Labor has been exhausting but with your birth team you're almost through the hardest part. The lights have been low, you brought your favorite essential oils, you've used the tub, birth ball, and shower for pain relief, and NOW THE TIME HAS COME. You start feeling "pushy". Finally you know what that means. The sharp pull at the peak of contractions begins to be replaced by a totally different, nearly unexplainable feeling. You have to get that baby OUT.
The nurse rushes in, pages the doctor, the lights come on (ESPECIALLY the big one pointed at your vagina), the bed is broken down, and you are instructed to 'HOLD YOUR BREATH AND PUUUUUUSH. COUNT TO 10 WITH US!' And now you start to understand why they call it "purple pushing". It isn't pretty or fun. The whole energy of the room has changed, and you're not sure that you like it. (DISCLAIMER- this doesn't happen at ALL hospital births. But it is VERY COMMON due to how most doctors and hospital staff have learned to manage the pushing stage. Listen to women tell their birth stories...you'll see the trend).
I love to discuss the benefits of physiological pushing. What does that mean exactly? It's letting the birthing mother decide when and how to push her baby out. It doesn't mean:
I always bring a copy of this lovely blog post by Rachel Reed of MidwifeThinking with me to prenatal visits with families that I'm working with, because it really emphasizes how the mother is the expert in pushing out her baby. Risks of "purple pushing" or directed pushing include:
Even though study after study has documented the risks of directed or purple pushing, the physiological pushing has been slow to take hold in most hospitals. This survey from 2005 documented that only 21% of women pushed when they felt like pushing. Over 90% gave birth on their back or semi-reclining. Some reasons for this likely include the fact that upwards of 60% of women in most areas choose an epidural, which leads to more management of pushing, but also it's just a fact that most birth professionals are taught directed pushing in their trainings, and they rarely see or experience anything else. Humans are creatures of habit, and we tend to fall back on what we know.
This study review has a great overview of the differences between physiological and directed pushing. Women who are pushing instinctively often push only for 3-5 seconds and then take a short breath, before pushing again. They tend not to close their mouths or clench their jaws. The mother often will chose a position such as kneeling or hands and knees. She might not put her chin to her chest and push "down" to the baby. I very often see women wanting to arch back and do just the opposite! There really are no "rules", and a position that works for all women. Remember: a woman's body knows how to give birth! Listen to it.
Now that you know that it's evidence-based and healthy for a mother to push when she feels like it, and in positions of her choosing, what can you do to maintain your physiological birth even if you are being encouraged to do something different? I love this article about saying "no" to purple pushing, but I've found that it's really not that simple when that moment comes. So here are my tips for saying 'no' and being successful at mother-directed pushing no matter where you are.
Strategies for Physiological (Mother-Directed) Pushing in the Hospital
The bottom line is that mother-directed pushing is safe for the mother and her baby. If you discuss this with your care provider and they are unwilling to consider this option, you might want to think about finding a care provider who will work with you, and the birth that you would most like to have. Or, you can share some of the linked studies with him or her and ask them to reconsider.
I've said it before, and I'll say it again. You can have a great birth no matter where you choose to be! Hospital, home, birth center...but it never hurts to know what you want, to communicate those wishes clearly, and to bring a supportive team who knows you well to help you achieve that goal.
A supportive birth partner, and a doula, can help to remind you of the plans that you made before you reached a point in labor where it's easy to think that 'those details weren't important, so let's just get this over with.' But you might feel differently once the hormones wear off. (I speak from personal experience when I say this, can you tell?) It's normal to feel like you need reassurance and guidance during this phase of labor, but remember that YOU are the only one giving birth to your baby, and your body knows what to do! Have your birth partner remind you of that! It's not the last time that you'll need to lean on your instincts as a mother to do what's best for your child.
What was your experience with pushing your baby (or babies!) out? Do you have any other suggestions for supporting mother-directed pushing? And thanks to the mothers who shared their beautiful birth pictures to show the various positions that women can choose for pushing!
5-1-1, 4-1-1, 3-1-1....Could be a secret code, but most pregnant women towards the end of their pregnancies know exactly what those numbers mean. Contractions every 5 (4, 3) minutes, one minute long, for at least one hour.
TIME TO HEAD TO THE HOSPITAL. (Or, call the midwife, even drive to the birth center.)
Birth partners are prepared for the big day by downloading the best contraction timing app. As soon as the first contraction hits, they excitedly pull out the iPad, or smartphone, and......wait for the next one.
"TELL ME WHEN YOU FEEL ANOTHER ONE!"
"DID IT START YET?"
"Oh no, I forgot to hit the button..."
"How long are they SUPPOSED to be?"
..........and so on.
You might have an idea where I'm going with this. In, "Your Hormones Are Your Helpers", Sarah Buckley draws a comparison between the labor of a cat and that of her human companion. While the human mother packs a bag and anxiously waits for contractions, the cat searches for a comfortable, peaceful, often dark, place to have her babies. Usually she does not have her babies until she is undisturbed, sometimes frustrating the would-be "helpers". In fact, the cat knows how to give birth instinctively with the hormonal processes that she is designed with.
AND SO DO HUMAN MOTHERS. But first a little bit of background information...
Many women learn in childbirth education classes or from friends that oxytocin is the "love hormone", at least partially responsible for beginning the birth process and helping contractions to progressively dilate the cervix and help to move the baby down. They may also be told that Pitocin is exactly the same as oxytocin. It is chemically the same, however oxytocin is produced by the mother's body, along with other hormones in an amazing feedback system between the baby and the mother. In contrast, pitocin is pumped into the mother at a constant and steady pace, with no possible feedback based on how the baby is doing, or how the mother is feeling. This is a VERY IMPORTANT difference.
Especially in early labor, the body's production of oxytocin is a delicate operation that can easily be reduced or even halted by adrenaline. Known as the "fight-or-flight" hormone, adrenaline basically works in opposition to oxytocin, although levels DO increase during the second stage of labor, during pushing. This is why waiting until labor is very well-established can help to keep labor from stalling once you actually leave your home if you are planning on giving birth somewhere else.
SO.....Why ditch the contraction timer?
Because before transition and pushing, a mother desiring a birth with minimal interventions should focus on minimizing the feelings of being "watched", on a clock, meeting a deadline, or having to be on someone else's schedule, to optimize production of oxytocin.
Have you ever had a paper to turn in, or a work assignment due in just a few hours, and you KNOW that it will be completed, but you just don't know HOW by the deadline? Maybe you start sweating, feel shaky, nervous, your mouth feels dry, and you feel "flighty". Maybe if you could just forget about the whole thing it would just go away.
That's adrenaline. And labor doesn't work well under those circumstances. It's not designed to. Although the contraction timer might seem like a fun way to "track" labor progress, it might do more harm that good. Focusing on making sure the contraction timer is being stopped and started and tracked just perfectly....it brings the focus to the mechanical and not the physiological processes of labor. After all, the most "effective" labor contraction is ONE THAT IS WORKING to make the birth process progress.
It does not HAVE to be LONG.
It does not HAVE to be PAINFUL.
It does not HAVE to be VERY FREQUENT.
It might be all of those things, but then again, maybe not! There are NO RULES in labor, because we are all unique.
For instance, in my own first labor I was having contractions every 6 minutes, but with a very mild one in between. My books assured me that I was still in early labor, especially since I had only been having them for a few hours. A few minutes later my contractions were 2 minutes apart, and 1.5 hours later, after some pushing, a lot of belligerent refusals to get in the car, and barely making it to the hospital, my daughter was born!
However, it's also possible to be having strong, frequent contractions, and for labor to be progressing slowly. This is okay! Often in this circumstance women will have to focus quite a bit during contractions, but will not have on their "serious face". Once transition gets close, a woman's facial expression will usually change to one of intense concentration and focus. She also may become more opinionated and "bossy". This is a great sign!
LOOK FOR THE SERIOUS FACE, not the clock face.
Suggestions for laboring women:
Suggestions for birth partners:
As usual, I'm not a medical provider. If you really want to time contractions, go for it! But remember that timing is less important than how you feel! The mother is the only one who can express how she is feeling during labor. Mothers, listen to your intuition, and your baby. Partners, listen to the mother!
Did you have an "unusual" contraction pattern during your labor?
'What? What is she talking about? Pregnant women should never ever drink alcohol!' (I might be exaggerating a bit there).
No, I'm not talking about alcohol. Who is going to get that into a hospital? I'm talking about water.
'Water?! Oh, water is great. Did you know that if you feel thirsty, you're already dehydrated, and pregnant women ESPECIALLY need to be drinking at least 100 ounces of water a day! And labor is just like a marathon, so keep your water and laboraid close and make sure that you're getting plenty of fluids!!'
Here's the thing though. EVERYTHING in life is about moderation. For some reason, this doesn't seem to apply to water. As I've written about before, this is likely due to misinformation and exaggeration, first on the part of bottled water companies, and then picked up and disseminated by the health industry. Statements like "drink 8, 8 ounce glasses of water a day", or, "drink one half of your body weight in ounces of water a day" may seem harmless even if they aren't based on science, but are they? Can this type of advice be particularly dangerous for pregnant and laboring women? Yes, there is evidence that it can be.
Our cells require a certain balance of nutrients and salts. What happens in hyponatraemia (overhydration/low sodium levels) is that the extracellular fluid becomes too diluted with water and rushes into the body's cells, which causes them to swell and triggers the sympathetic nervous system, or a stress response. That is of course a very simple version; the actual mechanism is way more complicated and also involves the interplay of potassium, calcium, and other minerals in the cells and cell membranes. However along with the stress response comes many symptoms which probably many of us who have taken the mainstream advice on water consumption have experienced:
….sound familiar? Yeah, I thought so. Yet many pregnant women who complain of any of these symptoms during pregnancy will be told…what?
"You're probably dehydrated, drink MORE WATER".
So it's a dangerous cycle. The authors of the study below note that "The maximum capacity of excreting a water load at rest is reported to be approximately 900 ml per hour in healthy women but is reduced by one-third in late pregnancy". So pregnant women are not able to get rid of extra fluid as quickly as a non-pregnant woman, which makes overhydration even more likely. They also note that "no physiologic warning system protects the body against overhydration". (See opening quote for a slightly different perspective on that). This means that once a person starts to become overhydrated, they can no longer trust what their body is telling them, because excessive thirst may not mean that the body needs fluid, but rather, salt. So avoiding that state is important!
Instead, here is what I tell pregnant women (and everyone, really). Drink when you're thirsty, and not a lot more than that. Animals and children know how to do this. Why do we, as adults, think that someone else has to tell us how much to drink to be sufficiently hydrated? And you don't even have to only drink water. There are many nutritious, tasty beverages that contain lots of water, but also minerals, salts, natural sugars, and probiotics. Some that you might consider are grass-fed whole milk, kombucha, water kefir, herbals teas, and even broth (homemade!).
Why This is Especially Important for the Laboring Mother
It's only been recently that hospitals have been "allowing" women to eat and drink during labor. Of course this is a basic human right, and a long time coming. However, it can also be a risk, because there are many women (especially those that are health conscious, who may already starting out labor slightly overhydrated) who have been told that labor is like a marathon, and that staying hydrated is vital to a healthy labor and baby. While part of this is true, and hydration is important, the truth is that labor is NOT like a marathon. Or rather, women's bodies in labor are not acting at all like the body of a marathon runner, or even someone exercising. A simple, crucial fact is missing.
Oxytocin, the "hormone of labor, love hormone", encourages the body to RETAIN water. So a woman that is drinking constantly throughout labor, especially a longer labor, may be in danger of drinking herself and her baby right into hyponatraemia. How can I say that? Not only have I heard of several instances from doulas where a client had a difficult, long labor and ended up with a cesarian birth, but there was enough awareness of it in the medical community to do several studies on it. The most recent is quite compelling.
In, Hyponatremia Complicating Labor: Uncommon or Unrecognized? The authors note that a high total fluid volume (2500 mL or approximately 85 ounces, by mouth and intravenously) taken in by a laboring woman was significantly correlated with overhydration, a longer second stage of labor, and other complications during the birth. Honestly you should really read the whole paper; it's not too long and really fascinating. But here are some key points:
Who are most at risk?
A woman who desires a natural birth and who is giving birth at home or a birth center should be encouraged to drink if she feels like it. Since the body retains more fluid during labor, she likely will need less fluids than normal. If she voluntarily is drinking more than 8 ounces of fluid an hour over the course of several hours, this could be worrisome and she might be encouraged to back off on the fluids. It's been noted before that the symptoms of overhydration often mimic dehydration, so keeping track of fluid intake can be very important.
I did some research on how much fluid a woman laboring in the hospital might be given if she requires an induction, antibiotics for Group B Strep, or an epidural. It's likely that if an IV of fluids is hooked up, the laboring mother will receive at least 1000 mL total, at 125 mL per hour (4.2 ounces) or sometimes even 250 mL (8.45 ounces) per hour. These women are likely most at risk, especially if they are also taking in oral fluids. Women who are continuously receiving IV fluids should be very careful with how much they add to that by drinking, and birth partners and doulas probably shouldn't be encouraging the mother to drink extra fluids. Remember, 26% of women who received more than 2500 mL (about 84 ounces), developed hyponatraemia, so it wasn't a rare occurrence by any means.
What is the Bottom Line?
Basically, all humans have the ability to tell when they're thirsty and when they need to drink. Sometimes we get so used to people telling us what to do, that we forget how to listen to our bodies, but pregnancy is a wonderful time to start really tuning in and trusting your body and instincts.
Despite the common advice to drink at least 64 ounces of water a day, and even more during pregnancy, there is no scientific proof to back this up. Each person is different and has varied fluid intake needs. During labor, a woman should be able to drink when she's thirsty, and not encouraged to keep hydrating unless there is clear indication of dehydration. However, thirst can't always be trusted as a sign of this, since excessive thirst is also a sign of being overhydrated. If a mother is receiving IV fluids AND oral hydration, especially over the course of a long labor, the care providers (or family and friends) should be especially careful to make a note of the total fluid volume, since these women are most at risk of overhydration.
To Be Continued....Implications for Baby
What do you think? Is overhydration more common or less common than the evidence suggests?
"Your baby is measuring much larger than normal."
"Your baby appears healthy but we are worried about his size; he may not be growing."
"Your amniotic fluid is low".
Generally all of these statements are probably followed by "We'd like to induce you". But you've had a perfectly healthy pregnancy! You've been planning to go into labor on your own. Your baby appears to be happy, how did you get to this point? Should you trust this commonly-used technology to guide decisions about your pregnancy and birth?
Many women find it amazing to see their baby on ultrasound. During my first pregnancy I had 3 ultrasounds, the first at 12 weeks to verify pregnancy, one at 17 weeks for gender, and another at 22 weeks to check anatomy. I was a low-risk, first-time mother. Women with any other risk factors such as gestational diabetes, hypertension, "advanced" maternal age (over 35), suspected genetic abnormalities, or clotting factors may find themselves with many more ultrasounds. As I continued in the pregnancy, however, I became more and more sure that I wanted to avoid an ultrasound late in my pregnancy. Why? Cue the music..
Late. Term. Ultrasounds. What are they good for? Absolutely. NOTHING. (almost)
It seemed to me that ultrasounds in late pregnancy are more often than not used to scare the caregiver and the mother into thinking that something is wrong. It's common knowledge that ultrasound measurements can be, and frequently are, inaccurate. But when it comes down to it...the doctor will usually want to "err on the side of caution".
There have been several studies on ultrasound after 24 weeks gestation in low-risk pregnancies, like this one, a Cochrane review of studies totalling over 25,000 mothers and babies: Read more here. The authors concluded that "routine late pregnancy ultrasound in low risk or unselected populations does not confer benefit on mother or baby. There is a lack of data about the potential psychological effects of routine ultrasound in late pregnancy, and the effects on both short and long term neonatal and childhood outcome."
This study finds that late-term ultrasound estimates of weight are not particularly reliable, and "must be applied with extreme care".
So there are no proven benefits to row-risk pregnant women and their babies, but what about risks?
A interesting study published in 1993 selected a group of women (sample size 2,834) to either receive "intensive" ultrasounds (5 from 18 weeks to 38 weeks), or "normal", which was only one scan at 18 weeks. There was a statistically significant increase in the intensive group of having a baby with a birthweight below the 10th and 3rd percentile. The irony here is that in my experience, late-term ultrasounds dramatically increase the chances of your baby being diagnosed with IUGR, whether or not the baby's birthweight is actually low at birth. Could the overuse of ultrasound be CAUSING the IUGR? The authors of the study found it "plausible". Perhaps because another study just a few years before had found a similar negative effect on growth and hypothesized that repeated ultrasound exposure most likely affects bone growth, not soft tissue growth. The good news is that a follow-up study found that this difference in growth seemed to disappear by age 8. But the authors of this study recommended that ultrasound use in late pregnancy be restricted to "those women to whom the information is likely to be of clinical benefit." Rather open-ended, but can we find more information on who these women might be?
GreenMedInfo published a blog post entitled "When Do the Benefits of Ultrasound Outweigh the Dangers?" I highly recommend reading the entire article! The author states that the evidence points to several instances where an ultrasound may have some benefit, among them locating the placenta to clear a women to attempt a TOL for a VBAC, when trying to turn a breech baby during an external version, and when utilizing reproductive technology such as IVF. Not included are:
Measuring large for dates
Maternal age greater than 35
Measuring small for dates
To measure the amniotic fluid
Diagnosed Gestational Diabetic
Factor Five Leiden or other clotting abnormalities
Measuring the "thickness" of a uterine scar internally before a woman attempts a VBAC
The author also points out that there are only a handful of issues that an ultrasound might help to diagnose and then treat before the birth of the baby, as well as a high false-positive rate with abnormal ultrasound diagnoses (I will be working on an article on fluid levels soon!), so the possible benefit to most mothers and babies is slim indeed. Even more concerning is that very few large, epidemiological studies have been performed since the allowable acoustic limits for ultrasound machines was increased in 1992. Part of the problem is that finding a control group of unexposed babies would be quite difficult because ultrasound use has become so common!
Although most other studies have been performed on mice, other possible adverse effects of late-term ultrasounds (based on evidence) include:
Damage to the neurological system
Thermally induced teratogenesis (the formation of congenital birth defects)
Left-handedness (in men)
For more studies on the possible adverse effects of routine ultrasound, please see GreenMedInfo's database here.
What is the Bottom Line?
Although ultrasound has been used in the care of pregnant women and babies for several decades now, there isn't much evidence to support it's routine use. There are many animal studies that suggest exposure to ultrasound increases the risk of abnormal neurological development in the brain and for growth restriction of the skeleton. A few women may benefit from ultrasound screening, but the possible risk of repeated exposure should certainly be discussed so that an informed decision can be made. Part 2 will discuss some of the emotional issues that women may face because of the use of ultrasound, and how it may affect them and their care providers throughout the mothers' pregnancies and births.
Birth is the culmination of a process that really begins before a woman is even born. Even as a baby girl is being formed within her mother, that environment is shaping the woman that she will become. The mother's feelings, fears, health, and diet affect the baby that she is carrying, and this relationship carries on through the birth process and breastfeeding relationship. A healthy, happy, nourished mother most often births a healthy, happy, nourished baby who thrives and grows into a healthy child.
Of course this is a difficult and rare achievement in the world that we live in. Regardless of race, income, or social status, nearly all women face a variety of stresses, and many even fear on a daily basis. Health and nutrition advice is also confusing and often misleading, and at the very worst, dangerous for mothers and their babies.
Even before a woman finds out she is pregnant, there is a fear that pervades much of modern society surrounding birth, to the point that a few women attempt to bypass the birth process altogether by planning a cesarean. At least, the majority of women chose to labor numb from the waist down to avoid the pain and trauma that they have been told inevitably comes with birth.
Then she actually sees the little blue line, and then the fear-mongering really begins.
"NO alcohol- you don't want your baby to have birth defects, do you?"
"No sushi- you know there's bacteria in that, right?!"
"Make sure you microwave all lunch meat" (Just to make sure there's nothing left of value..)
"Just get the epidural as soon as you can; you know that 35% of mothers NEED a c-section, so you'll probably want the epidural just in case."
"Why would you give birth at HOME? What if SOMETHING BAD HAPPENS?"
"Breastfeeding really hurts and lots of women don't make enough milk. Try, but don't feel badly if it doesn't work out."
"Never put your baby to sleep in your bed! You might roll over on him! Plus, don't you want TIME ALONE with your mate?"
Something is missing in this picture...how about some COMMON SENSE and confidence that until proven otherwise, a mother knows what is best for her baby, and can give birth intuitively and without intervention? And that she can also feed the child that she birthed without assistance and complicated schedules and contraptions? And that women have been birthing healthy babies for thousands of years without minute directions on what to eat and what not to eat before, during, and after pregnancy?
I hope that through this blog and talking to mothers in person that I can help to convince you that women are made to give birth and be wonderful mothers to their children, and that most do not need the fear based propaganda masquerading as helpful information that seems to dominate birth in our culture and in the media. I would also like to share some of the findings of Dr. Weston A. Price and other researchers who realized that nutrition is one of the keys to a healthy pregnancy, baby, and child, so that mothers can do all in their power to take their health and that of their children into their own hands.
Mothers need support during the birth process, but also before and after this momentous event. I hope that I can provide this for many women and their babies!
I look at birth from the perspective that our bodies are wonderfully made, and if we really believe that and work with the birth process and nourish our bodies properly, they will function optimally, most of the time!