Expectations of a normal vaginal birth

Today, I am sharing with you what you can expect during a normal vaginal birth. We will mostly go over different terms the nurses and docs will throw around as well as some other terms that only some "seasoned" mothers will be familiar with.

First things fist, what are common signs that your body is preparing for labor soon 

• the baby will drop which just means that the baby will move into "go-time" position by dropping deeper into your pelvis *hopefully* head first.  Some women notice, others not so much. I couldn't really feel a difference because by that time, I was feeling just a little smaller than a beluga whale. However, I had at least a dozen people (mostly my coworkers who were also nurses or providers) tell me that I had "dropped."
• more regular Braxton-Hicks contractions.  These "practice contractions" occur throughout the pregnancy though, so don't count on these too much. If they aren't regular and increasing in strength or frequency, then it's just your uterus doing some exercising.
• Mucous plug. I just remember being disgusted each time I discovered my mucous plug had come out. It's basically a "cork" in your uterus opening and the release of it generally means labor is soon.  Now, each body is different and soon might be tomorrow or perhaps a week.
• Dilation and effacement- your cervix may be ripening (or softening if ripening sounds too much like fruit) and prepping for baby to make its debut.  Dilation is the cervical opening widening and effacement is the cervix getting shorter/thinner. I will cover more on this in the next section below. Take a look at this video clip to visualize it better:

Signs that labor is about to begin or very near:

• Your water bag breaks.  The amniotic sac is the thin membrane that lines the uterus, is attached to the placenta, and holds the baby and all the amniotic fluid.  This can rupture on its own before any contractions are ever felt (less common) and it could be a trickle of fluid or gush depending where the baby's head/body is.  Providers sometimes rupture the sac by assistance or they will let it break on its own, depending on their practice methods.  Call your provider as soon as this happens as each one will have a specific protocol they follow.
• Contractions, the rhythmic movement of the uterine muscles that move the baby down, will be more frequent, about 3-5 minutes apart, and will increase in strength over the duration of time. This is key.  It can be confusing to any mom when contractions are felt and they feel strong but then go away.  The usual pattern is increased strength and frequency. For me, contractions felt like menstrual cramps that radiated upwards through my whole abdomen and, later in labor, to my low back as well.  Depending on the birthing method you choose, your contractions could feel different (pain vs pressure).

Let's take a moment to discuss dilation and effacement again.  You will hear these terms throughout your pregnancy and on Facebook statuses of laboring moms.  Right? "______ is at 6 cm now and 80%!!! Baby will be here soon!!" Dilation/effacement can occur weeks before labor actually begins though! For example, I had been having irregular contractions around 35 or 36 weeks and my doctor thought she'd just check and I was already 3 cm.  By two days before I went into labor at 38 weeks, I was 5 cm dilated- just walking around and working, halfway done with labor (ha! If only labor could be something we multitasked). To deliver, you must be dilated completely and go from 0 cm to 10 cm and be 100% (or close) effaced (paper thin).

One more term you will hear during labor is +/- station. This refers to where the baby's head is at in your pelvis.  Generally, you will here a range from -3 to +3. -3 is at the very top of your pelvis and +3 is when the baby is "crowning." Crowning is the visibility of the top of the baby's head beginning to peak out.  Here is another visual aid for fetal stations: 

We are so close to the actual birth now! Just to refresh you from previous pregnancy readings, labor comes in three stages (four if you're in nursing school).  The first is when productive contractions begin and you are awaiting complete dilation and effacement.  The second stage is actively pushing the baby out resulting with the delivery, and the third is the delivery of the placenta.  You will likely hear all about the ring of fire if you are researching med-free births- it is the reported burning sensation a woman feels as she is crowning and the skin is stretched to capacity.  Note that I say "reported" because I personally did not feel it during my med-free birth experience.  Some providers consider recovery as the fourth stage, but you probably won't hear this that often.  

So when the baby is coming out, your provider will try to as gently as possible guide the head out first.  Babies have flexible skulls that mold to the shape of your birth canal as they exit, hence some babies have coneheads when born.  Also, our coccyx bone (tailbone) is flexible, albeit somewhat limited, but can generally accommodate a baby.  After the head is out, your provider will untangle the umbilical cord that is sometimes wrapped around the baby, and guide one shoulder out at a time.  After the shoulders, the baby will come out more quickly.  Keep in mind, you are pushing during this time, often with your provider saying "push now, hang on, ok push again, wait," etc.  You may have a little more control with an epidural but without any medication, you may feel little control as your body goes into autopilot mode.  Time to visualize the birth with the following clip (don't you love the classical music accompanying the videos?):

The placenta will deliver on its own between 15-30 minutes postpartum (after birth). Sometimes the provider will tug on it gently to help it come out.  So that's what a normal delivery looks like! Complications, often minor, can arise at any point and interventions will be necessary.  Some common interventions during the second stage (pushing):

• forceps: if baby is posterior, gravity is working against you, or perhaps just  "stuck," your provider may suggest forceps use.  They look like giant metal salad tongs.
• vacuum: it is what it says and looks like- a baby head vacuum.  The suction may be just enough to help pull the head out, the widest part of the baby. 
  *just my personal input- I would try to avoid forceps at all costs if I could do my first delivery all over.  It is very invasive and will cause more tearing deeper inside, which makes recovery worse.  Nonetheless, if it can't be avoided due to safety, then take the forceps.
• episiotomy: this is an assisted cut to your perineum, the skin that is between the vagina and anus.  This will stretch thinly during the second stage and sometimes tear on its own (see this site more on the degrees of tearing) but if the provider feels that the natural tearing may be worse than an assisted cut, they will perform an episiotomy.
• amniotomy (or artificial rupture of membranes): this is when the provider ruptures your membranes/water bag.  The tool used looks a lot like a large crochet hook.

Common pain medications and other meds used during or to induce labor:

• epidural/spinal block
• IV or IM (muscle injection) narcotics- a common one is Nubain but I have also heard of morphine being used
• pitocin- also nicknamed "pit." Many women either have labor induced with this or if their labor is not progressing fast enough, they will be started on it.  It increases the strength and frequency of contractions. Sometimes a shot after delivery will be given just as protocol for postpartum bleeding or if there is a little excessive bleeding, an IV infusion will be started postpartum.
• prostaglandins- medication inserted into the vagina to induce labor. Cervidil is the most common one I know of.  Prostaglandins are naturally occurring hormones that when stimulated help soften the cervix and kickstart dilation/effacement.  A common protocol with this one is being admitted just before bedtime to induce labor overnight.  If labor doesn't start, than other induction methods will be used.
• other induction methods I know of: is the use of a Foley catheter.  A Foley catheter is typically used to drain the bladder.  It has a balloon near the tip and instead of inserting it into the urethra, it is inserted into the vagina and the balloon is inflated in the opening of the cervix, applying pressure to it to hopefully start the natural release of prostaglandins. Membrane sweep- or also called "stripping the membranes.  This is done in the office, often when the provider suspects labor is nearing and only if you are term and dilated to 1 cm or more.  The provider will use their finger and sweep along the inside of the cervix to manually pull the membranes away from the cervix.  This can also stimulate the release of prostaglandins

Before I end this post, I want to share a little about the, *ahem*, less glamorous aspects of a vaginal childbirth:

• you're often naked or really exposed.  Your va-jay-jay is everyone's business and really, you probably won't care after a couple of hours and a little fatigue.
• there can be poop involved.  It happens. But don't worry, your nurse will be really professional and probably not even make a comment cleaning you up because it happens to many women. And it'll be so fast, you may not even know it ever happened. Seriously, you're pushing like you're about to have the largest bowel movement of your life.
• you may say crazy things or get angry at loved ones
• you may get nauseous and need to expel some contents out of your stomach
• Feel free to comment below about other less glamorous things

Hoping this is another helpful post, let me know if you have any questions and I will do my best to answer you or find the correct answer!

Birthing Positions

Initially, I was going to include more about vaginal births in this one, but I found that I had a lot of material regarding birth positions, so I will cover vaginal births in my next post.

We are all familiar with the typical Hollywood birthing scene- ya know, where the mom is on her back and her feet are in stirrups:

A lot of times they are screaming, sweating, and appear to be in a LOT of pain. Well, there may be some of that if you choose to birth this way, but I have found that many women, including myself, don't really feel a ton of pain in this position because it is likely the only position you are allowed to be in with an epidural.  I will add that I'm sure there are some women who probably had a doctor say they could stand up with an epidural, because there's always exceptions, but really, sitting or laying down is safest when you're numb from waist down. 

Sitting semi-upright with your feet/legs in a mid-air squat (assisted by stirrups, your birthing partner, or nurses) is probably the most common position and it is out of convenience- mom gets to rest, doctor gets a very clear picture. Here's me after a few hours with my epidural during the birth of my son:

Pain-free gets a thumbs up.  Getting ready to push a baby out soon!

Many women have successful births in this position, but for those like me, it wasn't so much the birth that was rough (though there were several complications with that), it was definitely the recovery.  Because I had to be in this position, I wasn't really able to help my son with gravity and he was basically stuck for the 3+ hours I pushed for, which then led to a number of interventions.  I felt quite broken after delivery and recovery was worse because of how long it took for me to heal. With my daughter, I was able to move around more- walking, sitting in different positions, hanging out in the water for bit, and bouncing on an exercise ball.

So this leads me to share with you about other birthing positions that are available.  Some women go completely medication-free, others find that they would rather labor without medications first to help facilitate the position and then get some pain relief (as long as they didn't wait too long). I like this infographic both for the positions and the fact that the colors are aesthetically-pleasing:

Let's discuss these positions and how they can help:

Squatting- you can squat with a partner from behind, using furniture in the room, or some hospitals even have "squat bars" that provide stable support. Gravity is your friend here! This position really opens up your pelvis by aligning your birth canal with the pelvis.  Contractions are potentially more productive in this position too.  However, this position can be extremely tiring.  If you're like me, your legs may begin to feel jelly-like during labor so take fatigue into consideration. 

Sitting- chairs, beds, straddling chairs, on yoga balls (birthing balls. whatevs, they're just yoga balls), and the toilet (yes, seriously!) are all places that are good laboring seats.  This position is nice because you can rock your pelvis side to side or forward and back, utilizing gravity still.  This is a good resting position, but also note that when sitting, there can be more pressure on your coccyx (tailbone) and perineum.  I don't want to say that increases the likelihood of tearing or tailbone injury because honestly, those are both risks of vaginal birth no matter the position. Depending on how you are sitting, this can be difficult for your providers to check progress and sometimes can be less than ideal for pushing the baby out (no babies allowed in the toilet).

Kneeling- you can kneel with assistance like a yoga ball, a couple of pillows, on your partner's knees, or against the head of the bed (that's what I did with my daughter).  You can also just be on your hands and knees.  This position is really great for anyone who has back-labor because the pressure is lessened against your low back and contractions have been reported to be a little less painful this way. This is also a good position for somebody to apply counter-pressure against your low back for back-labor.  Kneeling is also another good resting position. This can again be a tricky for your providers if you are kneeling on the ground or sitting on your feet or if you're like me, I couldn't really see what was going on once my daughter was out and it was kind of pain to turn around and still have an umbilical cord attached to me.

Side-Lying- this is another good resting position, especially between contractions, and can also work for mothers who have an epidural if your provider allows it.  However, itt doesn't use gravity like any of the other positions so that is something to consider.  You would need assistance in holding your leg open while pushing though otherwise this would probably feel like the worst pilates move you've ever done.

Standing/Walking- the combination of gravity and being able to move around by swaying while standing or just walking around the room is something that helps facilitate birth for many women.  One way to birth in this position is to hug your partner around the neck (try not to strangle them) and then the provider can catch the baby. Leaning against the wall or supporting yourself on some sturdy furniture are also good options.  This can be a tiring position though if you are pushing for awhile or if your labor has already been long.  

a little more up close and personal than I prefer to share, but this is a good example of what laboring while kneeling looks like and my man applying counter-pressure on my low back (correct, he is not pushing my butt).

Every woman finds something that works best for them.  Like I said earlier, just because you get an epidural doesn't mean you won't have a comfortable birth! The best way to prepare is to just research your options, make a birth plan, and be flexible (flexible with your circumstances, though physical flexibility is always a plus).

Coming up next: Expectations of a Normal Vaginal Birth

*images from health-and-parenting.com and scene from Baby Mama

Overview of the last few weeks of pregnancy

So by now, you should hopefully know that human pregnancy is typically 40 weeks (I would advise against publicly expressing your surprise if this is news to you). Term is when it is the safest time for baby to come and this is at 37 weeks and after. It is common for women to go over their due date, especially first time mothers. Your physician will likely induce you when you hit 42 weeks at the latest as complication tend to arise 1-2 weeks post due date.

Now let’s talk about baby and how we all cross our fingers for them to be in the ideal position. There are many ways the baby can present, but I'm just covering four common presentations.

The ideal position is called occiput anterior position. If you are the baby, your face is facing mom’s spine and your back is against mom’s belly and the body is slightly rotated to the right or left. This is preferred because the smallest part of the head exits first and it allows the baby to arch his/her neck when exiting the birth canal. This is the most common position for baby to be in as well, though as I will share next, they don’t always cooperate.

Occiput posterior position, or facing “posterior” or endearingly “sunny-side up,” is when the baby is turned around and facing up. Baby’s face is toward mom’s abdomen and the back is toward mom’s spine. This position is harder on mom because of increased back labor (more pressure/pain in your low back during contractions as baby is pushing against your low back) and also harder on baby because there is limited flexibility on the neck. Your provider will likely try to turn the baby around and your provider may use an assistive device like forceps or a vacuum (yes, a vacuum. But not for carpet :) We'll cover more on assistive devices on the next post) to help baby come out.

frank breech position

Many of you have heard of breech. There are a number of different breech positions. Some babies look like they’re sitting cross-legged on top of your cervix, some appear to folded in half like they are touching their toes and their bum is presenting instead. There could be one foot ready to present first or there can be a combination of any of these. Contrary to popular belief, you can deliver certain types of breech babies, but it is often recommended to go with a c-section instead as it is safer and there is less chance of injury to baby’s head and neck.

Transverse is when the baby is lying horizontally in your uterus instead of with the head presenting. As with other non-ideal positions, your provider will attempt to rotate the baby prior to labor, but if labor has begun, a c-section is most likely because the baby would not be able to be delivered this way.

There is a website called Spinning Babies which is dedicated to different techniques of either making sure baby is in the right position for birth or flipping the baby around the right way on your own if you know they are not in the ideal position. I cannot personally say I have used any of these techniques as I didn't know my son was facing posterior until I was in labor and my daughter was facing anterior, but I know several moms who swear by the suggested techniques.

Remember, a successful childbirth is not strictly following your birth plan- be aware of your options, know that things can change last minute, and do what is best for you and baby!


Coming Up Next Week: Birthing positions and expectations of a normal vaginal delivery

* pictures courtesy of MayoClinic.com and BabyCenter.com

Welcome!

Hello readers! I am so excited to do this project.  As many of you are aware, I am completing my bachelor's of science in nursing (BSN) finally and this is my second to last semester.  I am taking a course in Nursing Leadership and for the clinical project, I have chosen to do a blog series regarding childbirth and recovery.  Now some of you may be wondering why an ER nurse would be interested in this area, so I will enlighten you:

I am passionate about pregnancy and childbirth! I love to see the miracle of birth unravel from the time I have a gummy bear in my uterus to the point of holding a snuggly little newborn in my arms.  It is even greater to watch that newborn grow and grow until they are walking and talking and sharing their opinions.  Furthermore, I want others to have a good experience with childbirth. With my son, I had a few complications with labor and it was a little traumatizing.  I didn't talk about it much with anyone but my husband, mostly because it was scary to talk about. I pushed a long time, had epidural complications, lots of tearing, forcep delivery, LOTS of bleeding, and an absolutely terrible recovery and initial breastfeeding experience. It is not a fond memory aside from meeting my little boy.

Now with my daughter, it was like night and day! I had a short and comfortable medication-free labor and an excellent recovery. I believe that the stark difference was all in the preparation.  I am not going to be telling you what I think you should do and I definitely will not be advocating one birthing method over another as we all have something that works or doesn't work for us, but I want to share with you a little about what you can expect with different birthing methods (epidurals, c-section, vaginal, meds, etc) and also touch on some things about recovery that you should expect, as there are few books that discuss what to expect when recovering from childbirth!

Thanks for reading, everyone, and feel free to share your personal advice or ask questions in the comments!