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

4-Month Well Visit and Cosleeping Commentary

I had an interesting visit to the doctor yesterday for GI's four-month physical. I like this doctor for reasons you will shortly understand.

First of all, GI was 26.75" long (tall?) and 17lbs., 7.7oz. This makes him slightly heavier and longer than SB was at the same age, but not nearly matching NJ's robust 18lbs., 14oz. SB's weight gain didn't level out until six months. GI may be slowing down sooner, possibly because he was born in his own time and was bigger to start with than SB was. SB had some catching up to do because he was a couple of weeks early. It will be interesting to see which brother's build GI's more resembles as he grows. My guess is that he's going to be a big, tall guy like his oldest brother, though. SB had his three-year physical last week and was in the 75th percentile for his age, but he always strikes me as being short and skinny, probably because NJ is just so big.

Anyway, back to the pediatrician.

First, he said obviously I'm doing fine with breastfeeding and to just keep doing that. (Not that I was worried!) He asked if I was giving Vitamin D supplements, which I'm not, mostly because I'm bad about it and not because I don't recognize that Vitamin D is important. I've been taking a supplement for myself, and we do get some sun every day. He then said that he's not so crazy about them, either. Ha!

Then he asked where GI is sleeping. I told him in my bed. He said the AAP is now recommending officially that babies not sleep in their parents' bed but in a crib nearby. I said the AAP is welcome to come and take care of GI at night if that's how they feel about it. He said that SIDS dropped to almost nonexistent after the back-to-sleep campaign in the '90s, but that the rates have been creeping back up, and that most of the babies who are dying of SIDS are in their parents' bed. He said he's supposed to tell me that but then admitted that all three of his kids slept with them (and sometimes still do) and that he loves cosleeping and understands why I do it. Ha!

According to my reading, in a controlled bed space with sober parents, especially if the baby is breastfeeding, cosleeping is quite safe and healthy for a normally developing baby. And mom gets a lot more sleep! But having the baby in the room with mom, whether in a bassinet, crib, cosleeper, or the same bed, has been demonstrated to be the healthiest way for a young infant to sleep, and the AAP does recommend room-sharing, if not bed-sharing! (Remember that in many other cultures, the family bed is the norm.)

This article by Dr. William Sears puts it very succinctly.

To be honest, I cosleep because it's convenient for me. Frankly, I don't love cosleeping. I find I wake up with a stiff neck and shoulder and feeling like my torso is twisted. It takes a hot shower and some time upright before I feel like I can move freely again. I'd rather him sleep in the crib which is currently wedged between my side of the bed and the wall. I had intended for him to sleep there, take him out when he woke to nurse, and put him back in when he was done. That lasted one night. I found myself getting totally confused when he'd rouse, take a while to realize that he was awake and looking for me, and then I'd fall asleep nursing him, so he wouldn't make it back into the crib. Ah well. The same thing happened with SB. Eventually the inconvenient squirminess of a mobile baby will outweigh the convenience of popping out a boob and going back to sleep, and GI will be in the crib more regularly.

GI is currently showing signs of the four-month sleep regression, so while he does sleep soundly, he's waking  more often to nurse and spending more time with my nipple in his mouth. The other night, I kept trying to roll to my back, only to find there was still a baby attached to me. The choice was to stay on my side or unlatch and risk a wake-up. My typical choice in that situation is to stay where I am. This is where cosleeping works out so well, because I'm not up and down and up and down all night. I wouldn't say I'm getting lots of quality sleep, but I'm getting more than I would if I couldn't "sleep-nurse."

In other news, GI is still showing dairy sensitivity, having spit up rather dramatically just now. I tried a smidge of dairy the last few days, and it seems I, well, shouldn't have. It does seem he now tolerates soy and caffeine better, so at least I have that. I'll get to have macaroni and cheese again one day. Just, not today. I did get an ice cream maker and have been making non-dairy ice cream, which is loads of fun and takes the edge off the whole dairy-free thing.

Playing Musical Car Seats

I've been going on about pregnancy and birth and breastfeeding a lot lately, so I thought we'd have a change of pace today and talk about car seats. Some of this post will simply be reiterating information I've already written about, but it's information that bears repeating.

When NJ was born, we didn't know much about car seats, other than that you needed one for your baby. We got a Graco travel system, which I selected based almost solely on the cute pattern. It turned out not to have been a very good choice of car seat, as it was very difficult to properly adjust the straps. Also, we found out quickly, as NJ was a rather large baby, that carrying the baby in the car seat carrier quickly became uncomfortably heavy. By the time he was two months old, we were tired of using the carrier and tired of how much space it took up in the car. At that point, I had somehow become more educated about car seats in general (I think because I was involved in a parenting forum on LiveJournal) and had learned that Britax are considered the best car seats. We bought a Britax Roundabout, which at the time had a rear-facing limit of 33 pounds and a front-facing limit of 40 pounds. (The one linked to here is a much newer version, with a higher weight limit and slightly different design than the one we bought five years ago.) We kept NJ rear-facing until he was about 16 months, and then turned him forward because he was getting very cranky in the car and we thought it would be nicer for him to be able to see out and look around. He used that seat until long after SB was born.

Here is baby NJ in his Graco infant seat. This was the day we came home from the hospital.

It looks like he's not quite buckled correctly. We were still car seat newbies at that point. It's close, but the shoulder straps look a bit crooked and loose.

When SB was born, we decided we needed a new infant carrier seat. We had planned to just start him out in the Roundabout, but when we put him in it when we left the hospital, he just seemed too small for it, even though it's supposed to be usable for babies as small as 5 pounds. I'm not sure I believe that. We had given NJ's old infant seat to some friends when they had a baby, so we asked for it back. They offered just to go in with a couple other friends and buy us a new car seat instead, because to ship a car seat across country would cost nearly as much as simply purchasing a new one online and having it shipped to us directly. I picked out the Chicco KeyFit30, which was supposed to be a phenomenal car seat that would allow a baby to stay in it until he was 30 pounds! At first, I loved it. But I realized a few things fairly quickly. First, a kid would outgrow this seat by height long before reaching the 30-pound weight limit, unless he was a very fat baby. Second, you do not want to try to carry a heavy baby around in this car seat. It's a fairly heavy seat to begin with, and once you add the heft of a growing baby, it's very uncomfortable to carry. Convenient? Yes. Practical? Reasonably. Comfortable (for the parent)? Not so much. Still, because SB was much smaller than NJ, he lasted in his carrier quite a bit longer. I believe I switched him into the Roundabout, which NJ had since vacated, when SB was seven or eight months old.

The problem I have with the KeyFit30 and other similar infant seats, such as the Graco SnugRide35, is that they are massive seats. They take up a lot of space. This is manageable when you have only one child, but once you add a second (and third!) car seat to your car, the space these seats take up is ridiculous. Not to mention how heavy they are. The nice thing about the lower-weight-limit carriers is that the seat itself isn't as big and heavy. My complaint is that you don't end up using it as long as you could, because you get tired of the big-ness of it. At least, that's what happened to me. And let's be realistic, here, how many babies hit 22 pounds before a year old? Even NJ was only about 26 pounds at a year old, and he was well over the 90th percentile.

Here's baby SB, about five months old, in his KeyFit30, buckled correctly:

(Note: You shouldn't have toys hanging from the handle of the car seat when the seat is in the car, as they become a hazard should there be an accident. In my defense, in this picture, the seat is not in the car, but on the ground at the park.)

When SB was born, one of the gifts we requested was a new car seat for NJ, so that SB could use the Roundabout. We got NJ a Graco Nautilus, which is a fantastic front-facing-only car seat which has a 5-point harness to 65 pounds and then converts to a booster seat up to 100 pounds. In other words, once you've turned your child front-facing, this is the last seat you'd need to buy. (It looks like Graco has since come out with a new seat, called the Argos, which has higher weight limits but appears to be otherwise identical to the Nautilus.) And we liked it so much that we got a second one for NJ as a backup seat in my mom's car. The problem with the Nautilus is that it is also a massive seat. It's wonderful; I love it. But it's huge. And when we started planning a third child, near SB's second birthday, we realized that we'd need to do some car seat revisions in order to fit three car seats. Thus, my post about the Three-Across Car Seat Adventure in August. For SB's second birthday, I asked for a Sunshine Kids Radian 65 (Sunshine Kids is now called Diono), which purports to be a car seat with one of the narrowest "footprints" on the market. They claim you can fit three across in a small car. It was supposed to be for SB, but he refused to ride in it. So he stayed in the Nautilus, and NJ used the Radian. The Radian has a front-facing five-point-harness weight limit of 65 pounds, like the Nautilus, although it does not convert to a booster. It was fine for NJ to use it, and he liked it. I have three complaints about the Radian. One, it's very heavy (23 pounds), so putting it in and out of cars is a pain. Two, I find it difficult to tighten the harness to my satisfaction. And three, I personally find it much harder to install correctly than a Britax, although I have a friend who bought a Britax and a Radian and found the Radian easier to install. It may depend on your car. I do like that the Radian has SuperLATCH, which allows you to use the LATCH clips until your child has outgrown the seat. With the Nautilus, I had to switch to a seatbelt installation when NJ reached 43 pounds. (Incidentally, a seat belt installation and a LATCH installation are equally safe if done correctly. The advantage to a LATCH installation is that it's easier to do correctly. Whatever you do, though, do not use both simultaneously. You must choose either LATCH or seat belt.)

Here is NJ in the Radian:

And SB in the Nautilus:

And SB in the Roundabout (in the garage - it wasn't installed in a car at the time I took the photo):

And now there's a third kid. GI is currently using the KeyFit30. GI, being an even larger baby than NJ was, is getting awfully heavy to carry around in that thing, but the convenience has kept me using it for now. I moved NJ into a booster seat, as he's 45" and 58 pounds now, and I feel that he is big enough to use a seat belt with a booster seat safely. Also, booster seats tend to be narrower than car seats, so it was one of the only ways I could get three across. SB is now in the Radian, as there was no way I could fit the massively wide Nautilus.

The other day, I spent an hour in the car trying to install the Roundabout, the booster seat, and the Radian in some formation or another. I even tried putting the Roundabout forward-facing for SB and the Radian rear-facing for GI, but the fit just wasn't happening. I'm not sure if it's the width or the shape of the Roundabout that makes it difficult to fit along with the other two seats, but I couldn't get it to work in any configuration. I was very disappointed. It seems my only option will be to invest in a second Radian when I've finally grown tired of using the KeyFit30. Part of me is tempted to try out a smaller infant carrier car seat, but that seems redundant and a waste of money, when that same money could be spent on a new Radian instead. I think once GI can sit up (in a high chair or supermarket cart), I'll want to switch him to a rear-facing convertible seat. I'd really like to put NJ in the middle and GI and SB outboard, but I couldn't make that work with the current collection of car seats because NJ wouldn't be able to buckle his seat belt. It's frustrating. Obviously, I can continue to use the KeyFit30 and just leave it in the car, taking GI in and out of the car seat as I would with a convertible seat, rather than replacing the seat any time soon. I will probably have to start doing this until I can get my second Radian!

And now, a quick review of car seat must-knows:

First, every car seat on the market in the United States has met minimum safety standards. This means you can buy any car seat you want and it will be safe to use, assuming it can be correctly installed in your car. (Some car seats are not compatible with some cars.) When you choose a car seat, you should take into consideration the weight limits, the size of the seat, your budget, your car, the age(s) and size(s) of your child(ren), and how many children you have or plan to have.

Harness:
Straps should be in a straight line and not twisted. Chest clip should be buckled and at armpit level. (This is the most common error I see in car seat usage.) In a rear-facing configuration, straps should be in a slot at or below the child's shoulders. In a front-facing configuration, straps should be in a slot at or above the child's shoulders. Straps should be tightened to where you can't pinch the straps at the child's collarbone and hold the fold.

Installation:
Use either the seat belt or the LATCH system, not both. Make sure the seat is secured tightly enough that you cannot shift it more than 1" in either direction while holding the car seat at the belt path. To get a tighter install, lean into the car seat with your hand or knee and tighten.

Rear-Facing:
The newest recommendations are to keep your child rear-facing until at least two years of age, or until he has outgrown the rear-facing specifications for his particular car seat. Rear-facing is the safest position for all passengers in a car, especially the smallest ones. Most states have laws that require a child to be rear-facing until at least one year of age and 20 pounds (this means that if you have a 20-pound nine-month-old, he should still be rear-facing; or, if you have a 17-pound one-year-old, she should still be rear-facing. The child needs to be both older than a year and more than 20 pounds). You should check your state's car seat laws and be familiar with them.

A child has outgrown a rear-facing car seat when he has met one of the following conditions.
1. The top of his head is within one inch of the top of the car seat; or,
2. The child is heavier than the rear-facing weight limit of the car seat.

Front-Facing:
The longer you can keep your child in a five-point harness, the safer he is. Many car seat manufacturers have come out with seats that allow you to harness a child as heavy as 70 pounds; some go as high as 80 or 85 pounds. You should check your car seat's specifications.

A child has outgrown a front-facing car seat when he has met one of the following conditions.
1. His ears are above the top of the car seat; or
2. The child is heavier than the front-facing weight limit of the car seat; or
3. You cannot adjust the shoulder straps to be at or above his shoulders.

Booster Seats:
There are two kinds of booster seats: high-back and backless. High-back booster seats give a child better shoulder-belt positioning and head support than backless seats. Most booster seats say they are for children who are at least three years old and at least 30 pounds. Some states have laws that state a child must be at least four year old and 40 pounds before transitioning from a 5-point-harness to a booster. When you do decide to put your child in a booster seat, make sure the seat belt goes across his hips and shoulder. If it does not, the child is probably still too short to safely use a seat belt and should remain in a five-point harness until he is taller.

Most children are not anatomically ready for using a seat belt without a booster seat until they are at least seven years old. Most states require a child to be at least six years old or 60 pounds before being legally allowed to be out of a car seat entirely. Many now recommend that a child stay in a booster seat until eight years old or 80 pounds. It is not difficult to find a booster on the market that will accommodate a larger child. Some go as high as 120 pounds.

Miscellaneous:
1. You should not put any after-market products on your car seat. This includes BundleMe-type products, as they go between the child and the seat and may interfere with the harness and not allow you to properly tighten the straps. This also includes the shoulder pads you put on the car seat straps - most car seats come with these anyway. Also, you should not use head-support pillows or newborn positioners that did not come with the seat. If it wasn't in the car seat box, then it shouldn't be on the car seat. Period. Car seats are tested with their various accessories for safe installation, safe buckling, flammability, and other criteria. After-market products are not.

2.  Unless it is specifically stated otherwise in your particular car seat's manual, you should not put anything between the car seat and the vehicle seat, such as a seat-protector mat. Many car seat manufacturers allow you to place a thin towel under the car seat to protect your vehicle's upholstery.

3.  You should not put your child in a car seat while wearing bulky clothing such as a heavy winter coat. It is impossible to tighten the harness straps enough while the child is wearing thick clothing. In an accident, the clothing will compress against the straps, and the child could be ejected from the car seat. Place your child in one or two layers (such as a shirt and a sweatshirt) and then put a blanket over the child over the harness, or put the child's coat on backward after he has been buckled.

4.  Car seats expire. Most seats are good for six years. There should be an expiration date printed somewhere on the car seat itself. Pay attention to this. After the expiration date, you cannot guarantee the safety of your seat anymore, and you should replace it.

5.  Once a car seat has been in an accident, it is no longer safe to use, even if a child was not in the seat at the time of the accident. Your car insurance should cover replacement of the car seat if it was involved in an accident.

Any questions? :)

C-Sections

It's hard to start a discussion about VBAC (vaginal birth after cesarean) until we've established what a cesarean section is and what it's for. So this post will be about c-sections specifically, and the next post will be about VBAC. This is a series of posts that are more "clinical" in nature than personal, but it's all from my own perspective, having been through both scenarios.

I'm not here to tell you that you shouldn't have a cesarean section, or that if you had one by choice, you did something wrong, or that if you had one that wasn't by choice, that you were in some way wronged. I'm not here to tell you that there is never a need for a c-section, or that all c-sections are bad, or that I wish c-sections never had to happen.

Indeed, thank G-d we have the medical knowledge to perform a c-section when necessary, because a necessary c-section is a routine, reasonably safe alternative to vaginal birth that can save the lives of both mother and child.

I do, however, believe that c-section is an overused procedure. A c-section is a sometimes-necessary abdominal surgery which requires the doctor to cut through layers of skin, fat, and muscle, rearrange internal organs, cut through the huge muscle that is the uterus, pull the baby out, and then close it all back up. It isn't a simple procedure like the removal of an ingrown toenail or unwanted mole. Major abdominal surgery carries risks to both mother and baby. 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 (where the placenta is blocking the cervix), future placenta accreta (where the placenta is too deeply attached in the uterine wall), uterine rupture, and risk of future emergency hysterectomy during birth. These risks increase exponentially with each additional c-section.

What Is A Cesarean Section?


A cesarean section is a surgery used to deliver a baby. Rather than a typical birth, during which the baby is pushed through the cervix and vaginal canal in order to leave the mother's body, in a cesarean section, a surgeon cuts through the mother's abdominal wall and into the uterus and removes the baby through this incision, then repairs the incision with sutures.

Here is an excellent photo essay with explanations showing a typical cesarean delivery. (Slightly graphic, although photos are small. If blood or depictions of surgeries disturb you, I don't recommend clicking.)

Basically, the surgeon 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, the umbilical cord is cut, the baby is (usually) shown to the mother, then taken to the warmer to be cleaned and examined. 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 would have to be discussed with the doctor prior to surgery.

When Is A C-Section Necessary?


**This is not a comprehensive list, just a sampling of instances when cesarean section is indicated.**

There are instances when a c-section is medically necessary. In such cases, it is determined that a vaginal delivery carries too much risk to mother and/or baby, and a c-section is a safer way to deliver the baby.

• Placenta previa. This is when the placenta is blocking the cervix. Attempting to deliver vaginally under such a circumstance would cause severe maternal blood loss, often leading to maternal death.
• Prolapsed cord. This is when the umbilical cord precedes the baby through the birth canal.
• Fetal or maternal danger which requires immediate delivery of the baby when induction of labor fails or would be too dangerous. An example of this would be preeclampsia or eclampsia, which is a dangerous rise in maternal blood pressure that can cause seizures or stroke. Eclampsia is often fatal to the mother. If maternal blood pressure fails to come into a safe range within a reasonable amount of time, delivery of the baby immediately is indicated, as delivery of the baby is the only "cure" for preeclampsia/eclampsia. Medical induction may be attempted, but if it fails, cesarean delivery is necessary to protect both mother and baby.
• True fetal distress during labor.
• Abrupted placenta. This is when the placenta detatches from the uterine wall before delivery of the fetus.

Thus, there are times when a cesarean section is absolutely needed, clearly saves the life of mother and/or baby, and we can be grateful that such a relatively safe method of delivery exists when vaginal birth is not possible or indicated.

Why So Many C-Sections?

However, the rate of cesarean section in the United States now exceeds 30% of all births. It's hard to fathom that almost one-third of all pregnancies and births result in a life-or-death situation such as one listed above. If that were the case, we would be seeing mothers and babies in mortal danger during childbirth far more often than we do. Indeed, the maternal and neonatal mortality rates in this country are reasonably low. What are some reasons for cesarean section that may not be medically necessary? (In some of the following examples, the end result of c-section may actually have been necessary. However, they are not emergency situations, and usually there are or would have been ways to avoid c-section in these cases.)

• Maternal preference. Some women just don't want to go through labor, so they request to schedule a c-section. This enables them (and their doctors) to know exactly when and how the baby will be born.
• Previous c-section. Many doctors and hospitals do not allow VBAC, so a woman giving birth through a particular care provider may not be offered the option of VBAC. In such a case, she will be advised to schedule a c-section. Alternatively, a woman may feel that the risks of VBAC are not ones she is willing to face and so elects a c-section. Or, perhaps the difficult or traumatic labor which resulted in the previous c-section makes her unwilling to attempt labor again, and planned c-section seems to be a more palatable option for her. Finally, depending on the reason for her previous c-section, she and her doctor may feel that any future labor would also result in c-section, so rather than take the risk of needing an emergency c-section, or of going through labor only to result in a second c-section anyway, she elects a planned c-section. In addition, if a woman has had three or more previous cesarean births, VBAC is considered too risky. Also, VBAC is not considered safe if the previous c-section incision is not the "low transverse" or "bikini" incision.
• Breech presentation. Breech presentation is when the baby is not head down at the end of the pregnancy or when the mother goes into labor. The preferred way to deliver a baby vaginally is head-first. Some babies do not turn around near the end of the pregnancy and present feet-first or buttocks-first at or near the onset of labor. Most OB/GYNs in the United States prefer not to attempt a vaginal delivery of a breech baby, and so they will recommend a scheduled c-section in order to ensure safe delivery of the baby. There are variations of breech presentation that would make vaginal delivery impossible or very dangerous to mother and/or baby, in which case, of course, a c-section is indicated.
• Prolonged labor. Some women may labor for many hours or days. Sometimes this is because labor is not progressing as it should, the cervix is not dilating properly, or despite hours of pushing, the baby does not come down into and through the cervix even after full dilation. These cases are usually labeled "failure to progress," and the doctor or midwife may suggest a c-section to deliver the baby and relieve the mother. It is difficult to know from case-to-case whether a c-section was necessary, because it depends on the reason that labor is not progressing. However, often the mother, doctor, midwife, or other birth attendant can make changes that may help move labor along. I won't get into a long list here, but "failure to progress" is a vague term, and in order to determine whether c-section was medically necessary, one needs to know the reason for the stalled or prolonged labor.
• Twins. It is possible to deliver twins vaginally, although most OB/GYNs and hospitals prefer to deliver twins via c-section. There are additional risks during vaginal delivery of twins that simply do not exist in the delivery of a single baby, so these risks need to be discussed with your doctor.
• Large baby. Sometimes it is estimated that a baby is simply very large and the mother will have a very difficult time delivering him or her vaginally. This is not to say that a vaginal birth is definitely impossible with a large baby (plenty of women have delivered 10+-pound babies vaginally). However, if it looks like your baby is headed into the 10-pound or more range, your doctor may bring up the possibility or probability of scheduling a c-section.

Disclaimer

I really want to stress that neither the first list, of universally indicated reasons for c-section, or the second list, c-sections that may not have been necessary, is comprehensive. Depending on your situation, you should discuss with your doctor or midwife your birth preferences and particular conditions before determining whether you should have a c-section. Obviously, during labor, especially during an emergency in labor, there isn't time for much discussion, so it is important to be fully informed of the risks and benefits of c-section in various cases before delivering your baby or going into labor.

Non-Medical Risks Of C-Section

C-section, especially unplanned or unwanted c-section, can result in feelings of failure on the part of the mother, i.e., Why couldn't I deliver naturally? Why did my body fail me? Why couldn't I make a perfect pregnancy? This can lead to postpartum depression and delayed bonding with the baby. C-section, depending on the environment or circumstances in which it was performed, can also delay initiation of breast-feeding, which carries its own set of risks for mother and baby.

In this blog, I am more concerned with the non-medical risks of c-section, although I do think it's important to know that, even though c-section is a routine medical procedure that is relatively safe, it is still major surgery that carries risks to both mother and baby that do not exist (or exist at a much lower rate) during a traditional vaginal birth.

Elective C-Section 

I want to expand on elective c-sections for a moment before signing off for tonight. Many women choose to schedule a c-section near their due dates despite having no medical reason to consider c-section. Perhaps they simply do not want to experience labor, or they want control over when their baby will be born. For many women who choose this route, they are very satisfied with the outcome, do not harbor negative feelings toward their chosen method of birth, and both mother and baby recover well and quickly.

My only concern in such cases is that c-section is, as described above, major abdominal surgery that does carry risk. If we look at c-section as elective surgery, we can discuss it in similar terms to something like gastric bypass. In most cases, or nearly all cases, gastric bypass is a "last resort" attempt to control obesity and its associated health problems. Typically, a person is not a candidate for gastric bypass unless all other weight control options have been eliminated and the person's health is in danger from obesity-related complications such as hypertension, diabetes, arthritis, etc. Gastric bypass carries risks that need to be weighed against the benefits of performing the surgery, and against the risks of not performing the surgery. Certainly, gastric bypass has helped many individuals lose weight and improve their quality of life and is a viable option when risks and benefits have been appropriately discussed.

I feel that c-section should be considered in the same way. It is a life-saving surgery that has helped many women and babies survive relatively unscathed a birth scenario that without c-section may have ended in tragedy. However, like any other surgery, c-section involves risks that must be weighed against (a) the benefits of having a c-section, and (b) the risks of attempting a vaginal birth. If both mother and doctor approach the topic of c-section in this way, a more productive discussion of birth options will result.

Jumping Right In - My First Birth

I don't think I need to start with an introduction. It doesn't matter that much who I am. I will say up front that I don't have any specific credentials - I'm not a lactation consultant, a doula, a midwife, a licensed medical practitioner. I'm not a birthing coach or a childbirth class teacher. I'm not a licensed anything, really. But I am a mom, and I've done this pregnancy and childbirth thing twice, and I'm now pregnant with my third. And I've done a lot of reading, and I've done a lot of self-educating. And what I've found is, I'm passionate. I'm passionate about passing along information about childbirth, about breastfeeding, about what goes on in hospitals that can throw you off track, and about what every woman should know before giving birth, whatever her proclivities, inclincations, or beliefs. I don't so much care what you choose to do. I just care that you make an informed choice.

Okay, that's out of the way. I say right up there in my blog description that I've had a c-section. So let's start there, with the story of my first son's birth, slightly abbreviated, but not leaving out anything important. I’m also going to try to write this as neutrally as possible, even though there are a lot of emotions attached to this story, which I’m sure will come through no matter how hard I try. I think that’s okay. Those strong emotions pretty much changed my life.

When I was pregnant with son #1 (who is now four years old), I was 24 years old, had been married for four years, and was pretty sure I had this pregnancy thing under control. I went to all my prenatal appointments, thought I had taken charge of my body, and thought I had made all the important decisions, like what hospital to go to, how I was going to feed the baby (breast-feeding, because “breast is best”) who would come with me, and whether or not I would want pain relief (I did!). I figured, beyond that, the doctors and nurses in the hospital would know better than I what to do, and I trusted the OBs in the practice I’d chosen, and I trusted the hospital staff.

My son was due October 20, 2006, which was a Friday. That night, just after midnight, I entered the early stages of labor. I lost my mucus plug and started having contractions. We waited about two hours, called the OB on call, and were told to come on in. I spent four hours on the L&D floor, walking around, trying to move things along, only to find, at 6:00 A.M., that I hadn’t dilated at all. They sent us home and told us to come back when the contractions were more painful and closer together. We dutifully followed directions.

As a side note, we had bought a car that evening, not long before I went into labor. We had to pick it up Saturday morning, so we went ahead and did that. I don’t think the salesman had a very good sense of what it meant that I was in labor. He just went on with his spiel, for what felt like hours, giving us a tour of the facility, showing us everything we could possibly want to know about our new Toyota Rav4, and generally doing his salesman thing. I really wanted to go home.

Anyway. We went home. I had no idea what to do with myself. My husband called his parents in Israel. Their neighbor is a midwife, and she got on the phone and told my husband to tell me to take a hot shower. Now that was a great suggestion. The shower felt so good, and it sped up my contractions because I was standing up. Eventually, I got out of the shower, and the contractions slowed down, but it had been another 10 hours or so, and we decided it was time to return to the hospital. This was about 4:00-ish on Saturday afternoon.

I had dilated to a whopping 2cm by then, so they let us stay, since we were now sure I was in active labor. I had had quite enough of this labor thing by then, and couldn't believe the long road I still had ahead of me, with eight centimeters to go! I requested pain relief, but I wasn’t quite ready for the epidural, so I got a narcotic cocktail instead. That lasted about 90 minutes, during which I was high and having the weirdest visions/dreams. I really had no idea what was going on, how much time was passing, or who was in and out of the room.

That wore off, and I labored some more, mostly lying on the bed. My mom was there with me, along with my husband. My mom had given birth to both me and my brother totally naturally, drug-free, and she said I should walk around. But I didn’t feel like it. I was tired, and it was hurting, and lying down was so much easier. Besides, my mom was a crazy natural-birther. I wasn’t crazy like that. Our (my husband’s and my) motto at the time was, “There’s pain. There’s pain relief. This isn’t a test anyone should fail,” which is a quote from one of our favorite shows, “Coupling,” uttered by a father-to-be about whether he thought his girlfriend should have pain relief during labor.

By the time I reached 4cm, I wanted the epidural. It didn’t go very well and actually took two attempts before the anesthetic took hold, but it did its job at that point. I was then stuck in the bed whether I wanted to be or not, but I did enjoy the break from the pain. My water broke at around 5cm, just as the OB was getting ready to break the bag of waters manually.

Much of the next several hours is kind of an epidural haze. They started Pitocin at around 7cm, hoping to move things along. By 5:00 A.M. Sunday morning, I had finally fully dilated, and they started coaching me on pushing. “Here comes a contraction. Take a breath. Hold. Push. 1, 2, 3…10. And breathe. Hold. Push 1, 2, 3…” Etc. They told me my pushing technique was good. But the baby wouldn't budge. It seemed he was occiput posterior (OP), which means the top of his head was toward my back, instead of the more comfortable occiput anterior (OA), where the top of the head is toward the mother’s stomach – the baby comes out more easily if he is face-down during delivery. Many babies will turn in the birth canal as they come out, but mine didn’t want to. It turned out he also had a very big head. I’m making a digression for the point of education. Basically, the head needs to travel through the cervix and under the pelvic bone, which requires the neck to bend. This is accomplished more easily if the baby is OA, although being OP does not automatically make a vaginal delivery impossible.

What I’m getting at here is, after two hours of pushing, he had not moved at all. He was still up in the cervix, with no apparent desire to come out and see the world. My OB told me that I could keep pushing if I wanted, but he wasn’t making any progress, and it might be time to consider a c-section. She was not at all confident that this baby was coming out the more natural way. She stressed that he was not in distress – his heart rate was fine, he was holding up very well, and there was no immediate medical danger to the baby, or really to me, if I wanted to keep trying. However, I was feeling a great deal of pain despite the epidural, I was completely exhausted, and I just wanted this baby out. So my husband and I very quickly decided to go ahead and have the c-section.

They whisked me away to the operating room, where I was suddenly surrounded by a bunch of new people, including an incredibly sweet and caring anesthesiologist who held my hand and looked into my eyes and helped me stay calm during the procedure. My husband took a few minutes to get there, because he had to put on a sterile gown, gloves, hat, mask, etc., and I remember being terribly frightened and looking around wildly for him. I needed him there beside me. A c-section had been my greatest childbirth fear, and now here I was having to face it.

I was aware of some pressure in my abdomen, then a baby’s cry, and my husband holding him. I looked for him and saw my beautiful son. He was 9lbs., 1oz., and 20 inches. He was healthy and strong. And he had a big head, as advertised. And I couldn't even hold him, because I was still strapped down on the table being stitched up.

I’m going to stop here for now. I want to talk in more detail about my hospital stay after his birth, because what happened in the first three weeks after his birth has a lot of bearing on the following 26 months of my life and why I’m sitting here writing this story again. I’ve told it and written it down several times over the years, and the telling changes with every passing year, partly because of fading memory and partly because of my changing attitude toward my experience.

Please stay tuned for the next four days of my son’s life, in which he thrived and I floundered. Don’t worry, though, I’ll spoil the ending. Everyone came out all right.