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

The Last Few Weeks of Pregnancy: What to Expect

Pregnancy is a crazy time. It'll throw you for a loop over and over again. (May as well get used to the idea; babies and kids will surprise you at every turn, too!) But now you've finally made it to the third trimester, the last three months, the almost-end. You think you've experienced it all. You've gotten through morning sickness, back aches, frequent peeing, and lots of tests. You've dealt with constipation and heartburn and insomnia.

And then you hit about 36 or 37 weeks.

Just when you thought pregnancy couldn't get more uncomfortable; just when you thought you couldn't get more impatient for your baby to be born, you hit the home stretch.

I firmly believe that the last bit of pregnancy is so unpleasant so that you'll wish for labor just to get pregnancy over with. Otherwise, labor is pretty scary to contemplate, but if it means being done with this gigantic midsection, clothes that don't fit, sweating in weird places, aches and pains you couldn't imagine, heartburn and reflux and shortness of breath, loose tendons and nausea and insomnia and weird dreams, peeing constantly, hemorrhoids, constipation, and food cravings, well, maybe labor won't be so bad after all! At least it will end, and take with it a lot of these other discomforts and inconveniences.

So, what can you expect in those last few weeks?

Well, having just entered week 38, myself, let me tell you what's changed in the past week or so!

• Stronger and more frequent Braxton Hicks contractions. I've been having noticeable (but not painful) contractions for many weeks. These are totally normal and to be expected. You only have to worry if they become increasingly painful and more regular (more than 4 in one hour) and don't stop when you hydrate and rest. The contractions I've been having the last couple days are more powerful, occasionally borderline painful, more frequent, and certainly more noticeable!
• More pain in lower abdomen. The stretching of the ligaments that support the uterus (round ligaments) continues right up to the end. In the last few weeks, the baby is putting on half a pound to a full pound per week, which means you're still having to make room for him, and you're toting around all that extra weight. This stretching causes "round ligament pain," which you've likely been experiencing throughout the pregnancy. I'm finding it just continues to increase, and at times the pain is quite intense. It passes after just a few minutes, fortunately, but it's certainly unpleasant while it lasts. (If you have any reason to suspect that the pain you're feeling is not normal, or if any pain is accompanied by vaginal bleeding, contact your provider right away!)
• Increased pressure in the hips and pelvis. As the baby starts his downward journey to the eventual exit, his head will start putting pressure in new places. I feel like I constantly have to use the toilet, but most of the time I can't produce or don't actually have to go. (Too much information? Get used to it. Pregnancy robs you of all modesty. May as well be honest!) 
• Reduced heartburn and shortness of breath. One perk of the baby "dropping" is less pressure on the stomach and diaphragm, which means I can breathe better and am having less acid reflux. So there's that!
• Increased low back and hip pain. I find it increasingly difficult to get comfortable in bed, and I wake up with achy hips and lower back which often persist at a mild level throughout the day.
• Harder to get off the floor, reach my feet. Putting on socks and shoes is a whole new adventure. And if I get down on the floor to play with the kids, sweep, or pick up toys, getting up involves a lot of grunting and groaning.
• Less stamina. I run out of steam in the afternoon and absolutely must lie down. I often fall asleep when I do. Any extra physical activity takes more out of me than it normally would, so even going food shopping or taking the kids to the park feels like a much bigger energy investment than it did a few weeks ago or will after I recover from the birth.

Of all of these changes, I think the increased pressure as the baby drops is the most irritating. It's this feeling of "almost there" that is such a tease. And I know my life won't get easier once he's born, but I won't miss being pregnant, either.

It's also these big changes near the end that make women very impatient to give birth. Three weeks of this might seem interminable, and if you're one of the many women who goes "post-dates" (beyond the estimated due date), those "extra" days can be even more torturous. 

However!

Remember that every day makes a difference in your baby's development. Every day that your baby stays inside you is one more day for his lungs and brain and gut to develop properly, for him to put on fat stores that will see him through the first few days of life. Every day that you can wait is contributing in a positive way to your baby's overall lifetime health. Unless there is a medical reason for yourself or your baby that might require giving birth before you go into labor spontaneously, you are doing your baby good by being as patient as you can be. Continue your routine, pretend you've still got a month to go, make plans with friends, go for walks, see movies, go out to dinner with your partner, watch TV, read books, surf the Web, and go shopping. Pass the time. 

And if you are at or past your due date, here are some ways you might be able to help labor start, if your body and your baby are ready. At the very least, it might make you feel like you're doing something to move things along.

• Get that oxytocin flowing! Oxytocin is the hormone that promotes uterine contractions, and there are two ways outside of labor to get oxytocin going. One is orgasm. Another is nipple stimulation. As long as your provider has deemed it safe for you, and as long as your amniotic sac isn't broken, go ahead and have sex. As a bonus, semen has prostoglandins in it, which are hormones that help the cervix ripen (efface and dilate), so if you have intercourse, you might be helping yourself in two ways. Nipple stimulation can be done in a fun way (use your imagination) or by using a breast pump. If you've got a double electric breast pump, hook yourself up for 20 minutes or so. You might even mine some precious golden colostrum, which you can save in your freezer just in case your newborn needs a little extra or has any trouble breastfeeding at first.
• Walk! Walk up and down stairs, up and down hills. Alternatively, do some cleaning or gardening. Anything that gets your body moving in a way that will encourage your baby to move down, get his head bumping against the cervix, and open up your pelvis (squatting to clean the floor, for example) can help settle the baby into the most ideal position for giving birth. At the very least, this will help your labor be more efficient and the birth easier. At most, the physical activity might help labor get started.
• Look up some folk remedies. Some people swear by eating certain meals, drinking certain teas, or using certain herbs. I can't recommend anything specific, and I would definitely do some research before you ingest anything that you don't know is safe.

There's no real way to know if any of these methods actually induce labor, but it might help you psychologically to feel that you are making an effort to move things along. I want to reiterate that once your water breaks, nothing should go into your vagina! The amniotic sac protects your baby and uterus from infection. Once that membrane is broken, it's very easy to introduce bacteria in places you do not want it to be. Nothing nothing nothing, not fingers, not bath water, should go up there. If your water has broken and labor doesn't start within about 24 hours, contact your provider.

How were your last few weeks of pregnancy? How did you psych yourself up for the big day? Did you try any of these "natural" induction methods? Do you think they worked? What other methods have you heard of?

Check out my Ask-Me Monday video on this same topic, also published today!

Writing a "Birth Plan"

At some point near the end of your pregnancy, you will likely come upon the term "birth plan" or "birth preferences." Typically, it's a good idea to spend some time thinking through your ideal birth scenario and how you might react to various unexpected complications or changes during your labor and birth. Knowing in advance what your preferences are regarding pain relief, birthing position, birth location, various other medical procedures, monitoring, breastfeeding plans, and surgical interventions is helpful for you, your partner, any other labor coach who might be present (a doula, another family member, a friend), and your care provider, as well as anyone else who might be in attendance (a hospital labor and delivery nurse, for example). Many women choose to have a written document prepared and handed out to anyone who is present during the labor and birth process, while others simply like to have in mind answers to some of the questions that might come up throughout the process.

I don't like to talk about a birth "plan" so much, because birth often does not go according to anyone's plan, even if it all goes smoothly and you are satisfied with the outcome. I believe it's important to have two ideas in mind: (1) What is your ideal birth scenario? and (2) What are your preferences regarding certain questions in the event that something doesn't go according to your ideal? Instead of calling it a birth plan, I like calling it birth "preferences," as in, this is what I'd like to see happen, and here's what I've thought about in case this happens instead.

These are the major areas you'll want to think about when coming up with your birth preferences:

• Where will you give birth? (hospital, home, birth center)
• Who will attend the birth? (care provider, partner, nurse(s), doula, friend, relative)
• How will you give birth? (vaginal or surgical)
• What kind of pain relief do you expect to use? (epidural, narcotics, breathing techniques, birthing classes, birthing methods)
• How do you feel about the use of certain routine interventions? (fetal monitoring, IV, Pitocin, antibiotics, vacuum, forceps, episiotomy)
• Do you want the option to be mobile? (walking around, birthing ball, shower/bath, changing positions)
• What do you want to happen as soon as the baby is delivered? (immediate skin-to-skin, immediate breastfeeding, use of Pitcoin to deliver placenta/contract uterus, who will cut the cord, timing of cord cutting (delayed, immediate), preservation of placenta (for encapsulation or burying, for example), baby bath, vitamin K injection, protective antibiotics for newborn's eyes, weighing and measuring)
• Do you want to breastfeed? (immediate (within first hour) latch-on, rooming-in versus nursery, skin-to-skin)

Once you've figured out some of the basic direction you'd like to go, be sure to run these preferences by your care provider to make sure these desires are compatible with his/her policies, hospital policies (if applicable), and are realistic in your specific case.

You'll also want to come up with alternative preferences. For example, your desire may be for a spontaneous, vaginal birth without any medical intervention, but what if a complication arises during labor, such as fetal heart decelerations, maternal blood pressure spikes, or infection? You'll need to know what might happen and have a plan in place in case a surgical birth is warranted, for example. You don't have to write up a separate plan for every potential complication or question, but you should have a general idea of a what-if scenario.

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As an example of what you might want to think about, here are my birth preferences for my upcoming birth. You don't need to follow a specific chart or guideline or layout; you don't have to have an answer for every question. This is not a legal or official document. Simply talking with your care provider may be enough, or you may feel the need to put it all in writing, for yourself and for the others in attendance.

Location of Birth: [Local] Hospital.

Who will attend? My primary OB (if available), or other on-call doctor from the same practice; my husband; L&D nurse

Mode of birth: Vaginal birth (3rd VBAC)

Pain relief and other interventions: I prefer to avoid the use of any Pitocin during labor, as I have reacted poorly to it in the past (PP hemorrhage). I intend to avoid the use of any pain medications, including epidural or naroctics. I prefer to have an IV of saline placed for hydration and in case there is a need for additional IV meds (i.e., to prevent postpartum hemorrhage, of which I do have a history). I prefer to have assistance with breathing and relaxation techniques. I prefer not to be coached during pushing but to follow my body's cues. I prefer to use intermittent fetal monitoring if possible, and telemetry monitoring (wireless fetal monitoring) if available. I would like my waters to rupture spontaneously; I decline to have the amniotic sac artificially ruptured.

Mobility, pushing position: I would like the option to move around during labor, including walking, standing, sitting, squatting, depending on how I feel. I would like the option to use the shower. I would like to push in a "non-traditional" position, probably squatting, to open my pelvis, as my babies tend to have large heads. I prefer to avoid an episiotomy; if the care provider believes an episiotomy will be necessary, I prefer to be consulted first.

Upon delivery: I desire immediate skin-to-skin; please do not remove my baby from my person for any procedures, including weighing and measuring, until after the first breastfeeding has been accomplished. Please wipe him off with a towel but do not bathe, dress, or swaddle him (except a diaper) before he is put to my chest. All procedures, including Apgar scoring, vitamin K injection, etc., should be performed while I hold him. I prefer to delay cutting the umbilical cord. The doctor may cut the cord, unless my husband elects to. We have no plans to save the cord blood. If the doctor believes Pitocin is necessary after delivery for my safety and to prevent hemorrhage, I am open to this. Please use a local anesthetic when stitching up any tears or episiotomy. I do not wish to see or save the placenta; please dispose of it as usual.

Additional preferences: I decline to have the hepatitis B vaccination administered in the hospital. I decline to have him circumcised in the hospital. I insist on rooming-in to facilitate bonding and breastfeeding. I insist on delaying his bath until at least 12, preferably 24 hours of life.

Basically, my goal is a spontaneous, vaginal birth with little to no intervention. Because of my personal history of both pregnancy-induced hypertension and postpartum hemorrhage, I am aware that certain procedures or interventions may be desirable or necessary for my own safety. One of the decisions my husband and I have made in this regard is that I will always give birth in a hospital. Another is to allow an IV to be placed, as well as the use of Pitocin after delivery to help my uterus clamp down and slow the bleeding, if necessary. I am also aware (having given birth three times already) of both my capabilities and my limitations.

I have thought about possible complications. For most of these, I believe I and my husband are educated enough to make well-informed decisions if a situation should arise that is contrary to my stated preferences.

Surgical birth preferences: The most obvious less-preferable scenario would be a need for a cesarean section, either due to the baby's position or an emergency situation for me or the baby. The biggest concern if an emergency c-section is needed is that because I will most likely refuse an epidural in labor, a true emergency would require general anesthesia. If, however, it is possible to take the time to administer a spinal block, I would, of course, prefer to remain conscious during the surgery. I would then request immediate skin-to-skin and breastfeeding upon delivery of the baby, assuming baby is otherwise healthy once delivered. The rest of the surgery can be performed with the baby on my chest. I would want my husband in the OR with me.

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Did you write up birth preferences? How closely did your actual labor and delivery follow the "plan" you had in mind? Did you change your mind during labor about any of these preferences? Did you have a plan for any alternative scenarios? How open was your care provider to your birth preferences?

36 Weeks/9 Months!

Well folks, this is it, the final countdown, the home stretch, bottom of the 9th, um...I'm out of sports metaphors...I'm 36 weeks pregnant today, with about a month until my due date, which makes me officially nine months pregnant.

Over the next few weeks, I expect the baby to "drop" farther into my pelvis (which may, at least, relieve some of this relentless heartburn/reflux), more and stronger contractions as a preamble to labor, more discomfort, and plenty of impatience. And you, my fans, friends, and readers, will be anxiously awaiting that update, that notice, that announcement that the baby is on his way.

But when will that happen? Will he pop out on his due date or surprise me early? Will he be the first to throw me a curveball (ah, another sports metaphor) and hang on for a few extra days? Is he excited to come out and meet his brothers, or is he cozy and comfy in there with no desire to see the world? I surely don't know!

So, a fun little game, while we wait.

In the comments here or on the Facebook page, make your prediction! I'm taking guesses for birth date and birth weight.

Some vital stats, to help you make your prediction:
I'm measuring average/right on track for fundal height.
I have not gained excessive weight, but I'm far from tiny.
My first baby was born 2 days after his due date; my second was induced two weeks ahead of schedule (due to high blood pressure); my third was born 2 days before his due date.
This one's due date is October 22, according to LMP, or October 25 according to ultrasound. Take your pick.
My first baby was 9lbs., 1oz.; my second was 7lbs., 6oz.; my third was 8lbs.; 3oz.

Have at it! Let's hear what you think!

This, Too, Shall Pass, and Other Wisdom

I find myself, with about eight weeks left of this pregnancy, suddenly terrified of having a newborn again. This happens with each consecutive child. I cycle from excited, to thinking we must be crazy, to content, to excited, to terrified, to content, to excited, to OMG WHAT WERE WE THINKING?, then back to excited, then content, then terrified.

Part of it is our kids are spaced just-so, that we finally are at a point where sleep is basically working, routines are basically established, everybody's got some level of independence, and I feel like I'm in the groove, and then we throw another newborn into the mix and everything gets thrown out of whack again. And this being my fourth time through the ringer, well, I kind of do know what to expect.

In some ways, knowing what to expect is comforting. I know what to do with a newborn. I know phases start and phases end. I have almost seven years of watching kids grow up under my belt and have been through sleeplessness and teething and illness and firsts and potty training and nightmares and picky eating and tantrums and I know that "this, too, shall pass" is an absolute mantra of parenting. I know I can stick it out for a little longer until one problem ends as suddenly as another begins. I can pass along the sage wisdom of, "Just when you think you have it all figured out, they change it up on you again," and I can remember it for myself. I know that "do what works," "wait it out," and "give it another couple weeks" are absolute truths. I know that every kid is different, that every baby needs love, and that I have the strength and capacity to make it through this hour, this day, this week.

But in other ways, knowing what to expect is terrifying! I know about the sleepless nights, the crying for no reason (both me and the baby!), the stress of feeding issues and poo-splosions. I know about the pain of recovering from childbirth. I've experienced the complexities of balancing the needs of the older kids and the baby, and the sheer exhaustion of new parenthood. (And it's still new, even when it's for the fourth time.) I know about the disruption of routine, the randomness of life with a newborn, and the stress of evening fussiness. I know that sleepless nights and teething woes are once again on the horizon.

I find I do have a longer view than I used to. I'm already thinking about next fall, when my second will start kindergarten, my third will be three, and the new one, who is right know kicking and dancing within me, will be almost one. Because I can envision that, when it used to seem impossible that my kids would ever grow up, grow bigger, start school. It used to feel like toddlerhood was forever, that I'd be always wiping butts and noses (not simultaneously), cutting up food into tiny pieces, and washing sippy cups. Now I see that it is not. That life will change. That one day my days will be my own (except for school breaks and sickness), that my kids will be helpful in stores, that I won't have car seats to buckle or diapers to change, that I won't have to supervise trips to the bathroom, that as suddenly as life changes when you give birth, life gradually evolves again as that baby becomes a little person who walks and talks and has opinions all his own.

So, I'm terrified of the short term, of what I know is coming in the next few months and years. But I'm excited, too, about the long term, of watching another bright soul come into his own, of seeing our once-little family become huge and full of life and noise and warmth and love.

To those of you out there with one little one, or two little ones, who see life at knee-height, whose days are full of poop and whose nights are empty of sleep: give it a few weeks, months, a year. Life will expand. Your kids will grow. You will grow. You have the strength to make it through this hour, this day, this month. And while you may not look back fondly on every tantrum (yours or theirs), you'll look back and know that the weeks are shorter than they seem and that the months go by faster than you could ever have imagined.

Pregnancy Dreams

Pregnancy can bring on some very strange dreams. I remember when I was pregnant with my first, I dreamed I had given birth to a kitten and was nursing it. I then read another mother's story that she had dreamed of giving birth to spiders! I preferred the kitten dream.

If I'm experiencing any unrelated anxiety, it often translates in my dreams as pregnancy or delivery-related worries. This is especially true if I'm in any way uncomfortable as I sleep or if I'm experiencing any mild contractions (these are called Braxton-Hicks and are perfectly normal and of no concern unless they become progressively painful and more regular - more than four in a one-hour period).

The other night was one of those nights.

I dreamed that my baby was kicking so strongly that I could actually see individual toes through my skin. I then dreamed that I could actually see about half his body. My doctor informed me that I had a rare condition in which the baby was actually emerging through a hole in my uterus, and I required an immediate c-section. The next "scene" in the dream, I had just come out of the c-section, and was sitting at what looked like a cafeteria table, slightly uncomfortable. I asked the nurse if I could please lie down. She told me they had had to do an experimental new type of c-section in which the incision was horizontally across the top of my uterus instead of the more traditional low-transverse cut (also called the "bikini cut"). She said they didn't have a bed available, but that they'd give me one as soon as they could. I then asked if I could have my baby because I wanted to nurse him as soon as possible. She assured me they would bring him to me. Then I was holding my baby, who had a head of straight, black hair (my husband and I both have light-brown/reddish hair, and our three sons are two redheads and a blond) and looked slightly Asian in appearance (quite surprising, since my husband and I are both of European ancestry!).

That's about all I remember of the dream, but when I woke up, I found I was lying flat on my back and my arms were tingling. I had probably been in that position for a while and was experiencing the vague symptoms of reduced blood pressure and blood flow caused by the weight of my uterus on my vena cava. I rolled to my side and felt instantly better.

It's interesting, this dream, because the fact of the c-section itself didn't bother me at all. I was much more anxious about getting to meet and nurse my baby. I think my brain is coming to terms with knowing that I will in all likelihood have a successful and uneventful VBAC, but if a c-section is necessary, then it's necessary and isn't the end of the world. I also think I have so much on my mind right now that thinking about the birth is actually fairly low on the list of immediate concerns. Hey, it's nearly three months away right now. I've got stuff to worry about in the next few weeks totally unrelated to the birth of this baby. Indeed, my pregnancy is more of an inconvenience than anything! (Not that I'm not excited about the new baby!) In fact, in the dream I was already planning how I would present my birth story on the blog, both excited and slightly embarrassed to report on my c-section.

Obviously, I'm only about 28 weeks pregnant right now and have no intention of delivering this baby for another 11 to 12 weeks. But I know I'm definitely entering the third trimester, with all its associated discomforts and worries, and my subconscious is surely preparing itself for the birth, even if I have other things to occupy my conscious mind.

Have you had weird pregnancy or delivery dreams? Please share!

Guest Post: 8 Tips for Sleeping Comfortably During Pregnancy

Today we have a guest post from Scott Smith, a sleep counselor who advises on sleep and mattresses. He provides some tips for getting comfortable in bed during the different stages of pregnancy.

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Normally, the human body only makes significant changes to itself about every seven years or so.  The only natural exception to this rule is pregnancy.  Within nine months, body parts change size, the sleeping position that used to be comfortable is no longer possible, and the body is under a different type of stress and strain that may need different support.

While it’s unrealistic to change your mattress at every new stage, there are some things that can make you more comfortable on the bed that you have, through each trimester of pregnancy. 

First Trimester Tips:

• During the first trimester, the outside of your body isn’t changing much, but the inside is.  This is a great time to prepare your bed for the coming months by adding a waterproof mattress protector.  This will protect your bed against uncontrollable morning sickness, weakening of your bladder control muscles, as well as if your water breaks while in bed.
• You may notice some breast tenderness that will make stomach sleeping uncomfortable.  Try to sleep on your side, and hug a pillow to your chest to keep your chest open.  Also put a pillow between your knees to keep your hips comfortable.

Second Trimester Tips:

• As your body starts to change, your sleeping will also.  Sleeping on your stomach, if it was still possible until this point, will now be out of the question.  Similarly, back sleeping will become uncomfortable as your developing baby weighs on your other organs.  Sleep on your left side for optimal blood flow and nutrients to your baby.  Laying on the left can also help your kidneys do their job, which can ease swelling in your extremities.  Follow the pillow tips above for more comfortable sleep.
• Some women feel increased sensitivity in their ribs and hips, and may be tossing and turning a lot at night.  If this is the case, think about adding a mattress topper to your existing mattress, to make it a little softer and to ease those pressure points.
• Acid reflux can be problematic starting in the second trimester.  If you don’t have an adjustable bed, consider purchasing a wedge to sleep on at night, to elevate your head and torso.  Also, avoid eating right before bed, as well eating acidic foods such as tomato sauce, spicy food, or citrus.

Third Trimester Tips:

• Back soreness and pain is par for the course in the third trimester, so you want to make sure that you’re on a mattress that is supportive enough, without being too firm.  Have your partner stand behind you while you’re lying on your side, to make sure that your spine isn’t curved.  Arrange pillows to support your spine, by either placing them under your stomach, along your back, or between your knees.
• With all that extra blood that’s pumping through you, it’s easy to become overheated.  Instead of one big comforter, consider using layers to keep yourself warm.  That way, you can throw off and put on layers at will to maintain your perfect temperature.
• It may be difficult to get out of bed if you’re at the end of your pregnancy, especially if the bed is very soft.  Put a heavy piece of furniture next to the bed to help you pull yourself out.  Also, perfect the “pregnancy roll”, and roll yourself out of bed instead of trying to sit up.

Pregnancy is a wonderful time, but it can also be quite uncomfortable.  Your body is not only supporting itself, but is also forming a new person.  You need to treat it well, let it rest, and promote comfort so that it can put its best towards your new baby. 

If you are considering purchasing a new bed before or during pregnancy, really look hard at what you’ll need both during this time, as well as after. 

Scott Smith is the author of DrSnooze and a Sleep Counselor who also advises on sleep and mattresses. Follow him @DrsnoozeMatt and visit his blog at http://www.drsnooze.com/blog/ or http://www.drsnooze.com/brands/comforpedic.html

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Are you finding it difficult to get comfortable in bed as your pregnancy progresses? Try out some of Scott's tips and let us know if they helped you! Do you have anything to add from your own experience?

Some General Early Pregnancy Information and Advice

I started writing this as the second in my Childbirth Choices Series, and found that I was bursting with information to share about pregnancy, especially the early days. (Hey, I've done it four times, after all!) It doesn't seem to fit into the framework of the Childbirth Choices Series, but I wanted to make the information available. If you are thinking about trying to conceive or you've just found out you're pregnant, this post will probably be very informative. I've organized it by topic, so you can skip around to the specific questions you may have; you could also just read it top to bottom, of course, or come back and revisit sections as you go along. This would be especially good to read before your first provider appointment, since there will likely be some time before your first meeting. Often, you won't be seen until you are about eight or nine weeks along. If you are still trying to decide on a provider (and I hope my Childbirth Choices Series Part I post is helpful in that regard), you may try calling a few providers and asking if you can schedule a "meet and greet" before your first appointment - or even before you're pregnant - so that you can get a feel for their personality, the way their office is run, and ask any questions you have about their policies and practice.

Remember, also, that if after your first appointment you find that you're not comfortable with the person you met - for whatever reason! - you can switch to someone else. Your provider works for you, and you're under no obligation to remain with the practitioner you see initially.

Let's look at some common questions first-time parents have.

**Please note that I am not a medical provider  or practitioner. This advice is based on personal experience and research only. If you have any concerns, please contact your maternity care provider or general physician.**

How is my due date calculated? How "far along" am I?

In the early 19th century, a German obstetrician named Franz Naegele came up with a rule for estimating when a woman can expect to go into labor. The calculation is 280 days (40 weeks) from the first day of the woman's last menstrual period. This measurement is still used today as the standard calculation of your EDD - your estimated due date. If you know the date that your last period began, you simply count 40 weeks from that date on a calendar. Wherever your finger lands, that's your EDD. You can also find dozens of calculators on the internet that can help you do this. Just type "due date calculator" into your favorite search engine and one will pop right up. These will typically simply ask you for the date your last period started and then return your estimated due date. If you don't know the exact date of your last period, or you have a very irregular cycle, it may be difficult to estimate your due date. Some women have a sense of when they conceived. You can also use this date to find out your due date. Simply count 38 weeks from that date. If you really have no idea, then your provider can use a transvaginal ultrasound at your first appointment to take a look at the fetus and estimate its gestational age based on its size and development. From the gestational age, they can calculate a due date.

Please remember that 40 weeks is an estimate, a convenient and standard measurement to gauge the length and health of the pregnancy. Many, many pregnancies progress beyond the 40-week point, and it is normal to continue even on to 42 weeks without complications or danger to you or your baby. Your provider will want to monitor you and the baby if your pregnancy goes "post-dates" or overdue (beyond the EDD), but you should be aware that the average first pregnancy may run as long as 41.5 weeks. A "full term" pregnancy is considered one that runs to at least 38 weeks before the spontaneous labor begins.

Some definitions before we continue:

LMP - Last Menstrual Period - Use this date to find out how long you've been pregnant. Count the number of weeks and days since the first day of your last period. For example, if your last period began on January 15 and it's now April 1, you are 10 weeks and 5 days pregnant, often abbreviated 10w5d. Also use this date to find out your EDD by counting 40 weeks from that date.

EDD - Estimated Due Date - The date 40 weeks from your LMP, or a date chosen based on the measurements obtained in an early transvaginal ultrasound.

Transvaginal ultrasound - Your provider may use a special ultrasound machine to confirm and date your pregnancy. This machine has a computer screen and a probe that she or he will insert into your vagina. The probe emits sound waves which bounce off structures inside your body, creating a picture on the screen. Your provider will use this to find the developing fetus in your uterus. You will be able to see the heart beating, and the provider will take measurements to estimate the age and size of the fetus. These estimates will be compared to the EDD based on your LMP (if you know it), and your due date may be revised if there is a large discrepancy between the two estimates. An ultrasound may also be used if any problems are suspected, to check the placement of the pregnancy (ensure that it's in the uterus and not in the Fallopian tube, which called an ectopic pregnancy and is life-threatening to the mother), and to view the heart beat, since it cannot be heard externally early in the pregnancy. Your provider will likely print off a few pictures for you to keep. At about 8 to 9 weeks, the baby will look like a peanut in the ultrasound picture.

Gestational Age - The gestational age is how "old" your baby is inside the womb. "Gestation" is the length of the pregnancy. So the gestational age of your baby is how long you've been pregnant. 

So, when someone asks you how far along you are, you can give them the number of weeks and days since your LMP, if you want. You can also estimate how many months until your due date and subtract that from nine if you want to give a more vague answer. So, if you're due at the end of October and it's now mid-May, you can say that you're about four months along. (There are five months from May to October. Nine minus five is four.)

This can be confusing, because you aren't actually pregnant yet when your period starts (obviously). Your date of conception is hard to guess. Even if you had intercourse exactly once in the past few months, and know this exact date, that is probably not the date of conception, since it can take one to five days for the sperm to encounter and fertilize the egg. Since the LMP is a more exact date, it is easier to calculate from that point. Especially if you have an irregular cycle, you may have no real idea of when you actually ovulated.

Spontaneous labor - Most of the time, your labor will begin on its own when your baby is ready to come and your body is ready for birth. When you go into labor without any assistance or intervention from medications, this is called "spontaneous labor." Spontaneous labor after 38 weeks is considered a full-term pregnancy, and your baby should be fully grown and ready to face life outside the womb. If you go into labor before 38 weeks, your baby may be considered premature and may need medical assistance in the early days of life. If the labor begins very early in the pregnancy, your provider may recommend attempting to stop the contractions and take measures to put off the birth as long as it is possible and safe for you and the baby to do so.

When should I announce my pregnancy?

You may want to wait some time before you announce your pregnancy. This is normal and expected, and the reason is simple: miscarriages in the early weeks are quite common, occurring in about 10 to 25% of pregnancies. I don't want to sound negative or tempt fate, but if you've happily announced your pregnancy to everyone you know, only to suffer a miscarriage, it is no fun to have to figure out who knows and go back and tell everyone "never mind." Not to mention the pain of having someone asking when you're due or how far along you are now because they didn't get the message. Most women wait until at least the first prenatal appointment, when the health of the pregnancy can be assessed, or even until after about 12 or 13 weeks, when the risk of miscarriage drops considerably. And, some families choose to wait until the pregnancy starts to show, which can be as late as four or five months, or even longer depending on how you're carrying. You may want to choose a trusted family member or friend to tell sooner in order to get support and advice, especially if it's your first pregnancy.

What are the early symptoms of pregnancy? What can I do to feel better? How long does morning sickness last?

Here is a list of symptoms you may or may not experience in the first few months of pregnancy. Some women experience all of these, while others experience none. You may also experience symptoms that are not on this list. They may or may not be caused by the pregnancy. We tend to attribute anything "weird" to the fact that we're pregnant, even if it's actually just something we ate!

• fatigue
• insomnia
• constipation
• frequent need to pee
• nausea and/or vomiting
• heartburn
• food aversions (feeling disgusted by eating or smelling certain foods that you'd normally enjoy)
• food cravings (sudden overwhelming desire to eat certain foods or types of foods)
• increased appetite
• decreased appetite (if you're feeling especially nauseous)
• sore/tender breasts
• sensitive/sore nipples
• irritability or mood swings
• a feeling of tugging or pulling in your lower abdomen
• lower abdominal pains or uterine cramping
• low back pain
• vaginal dryness or itching
• increased vaginal discharge
• vaginal yeast infection or bacterial vaginal infection
• stuffy nose
• heightened sense of smell
• bizarre and vivid dreams
• decreased libido

Morning Sickness

The hallmark of early pregnancy is, of course, "morning sickness." Morning sickness affects many women in the first three months or so of pregnancy and is usually characterized by nausea (the feeling that you're going to throw up) and/or vomiting, especially in the morning or on an empty stomach. (You typically experience it more in the morning because your stomach is empty.) If you talk to other women who have been pregnant, or you look on the internet, you'll find numerous "remedies" for morning sickness. Like hiccups remedies, some of these work for some people, while others simply suffer no matter what they try. 

Here are some general tips for managing mild to moderate morning sickness that I've found helpful through four pregnancies:

• Eat! Even though you don't feel like it, the nausea is usually worse on an empty stomach. If you can eat a few crackers or something before the nausea sets in, sometimes you can head it off.
• Stay hydrated! The nausea is worse when you're dehydrated. Also, if you are vomiting more than once or twice a day, you're probably losing fluids, and you need to make sure you're replenishing them.
• Some foods help some women find relief from nausea. These include ginger, almonds, ginger ale, crackers, or toast.
• Motion sickness wrist bands help some women.
• Eat what you crave. This may sound odd, but sometimes you'll feel better if you just eat what you feel like eating (unless you are craving a non-food item, such as chalk, dirt, or ice. This is called "pica," and can be indicative of a vitamin or mineral deficiency. If you experience pica, contact your provider).

For most women, morning sickness goes away around 14 or 15 weeks of pregnancy, when you enter the second trimester and your hormonal balance changes. Some women find that they are sick for most or all of their pregnancy. If you feel you are experiencing excessive morning sickness, especially if you are losing weight, you may want to contact your provider for advice or an earlier examination.

Hyperemesis Gravidarum

For some, perhaps 2% of pregnant women, "morning sickness" is very severe. They may vomit multiple times a day, experience rapid or severe weight loss due to inability to keep down any food, extreme nausea, and severe dehydration due to inability to keep fluids down. This can be very dangerous to you and to your growing baby. These symptoms may last well beyond the first three months and may even continue throughout the pregnancy. Excessive vomiting in pregnancy is a medical condition called Hyperemesis Gravidarum (HG), which literally means "excessive vomiting of pregnancy". If you are experiencing these symptoms, contact your provider. Some women respond well to anti-nausea or anti-vomiting (antiemetic) medications, while others may require stronger interventions such as IV fluids or even hospitalization. If you have or think you have HG, you may find www.helpher.org helpful for information and support.

What is a trimester? What trimester am I in? What kind of symptoms can I expect in each trimester?

Pregnancy is about nine months long and is divided into three approximately three-month segments, called "trimesters." Each trimester has certain characteristics, and as you move from one trimester into the next, you will probably be able to tell that you've entered a new "phase."

The First Trimester

The first trimester runs for the first 12 to 14 weeks of the pregnancy. Your pregnancy may not show yet, but you may experience some of the symptoms listed above as "early" symptoms of pregnancy. (Some of these symptoms may continue on and off throughout the pregnancy.)

Many early pregnancy symptoms will be similar to the symptoms you experience just before or during your period. I don't want to scare you with that list. Like I said, you may experience some or all of these symptoms. You may not have any of them, and some lucky few will have all of them. They may come and go throughout the weeks. And sometimes they may be there but not bother you that much, or you'll get used to it. The absence or presence of any or all of these symptoms is not a measure of how healthy your pregnancy is.

Toward the end of the first trimester, or perhaps early in the second trimester, your care provider will be able to start listening to your baby's heartbeat externally using a stethoscope or Doppler machine. It is fun and reassuring to hear the heartbeat thump-thumping away at each prenatal visit!

The Second Trimester

The second trimester runs from about 12-14 to 28-30 weeks of pregnancy, the middle three months. The second trimester is usually the most pleasant phase of pregnancy. Your body will start producing hormones that give you a sense of well-being and excitement about your pregnancy. Many of the early symptoms will fade, especially morning sickness for most women, and you should have more energy. Your pregnancy will likely start to show sometime in the second trimester (if it doesn't show already), and you'll probably begin to tell people about it. You should find that some of the insomnia fades as well. Your strange and vivid dreams may continue, as will your enhanced sense of smell and some other symptoms. By the beginning of the second trimester, your breasts have begun manufacturing and storing colostrum, the early milk that will nourish your baby for the first three or four days after birth. Some women may experience a small amount of colostrum leakage, seen as a yellow crust on the nipple or in your bra, although this doesn't typically start until the third trimester, if it happens at all (all of these scenarios are normal). Your breasts may still be tender. You may find you have an increased libido (which should please your partner) in the second trimester as well, and your breasts will likely have become noticeably bigger.

In the second trimester and forward, you'll want to avoid lying flat on your back for long periods of time. The uterus is getting bigger and heavier and will put pressure on the vena cava, a major vein carrying blood from the lower half of your body back to the heart. You may start to feel light-headed or uncomfortable if you lie on your back. Lying on your left side is the best position for maximizing blood flow. If you find you've rolled onto your back while sleeping, don't panic! Just roll to one side or the other (preferably the left side) once you become aware of your position.

Try not to overeat. Especially when or if your morning sickness goes away, you may find that you are hungrier than you're used to being. You are expected to gain some weight during pregnancy - up to 25-35 pounds by the end. I'm not here to tell you to diet or starve yourself, and I'm not able to give you specific nutritional advice. But be aware that you are not actually "eating for two" - pregnancy consumes approximately 300 more calories per day than you would need if you were not pregnant, so plan your meals accordingly.

The best part of the second trimester is that at some point you'll start to feel the baby moving and kicking. You can start feeling this as early as 14-15 weeks and as late as 22 weeks, depending on your size, how you're carrying, the baby's position, and the location of your placenta. (If the placenta is anterior - in the front - then it will block the sensation of kicking until the kicks become stronger.) At first, these "kicks" will feel like little twitches in your abdomen. Most women compare them to feeling like gas bubbles or minor muscle spasms. After a while, they'll become unmistakable as coming from the baby, and you'll enjoy knowing that your baby is busy in there. Your provider may ask you to do "kick counts," which just means to make sure you feel 10 movements in one hour each day, just to make sure the baby is okay. If you go a day without feeling any movement, you may want to try drinking a glass of ice water or orange juice and paying close attention. It may be that you were just distracted from baby's movements, and a glass of cold, cold water or orange juice will encourage the baby to move around so you can be sure everything's okay. Your provider will tell you at what point you should call if you are concerned about a lack of movement.

Sometime during the second or third trimester, you may become aware of mild but strong contractions, usually not painful, in your uterus. Since early pregnancy, your uterus has starting contracting occasionally to "warm up" for the big day. These contractions are normal and are called "Braxton-Hicks" contractions. If these become strong or bothersome, you may want to try drinking at least three glasses of water and then lying down on your left side for a while. Sometimes you may experience strong contractions if you are dehydrated and/or tired. If you experience four or more strong contractions in one hour, or the contractions develop into a regular pattern that lasts for more than one hour after you've made sure you're hydrated and rested, you should contact your care provider to see if you need to have your cervix checked or what your next step should be.

The Third Trimester

The third trimester is the final three months of the pregnancy, running from 28-30 weeks to the onset of labor or delivery of the baby, generally between 38 and 42 weeks. The third trimester is can be fairly uncomfortable. Your belly is getting bigger and your baby is getting heavier, which may cause more aches and pains, especially in your back and legs. Your fatigue and insomnia may return, partly because you find it more difficult to get comfortable in bed. You may experience some swelling in your hands, feet, and ankles. You will probably need to pee more often, because the baby is putting pressure on your bladder. You may also experience pain and pressure in your pelvis or hips. During pregnancy, your body releases a hormone called relaxin that causes your joints to loosen up so that your pelvis can expand for delivery of the baby. This can cause other joints, such as your hips, knees, ankles, and wrists, to also become more injury prone. You may find that you have to stand up more carefully or that you develop soreness in your wrists, especially if you work at a repetitive motion job such as typing. It is fairly common to experience carpal tunnel syndrome, for example, during pregnancy.

In the third trimester, you'll want to pay close attention to your posture. When you stand up straight, you don't want to allow your back to curve inward too much - this will cause your lower back to hurt more. Let your bottom drop a bit to rotate your hips toward your back slightly. You'll know when it feels right. Also, if you wear a shoe that has a slightly raised heel (about 1 to 2 inches), this can be quite comfortable. There are products that can help support your belly if your back hurts badly as well. When you sleep, you can stick a pillow between your legs when you lie on your side, and you can support your back and belly with pillows as well to find more comfort.

Can I exercise when I'm pregnant?

Yes! If you had a regular exercise routine before you became pregnant, you can probably continue with this routine during your pregnancy. You may need to modify some of your activities depending on how strenuous they are or how much pressure they put on your abdomen. Some activities may become impossible, impractical, or dangerous to the baby due to potential falls, such as biking or horseback riding. If you're a runner, you will want to be careful, as your balance will be affected by the changes in your center of gravity as your baby grows. Swimming is excellent exercise while pregnant, as are yoga (with modified poses for pregnancy), pilates (again, modified for pregnancy), and walking. If you have not had a regular exercise routine before becoming pregnant, don't start something intense or strenuous that your body is not used to doing. Starting a walking routine or some other type of low-impact, low-stress exercise is very beneficial both for weight management and your overall health and feelings of well-being. In addition, being active during your pregnancy will help settle the baby into a good position for labor and delivery.

When you exercise, pay attention to what your body is telling you. Make sure you don't allow yourself to overheat and stay well hydrated. If you find you are getting sore or tired, stop. You may not be able to do as much or exercise for as long as you could before you became pregnant. If you find that you are having contractions, stop, drink two or three glasses of water, and lie down on your left side for a while. Contractions are usually triggered by exhaustion and dehydration, and if it is not time for you to give birth, you need to heed your body's message that you need to rest. If you notice any vaginal bleeding, stop what you're doing and call your care provider. If you have any questions or concerns about your exercise routine while pregnant, talk to your care provider.

When should I contact my provider?

Any time you have a concern, you should feel comfortable calling your provider. Your provider should also give you some general guidelines as to when you should definitely call. These may include (but are not limited to)*:

• regular contractions, at least four in one hour lasting at least 30 seconds each
• vaginal bleeding (some light spotting in the early days is fairly normal, but heavy bleeding is not)
• excessive vomiting, inability to keep food or liquids down
• severe abdominal cramping or back pain
• sudden severe headache and vision changes
• sudden swelling in the ankles and hands
• lack of movement from the baby for 24 hours after you've started feeling regular kicking

*Please remember that I am not a licensed medical professional and cannot give you specific medical advice. If you have any concerns about your pregnancy or you want to know if something you are experiencing is normal, please contact your provider!

What should I stop eating? What should I start eating?

For the most part, you can maintain your usual diet while pregnant. You want to make sure you're getting enough vitamins and minerals, especially B vitamins, folic acid, calcium, and Vitamin D. Taking a prenatal vitamin or other vitamin supplements can help. Since pregnancy can make you prone to constipation, make sure you drink enough water and get plenty of fiber. If you're not sure whether you need to make specific changes to your diet, of course speak with your care provider. You may find that you're hungrier than you normally would be. Building another human takes calories, but pregnancy typically takes only about 300 more calories than you'd need in a day if you weren't pregnant. This means you don't need to increase your food intake by much - you are certainly not eating for two. The bulk of those extra calories should be from healthy foods, if possible!

There are a few foods to think about minimizing or eliminating while pregnant. While your system may be strong enough to handle food-borne toxins and bacteria, your baby's may not be. Foods that you may want to avoid for this reason include unpasteurized soft cheeses, processed deli meats, and raw sushi (you can still eat vegetable sushi or sushi made with cooked fish). Tuna and salmon tend to contain high amounts of mercury, which may negatively affect your baby's development. Mercury is toxic and can cause brain damage in high doses, especially to the developing brain of a fetus. Mercury is considered to have a cumulative effect, meaning that the more of it you consume, the more you store in your body. For that reason, it is recommended that pregnant women eat no more than one to two 5-ounce cans of tuna per week. If you're nervous about mercury, you can simply avoid tuna, but do eat other fish if you can, because the fish oils are very, very good for you and your baby! Plenty of other fish are quite safe (when cooked, of course!), such as cod, haddock, tilapia, and mahi mahi.

What medications can I take while pregnant? Do I need to stop taking the medications I'm on?

As I am not a doctor or pharmacist, I can't speak about specific medications. However, it is useful to know that there are certain medications that are considered safe during pregnancy. Personally, I try to avoid taking anything unless I absolutely have to, but sometimes that headache or backache is just too much, or you have a bacterial infection, or you can't sleep because your nose is soooo stuffy or you can't stop coughing. In those cases, if less medication-oriented remedies don't help, you can contact your care provider for suggestions. In the past, I've had doctors and midwives tell me it's safe to take Tylenol (as directed on the bottle), Benadryl, and certain decongestants and expectorants. I've also taken certain antibiotics for sinus infections and UTI's during pregnancy. There are definitely medications that have been proven to be harmful to the fetus, and there are some that are suspected to be harmful. For example, ibuprofen (Advil/Motrin) is not generally considered safe during pregnancy.

If you are on a medication for a chronic condition such as a psychiatric disorder, high blood pressure, diabetes, or asthma, talk with your prescribing doctor and your care provider as soon as you find out you're pregnant - or even sooner if you're planning to become pregnant - to see if what you are taking is safe for the baby. You may have to weigh the relatives risks and benefits of taking a medication if it is essential for your own physical or mental health, and that is something you'll have to discuss with your doctor(s).

Why do I need to take a prenatal vitamin? Can I take a regular multivitamin instead?

It is important that you get enough folic acid while pregnant to prevent neural tube defects in your baby. The most well-known type of neural tube defect is spina bifida, which can cause severe disabilities or death in your baby. Taking 800mcg (micrograms) of folic acid daily can prevent spina bifida and other related disorders. Prenatal vitamins are specifically formulated with extra folic acid and a balance of other vitamins and minerals that you need as a pregnant woman. If you can't tolerate your prenatal vitamin (and they do make some women feel sick), you can talk to your care provider about taking a regular or gummie multivitamin or even a children's multivitamin, or you can ask if there are other options available. You will also want to make sure you are getting enough iron in your diet to prevent anemia. If you are having trouble with muscle cramps, a calcium-magnesium supplement can help as well.

What can you tell me about using alcohol and cigarettes while pregnant?

The general rule with alcohol during pregnancy is don't drink alcohol. This is because it is not known what the threshold alcohol intake is before it begins to affect the baby's development. For some women, it appears that just one drink can cause problems, especially if she has a history of heavy alcohol use. In my view, and in the view of most practitioners, it's easy enough to simply not drink alcohol and not take the chance. Fetal alcohol syndrome is real, and it's permanent, and it's preventable. In Europe, you'll find a slightly more relaxed attitude toward alcohol during pregnancy, but this is something you'll have to discuss with your care provider and do your own research on.

As far as cigarettes, smoking during pregnancy can cause a host of problems for your developing baby as well. Because smoking reduces oxygen to your baby, smoking during pregnancy can cause your baby to be of low birth weight, which may cause long-term problems. Smoking may also contribute to preterm birth, which can mean lengthy hospital stays and lifelong health problems as well. Smoking during pregnancy also increases the baby's risk of asthma and other breathing problems as well as the risk of SIDS (sudden infant death syndrome, also known as "crib death"). Nicotine may also cross the placenta and affect the baby's brain development. If you can quit, that would be the best option. If you're finding it too stressful to quit cold turkey, speak with your care provider about getting support and help with quitting, and try to cut back as much as you can, or go as long as possible between cigarettes to maximize the oxygen your baby gets.


Do you have other questions about early pregnancy you'd like answered? Comment below!

Sitting Around Waiting To Go Into Labor...

No baby yet. I still hope to be posting a birth story soon. (Like, really soon? Maybe?)

I'm very happy to report that this pregnancy has been my "healthiest," in terms of weight gain and overall feelings of well-being. The very beginning was rough. I didn't have much morning sickness, but I had some other weird symptoms that were apparently hormonal, and I also had a lot of trouble with my sciatic nerve until the middle of the second trimester. However, I haven't gained nearly as much weight as I did in my first two pregnancies, and, in even better news, my blood pressure has been very stable! Every week now when I see my CNM, I wait anxiously for the blood pressure monitor to display my numbers, and every week I heave a great sigh of relief when the numbers are in the normal range once again. My biggest worry since the beginning of this pregnancy would be that I would have high blood pressure again and need to be induced or c-sectioned.

I am now 38 weeks, and delivery seems imminent. For almost two weeks, now, I've been having intermittent contractions, strong but relatively painless. I can feel that the baby is moving down, and when I told my CNM that I had showed up to the hospital dilated 4cm with my second son, she decided to check my dilation at my office visit just to see what was going on. As of Wednesday, I was 3cm dilated and 80% effaced, and she could just feel the baby's head! She swept my membranes, saying that if labor was on the verge of starting, doing so could get things going. And yet, here I am, five days later, still no baby. Amazing how pregnancy can fake you out even right at the end.

I wrote out a "birth plan" and then decided not to print it. I have just a few desires for this birth, the main one of which is "have a vaginal birth." My intention is to avoid all interventions (IV, Pitocin, epidural) not because I have any kind of "earth mama" thing going, not because I'm altruistic or hippy or crunchy, not because I have any kind of "I am woman, hear me roar" complex (I'm more likely to whimper than roar), but because, to be honest, I'm more afraid of the drugs than I am of the pain of labor. Now that I know as much as I do about how interventions can negatively affect the birth outcome and the health of the mother and baby, I'm afraid of them.

I know this sounds a bit silly. I've had Pitocin and epidural with both previous deliveries. How can I now be afraid of them, when I consented to them before?

Well.

My first birth did not go at all as I'd hoped, ending in a rather unfortunate c-section as it did. I went into that birth wholly uninformed about what epidurals and Pitocin really do. My second birth went phenomenally well, but even so, I avoided the epidural as long as I could because I knew being mobile might be key to having the VBAC I wanted. As for the Pitocin in that second birth, when they present to you your option of "have a stroke or give birth right now," it's sort of a no-brainer.

So why am I so afraid now? Well, I learned that the use of Pitocin is linked to increased risk of both postpartum hemorrhage in the mother and jaundice in the baby. Both of my sons were jaundiced enough to require home phototherapy, and both births resulted in postpartum hemorrhage for me. I don't think it's unreasonable to want to avoid Pitocin, knowing that! And I'm more likely to avoid Pitocin and get the baby out more easily if I also avoid an epidural, which would require me to spend the rest of the labor on my back, which I'm really not that interested in doing. I figure I'll play it by ear, though.

This time, my blood pressure is steady, my weight gain is good, the baby seems to be average size (I've been measuring right on target for fundal height, at least), and everything is progressing normally. I get to have a spontaneous labor, and I'm GBS (group B strep) negative, which means they won't require IV antibiotics during labor, which means I get to choose, well, pretty much everything. Having so much choice, in a way, is scary. I admit that part of me was hoping my blood pressure would spike and they'd tell me they had to induce (a very very small part of me, of course). Part of me was hoping that when she did that internal check and swept my membranes, labor would start. The biggest part of me, certainly, keeps reminding the rest of me that "He'll come when he's ready" and "Don't be in such a hurry." Really, I'm just uncomfortable.

I think what gets me is the uncertainty. I've been so sure, every evening, that tonight will be the night. And then it isn't. But surely tomorrow? No? I keep reminding myself that I haven't even reached my due date, but when you've been having contractions for almost two weeks, the due date starts to seem a little irrelevant. Why won't the contractions build into labor?

Because?

Because either the baby or my body just isn't quite ready. I'd venture to say my body is quite ready, which leads me to believe the baby has just a little more growing to do. And I want to let him do that.

Did you know that in the last few weeks, the lungs and brain are still developing? That's why medically unnecessary scheduled inductions and c-sections before 39 weeks are not recommended. In fact, some hospitals are banning them. Babies born between 37 and 39 weeks are being called "late-term preemies," and quite a few beds in the NICU are taken up by these babies who were born, unnecessarily, before they were quite ready.

So I'll stick it out a bit longer. I'll be 39 weeks on Wednesday, and then I'll have a serious talk with the little guy inside, because, really, I'm kind of tired of all this almost-labor business. I've reached a point where when I sit on the toilet, I'm sure I'll go to wipe and find his head crowning. In some ways, that's pretty cool. In other ways, well... My preferred hospital is 45 minutes away, and I'd like a little warning before the whole crowning thing!

So, here's hoping my next post will be a birth story. In the meantime, anyone else out there who's almost in labor, like me, hang in there! We won't be pregnant forever, and a week isn't really that long.