decision with your partner to make sure you both feel the same way.

Your next appointment will likely be scheduled for four to six weeks in the future, and you will probably be asked to have your blood tests in the meantime. Some blood tests need to be taken during a specific time frame for accuracy.

Your provider will then likely discuss with you some issues such as exercise and diet and what you can expect in the next few weeks. You should be given an opportunity to ask any questions you may have and air any concerns that have come up.

If, for any reason, during your appointment, you feel uncomfortable, you should let the provider's office know via a phone call or, better, a letter. If it's in writing, you have evidence of what you said. If you do not wish to return to see this provider, start looking for a new one quickly so you can schedule your next appointment, and arrange to have your records sent over to them. You also have the right to request a copy of your records to keep for yourself if you want. The provider's office may charge a copying or processing fee, usually not more than $25, for the time and supplies used by the office staff in copying the records, but they are not allowed to refuse to give them to you.

If this is not your first pregnancy and there was anything of note or unusual about your previous pregnancy(ies) and/or delivery(ies), you may also want to request your hospital records from the birth(s) so that your new provider will know about these circumstances. That information can be valuable in planning your next birth.

Stay tuned for the next article in this series. If you have any questions about this or any of the topics covered in the Childbirth Choices Series, feel free to comment below or on my Facebook page, or send me a private message via the Facebook page.

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More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part 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!
Part VI: Labor and Delivery

On That Episode of Downton Abbey (Spoilers)

If you've seen it, you know the one I'm talking about. If you haven't, stop reading NOW. I was grateful no one spoiled me for this one, and I'd hate to inadvertently spoil anyone else. This is Episode 5 of Season 3, which aired January 27, 2013 in the United States. (I'm trying to write enough that the preview of this post will not show any spoilers.)

This episode was fascinating to me, for obvious reasons. Birth in 1920 wasn't handled all that differently from today, except considerably fewer births took place in the hospital. I'm reminded of reading Cheaper by the Dozen when I was in sixth grade, which takes place around the same time. The mother decided to try having one of her babies at the hospital, though all her other babies were born at home. A few hours there, and she came traipsing back home, saying that a hospital was no place to have a baby. At the time, I had no idea that babies sometimes weren't born in hospitals, and I had no idea that there was such a thing as a "home birth."

It's funny to think that now, less than 100 years later, giving birth at home is the unusual way.  Times change.

And yet.

If you watch the episode from the point of view of birth advocacy or knowledge of birth, watching the two doctors argue over the best course of action was eerily similar to what happens today. Watching Lord and Lady Grantham disagree over which doctor to listen to, watching poor Tom's distress over his wife's potential fate, watching the sisters try to understand what was going on - well, those kinds of panicked discussions happen just as much today, when the doctor raises the question of fetal distress or other potential birth emergency that may necessitate a cesarean or other intervention.

Dr. Clarkson, the beloved village doctor, wanted to take her to the hospital for a cesarean. There was no way to know, of course, whether it might already have been too late. (And, of course, this is all fiction, so the writers could have taken this in whatever direction they wanted. But let's pretend Lady Sybil, Dr. Clarkson, and Sir Philip were real people, just for the sake of discussion.) There was no way to know whether the cesarean itself would be more risky than allowing labor to continue. They didn't have the option of Pitocin to move things along, or magnesium sulfate to prevent seizures, or fetal monitoring to see how the baby was doing. But they had seen toxemia (preeclampsia) before, and they had seen eclampsia before, and how painful it must be to see those seizures begin and know the patient is going to die and know there's nothing you can do. Eclampsia is still a major cause of maternal death, and it is still unknown what causes an otherwise healthy woman to have a spike in blood pressure, organ failure, and seizures leading to death. It is known that the only way to prevent it is to deliver the baby before the pre-eclampsia becomes eclampsia.

Dr. Clarkson's recommendation to attempt a cesarean section in hopes of saving Lady Sybil's life was not made lightly. He knew the only way to avoid eclampsia was to deliver the baby as quickly as possible. He also knew that a cesarean section was extremely dangerous, a last resort. Until the 1970s, c-sections were performed extremely rarely (4% or fewer of cases). It was known that the risk of infection to the mother was high for surgery performed in a public hospital. Obstetrician-to-the-nobility, Sir Philip, who Lord Grantham hired because he wanted his daughter to be in the best of hands, was aghast that Dr. Clarkson would even suggest such a thing. He felt the risks associated with a cesarean section were higher than the risk of eclampsia. It's possible professional pride prevented him from admitting that he, too, saw the signs of toxemia. It's also possible that he felt labor was progressing well enough that no intervention was required. When the baby was delivered healthy and Lady Sybil appeared to be fine, it looked as though Sir Philip had indeed been correct. Unfortunately, hours later, we learned that Dr. Clarkson's dire prediction was to be borne out.

A case like Lady Sybil's today would probably have been a no-brainer. She would have been taken in for an emergency c-section, and very likely both she and the baby would have been fine. By the end of pregnancy, a woman receiving regular prenatal care would be seeing her doctor or midwife weekly. Her blood pressure would be monitored, and if there was any suspicion that her blood pressure may be rising or that she may be at risk of preeclampsia, she would be told to watch for symptoms such as those described by Lady Sybil - sudden swelling of the ankles and hands, headache, disorientation, visual disturbances.

With both my first and second sons, my blood pressure rose toward the end of my pregnancy, and I was given weekly or even twice-weekly reminders to call my doctor immediately if I should experience any of these symptoms. As it happened, though I was not diagnosed with preeclampsia, my blood pressure was high enough, and stayed high enough, at my 37-week appointment with my second son, that the decision was made to deliver him to protect both of us. Fortunately, a Pitocin induction, in my case, worked perfectly, and my son was born healthy and full-term, and I was fine. My blood pressure came down immediately upon delivery and I experienced no further symptoms that would suggest preeclampsia.

As with any medical decision, decisions regarding birth and interventions during labor require a weighing of the risks and benefits of action or inaction. Sometimes the safest route really is to simply wait and see. Other times, an emergent situation changes the balance in favor of intervention, up to and including immediate surgery. As the helpless viewer of Downton Abbey, we could yell and scream at the TV to go do the cesarean, or that no, she'll be fine, or however we felt, but we couldn't affect the outcome. I could see they were leading up to something when Sybil complained to Mary about the swollen ankles and headache she was experiencing a few days before she went into labor. I was puzzled that Dr. Clarkson didn't mention anything about her blood pressure at that point, since they specifically showed him taking a measurement. I don't know enough about 1920's medicine to comment on his knowledge of the significance of blood pressure in pregnancy. In any case, as committed as I am to allowing labor to take its course in most cases, it became clear that we were supposed to root for Dr. Clarkson's proposal and to be angry at Lord Grantham for agreeing with Sir Philip.

In 2013, a c-section is a relatively safe option in a first-world hospital setting. However, as with any medical or surgical procedure, it carries risks, including infection and complications. The issue, as always, is whether those risks outweigh the benefits of performing the procedure. When the life of the mother or baby is clearly in immediate danger, the benefit of mother and child surviving is obviously greater than the risk of infection, for example. It is important to know what the risks are to both mother and baby of performing a c-section under various conditions and to consider whether the benefits truly make those risks worth taking.

Of course in Lady Sybil's case, the risks of c-section were considerably higher than they would be today in a modern hospital setting, so the decision was nowhere near as clear-cut.

There's a lot of discussion these days about encouraging doctors and hospitals to be more hands-off during birth, to allow nature to take its course, to trust in the birth process. The issue of eclampsia and other life-threatening complications of pregnancy are a stark reminder that modern medical practices during birth also save lives, and that there is definitely a time and place for these interventions. We can hope that, in the future, there will be a better balance between the use of interventions when necessary and relaxing and letting things progress normally when appropriate.

As a side note, I did spend quite a few minutes wondering who is feeding the baby?! when everyone was tending to Sybil and the baby was nowhere to be seen. I was glad when they mentioned that they'd found a nurse for her, though it seemed a throwaway line just to cover that detail. That was the main option for a family of means when the mother died in childbirth. Today, the idea of wet-nursing seems odd, but they didn't have the fancy formulas we do today. Though rudimentary formulas and other infant-feeding options did exist, including simply feeding sheep's or goat's or cow's milk directly, a wet-nurse, if the family could afford and find one, was a better option.