What are most expecting moms thinking about as they prepare for parental leave? Labor & Delivery.

There's a broad spectrum of how people feel going into the experience, but it is a really pivotal event. How delivery unfolds is unique to you and your baby. 

Dr. Christie Porter joined us to listen to birth stories from recent moms, and unpack the labor interventions they experienced.

Jill’s vaginal delivery

Jillana is a cancer survivor who didn’t expect to be able to have a baby. So when she found out that she was pregnant, she had a lot of anxieties to work through. Her history with chemotherapy and her age put her in a high risk category. Towards the end of her pregnancy, she experienced severe sciatica pain and some really bad back pain. 

Dr. Porter shares: usually chemotherapy does prevent you from ovulating. But you can have spontaneous ovulation - Jill and her partner just happened to have sex at the exact correct time. At age 35 (and older), you get the fun title of Advanced Maternal Age (AMA) which adds the extra risk factor (which is fine). 

Jill’s labor contractions started on a Tuesday, 2.5 weeks before her due date. She had planned on using HypnoBirthing technique - striving for mind over matter, very calm and breathe through contractions. She planned to avoid as many interventions as possible with being open to whatever might be needed.

Jill worked through the day Tuesday, with contractions 30-45 minutes apart. After wrapping up work in the evening, they kicked into high gear - 10 minutes apart and then about 5 minutes apart. She and her husband got to the hospital about 10:00 p.m…already fairly exhausted after not sleeping well Monday night and working all day Tuesday. 

In triage space, Jill and her husband kept the room dark, lit only by the light of the moon, and focused on her breathing exercises. Within a couple hours, she was measuring 5cm dilated and moved from triage to an assigned L&D room. During the walk through the halls, Jill discussed with her team what was coming next; she was really feeling the lack of sleep. 

“I was at the point where it wasn't the pain of contractions; now I'm doing this intense physical marathon and so it was simply the rest that made me scrap my plans for an unmedicated birth.”

Based on hearing how long different medication options would take to get set up and be effective, Jill opted to get an epidural started. The nurse shared that it would take about 45 min to get settled in the room, get the anesthesiologist in, and then get the epidural running. 

Once that happened, Jill was able to get a short nap in. She says “I swear that that put the wind in my sails. I woke up and was just like okay. I am ready to go.”

Dr. Porter says: never feel bad when you get an epidural. Labor is a pain that you have never experienced before so you don't know what you're going to anticipate or how your body is going to react to that pain. Getting an epidural is not something to feel defeated about. 

Labor is a marathon (~36 hours in Jill’s case) and then you have to run a second marathon of pushing! The average push time for first time mamas is 2 hours. Some can push a baby out in 30 minutes and others need 3-4 hours. Sometimes that nap is needed, that epidural can really help when you’re exhausted.

Jill partied …err labored…through the night (hypno silence out, good music in), chatting with nurses between contractions. As the 7am shift change came around, her OB told her “this baby needs to come out. Right now I'm giving you like 15 minutes here and if we don't get the baby out I might have to get the vacuum.” That was enough motivation. Within that 15 minutes, Baby Odesa joined the world! 

Dr.P: As an OB, I talk about the risks & benefits of a vacuum when there are signs that we need to have the baby soon. I want to have a full-on conversation before it gets to the emergency. That's something you can do with your OB - Pause, and ask “Can we please talk about this more?” to make sure you understand the risks & benefits of it for your situation. In Jill’s case, her baby had some heart tone problems that raised the concern around timing.

“For all the anxiety and fears I had about labor and delivery it felt like I had put way too much thought into that and not enough into breastfeeding and everything. If anybody out there is anxious like I was, it's an experience for sure, but one that you know deep down, one way or another your body, yourself, your doctors - you're going to get through it.”

Other considerations from Dr. Porter:

• An epidural also helps with pain for any repairs your doctor needs to make (stitches from tearing). If you haven't had an epidural, we use a little bit of lidocaine to numb the area.
• Intrauterine pressure catheter (IUPC) is a small device that slides in between your baby and your uterus that can tell us the strength of contractions. 
• Fetal scout electrode (FSC) - wire that goes into the skin on baby’s head to check the heart tones, and gives us a direct reading of the fetal heart rate. This may cause a tiny scab which will fall off (like other tiny scabs). 
• Labor & pushing are intense for you, but it's also intense for your baby. If they're having heart tone problems, they probably didn't get the huge squeeze needed to get all the fluid out of their lungs. It’s very common to give some oxygen to help open up those lungs and get that fluid out. They've changed the guidelines for neonatal resuscitation to be more aggressive with getting fluid out to help prevent bad things. And so a lot of babies get a little bit more oxygen at time of delivery or brief 24 hours to spend in the NICU. 
• Peanut Ball looks like a circus peanut that goes in between your legs to help open up your pelvic outlet, allowing for the baby's head to rock and come down into the pelvis. 

Caitlin’s journey to C-Section Delivery

Caitlin worked with an OB/GYN and planned for an induction around 38 weeks from the start of her pregnancy. She was considered high risk due to her age, elevated blood pressure (pre-pregnancy) and having gone through IVF. 

Dr.P: Chronic hypertension does put you at higher risk for preeclampsia. And the risk of developing postpartum preeclampsia goes up to 6 weeks postpartum. The American College of Obstetrics & Gynecology (ACOG) is our governing board that publishes guidelines for what to do related to maternal and fetal health problems. With chronic hypertension, the recommendation is to induce between 38 and 39 weeks. If you develop high blood pressure during pregnancy, then it's usually 37 weeks. 

Caitlin had an enjoyable, easy pregnancy. She planned the induction for 38.5 weeks with an epidural, and knew that it was likely to be a long labor because her cervix was fully closed at her last appointment. When she went in Monday morning for her induction, her cervix was fully closed. Caitlin felt lucky to have one of her best friends, a labor and delivery nurse in the room with her. It felt so nice to have a confidante with her! The medical team gave her a vaginal suppository to ripen the cervix. In mid-afternoon they put in a Cook balloon catheter to put some more pressure on her cervix. It had been a long, slow day with many cervical checks; Caitlin was 1 cm dilated Monday night, when they started Pitocin along with some pain medication. On Tuesday morning the team removed the catheter to try to let the baby’s head settle down into her pelvis a bit more. 

Dr. P: Your induction story happens a lot. When we have to induce early for medical reasons, the majority of women have a closed cervix (especially first time moms). I usually prep my patients for a long process - 24-36 hours to deliver their baby. 

Ripening agents are intended to get your cervix prepared for labor. Think about a hard, unripe fruit - very hard to squish. We want your cervix to be soft, like a ripe fruit, to dilate as you have contractions. Cytotec is a tiny pill that we put in your vagina. Other options include Cervidil, Mifepristone, cooks catheter or foley balloon.

In retrospect, Caitlin wishes they would have encouraged her to move around more. Now she laughs at what she brought to the hospital - a Kindle, with the expectation to lay around. When her friend came back on shift she said “get out of bed, you got to start moving. You got to get on this ball. You need to keep moving around. This baby needs to come down.”

The cervical checks were frequent and uncomfortable, and the team wanted to break her water to try to get the baby's head a little bit lower, with the hope that it would speed up dilation. So Caitlin moved forward with an epidural and then her water was broken. They thought that they saw meconium in the water, which triggered discussion to involve a NICU professional and having the baby within the next 12 hours. Throughout the day Tuesday, the level of Pitocin was cranked up; at 7:30pm, they stopped the Pitocin to give her uterus a break and assess the options.

1. If it seemed like the baby was in distress based on fetal monitors, they would move to a C-Section
2. If Caitlin’s uterus got too tired, they would move to a C-Section
3. Contractions start up again and see how things go 

The Pitocin was high, but she didn’t feel the contractions very strongly. Knowing that going into a C-Section the next morning was likely, Caitlin was able to use the overnight time to do some research about her options; specifically thinking “how can I still have some of my birth plan?” With discussion with her doctor, she was able to ask for delayed cord clamping and skin-to-skin time. 

For anyone expecting, Caitlin encourages: Think about all the different outcomes and how there might be some things that you can get; and it might not be everything on your plan. 

Dr.P: Sometimes contractions slow down; that's where we have to start Pitocin to keep the contractions going or we can break your water (referred to as AROM - artificial rupture of membranes).  For that, we put this little tiny hook in (like a crochet hook) and it's kind of like a water balloon where you just kind of scratch it until it snagged and then your water breaks and then you have this weird release. When your water breaks, we don’t necessarily have to get the baby out by 18 hours, but we are monitoring for symptoms of an infection (choreo ammonitis = fever during labor). 

And this is the point where we start to look more at the possibility of a c-section. I usually like to have a sit-down conversation if we have time, but that’s not always possible. Listen to your doctors and nurses if they are mentioning the possibility of a c-section.

So Wednesday morning after two whole days of the hospital Caitlin did go into C-section. While generally a “go with the flow”, not anxious person, she felt shaky and on edge from two days of labor. She hemorrhaged during the c-section, but while they were dealing with that she was able to get some skin-to-skin with her baby. The medical team did their best to delay cord clamping while they worked on her hemorrhage. She feels very thankful for the 12 hours of time to research and feel mentally prepared going into surgery.

Dr.P: Hemorrhaging is common when you've had that long of an induction, my experience is that after 48 hours of induction, everybody in the room is prepped for a hemorrhage, have all the meds in the room. It can still be really intense and scary. 

Your uterus was TIRED. Your uterus had been contracting for 48 hours straight. Imagine if you had just run for 2 days - you don't want to work harder. You want to sit down and rest.

So your uterus is tired, but we need it to contract down after you deliver to help decrease bleeding (there's a whole bunch of spiral arteries bringing blood to your uterus). If your uterus doesn’t contract down, it just bleeds. So that's why we give you all his medicines to make a contract down

Caitlin’s doctor shared later that her baby was coming down at an angle, not landing on her cervix in the best way to dilate it (and probably why she got stuck at 2 cm). 

Dr.P: Sometimes no matter what positions we put you in, the baby’s position doesn't resolve. If you're only 2 cm dilated, we can't reach up to grab the head and move it (sometimes if you’re at 5-6 cm we can adjust the head to get into the right spot).  

Caitlin spent a few days in the hospital after her c-section, and developed postpartum preeclampsia - caught just before she checked out of the hospital. 

Even though it did suck and I was feeling like I was in the jail cell by the end, I am very thankful because dealing with a new baby - I don't know if I would have been taking my blood pressure even though I had been so much on the front end. I honestly don't know. I was not feeling any symptoms either - all the questions they ask about blurred vision or spots or anything at the time. So even though it was a drag, I'm thankful that it was caught at the end.

Dr.P: Many women experience their blood pressure going through the roof on the day they are supposed to go home. It is really discouraging to be kept at the hospital when you just want to go home, be with your baby and your family. I 1000% get that, but postpartum preeclampsia is one of the highest causes of readmission for new moms, and having to come back through the ED, without your baby is a terrible experience.

Q&A

What are the potential upsides of a C-Section? (question from expecting mom who has a 50% likely C-section delivery and is feeling really bummed about it)

With a C-section, you fast the night before, you go in, and you have a baby. That’s the upside - you don't have this prolonged induction or painful labor process, pushing, etc. They start an IV and then you have a baby. You aren’t as tired because you didn't run a labor marathon before having major surgery. 

There's a reason c-sections were developed. It's because at the end of the day we want a healthy mom & a healthy baby. 

Can vaginal checks or losing your mucus plug cause early labor?

Jill’s description of low back pain around 35-36 weeks could have indicated labor and warranted a cervical check. A “membrane sweep” is a different movement in the cervix; that works 50% of the time to kickstart labor. Spot bleeding after a cervical exam (or after sex during pregnancy) is very common. Heavy, period-like bleeding is not normal. 

Losing the mucus plug is not really a determinant of whether or not you go into labor. You can lose your mucus plug and it can actually reform!