- In labor, continuous monitoring increases the risks of many interventions, including pitocin, epidurals, and cesarean birth, without improving birth outcomes for mother or baby. Asking a woman in labor to be still (and often in bed) so the monitor can do its job is not a benign request since it can result in a longer labor and more painful contractions. The American College of Obstetricians and Gynecologists (ACOG) doesn’t recommend routine continuous monitoring in labor.
- It is sometimes possible to be monitored near the bed (sitting on a birth ball, standing and swaying, leaning on the bed, etc.) rather than in bed, to increase comfort and encourage the labor to continue to progress. When mothers or babies need to be continually monitored, it is sometimes possible to get a telemetry monitor, which can be worn and allows the mom to walk the halls during labor.
- Babies are expected to have periods of sleep and wakefulness during labor. They will usually have a flat (steady) heartbeat during sleep and a baseline variablity during the times they are awake. Only the variable heartbeat is considered reassuring, so more monitoring is often done when a baby is initially asleep.
- Cold and sweet foods make babies move. Eating something cold and sweet prior to monitoring will help ensure a variable heartbeat and a shorter period of monitoring.
- Normal fetal heart rate is 110 to 160 beats per minute. A heart rate that is below 110, above 160, or flat for long periods of time is considered non-reassuring. The old term is fetal distress, but the wording was changed to acknowledge that no one can say for sure that a baby is in distress based on heart tones alone.
- Monitors can distract support people’s attention away from the laboring mom, and some families choose to turn the audio off and cover the monitor. Electronic fetal monitoring will show the length and frequency of contractions, but not their relative strength.
- Women birthing in hospitals can expect a period of monitoring of about twenty minutes when they are admitted in labor. Those birthing in free standing birth centers and at home will not have to meet this requirement.
- Interventions such as pitocin (used to induce or augment labor) or epidurals, and conditions such a premature labor, require continuous monitoring because of the increased risk.
- There are alternatives to electronic fetal monitoring. Fetoscopes can pick up the babies heart rate without exposing mother and baby to ultrasound. Since dopplers are handheld they are usually not used for more than a few minutes at a time, and thus are usually more comfortable than electronic fetal monitors which are held on with belts. If you are on the electronic fetal monitor, consider asking the nurse how long you’ll be on, and buzzing her after that amount of time if she’s not with you in order to be taken off the monitor.
- Internal monitors are both more accurate and more invasive than electronic fetal monitors. They are often accompanied by a fetal scalp blood sample, which gives additional information about the state of the baby. They require the bag of waters to be ruptured if it hasn’t released on its own, and once placed are usually used for the remainder of the labor. They are used when there is a concern about the baby’s heart rate, or when it is difficult to get the heart rate. Because they are less likely to produce a false positive reading, they can help to avoid an unnecessary intervention.
Julie Brill, CCCE, CLD is the author of the doula anthology Round the Circle: Doulas Share Their Experiences. She has taught thousands of childbirth students over the last twenty-four years and is currently offering independent childbirth classes and CAPPA workshops for childbirth educators and labor doulas.
Have you thought about what you’re going to do in early labor? A friend of mine who is a midwife suggests baking cookies in early labor. I think this is excellent advice. First of all, then there will be cookies. But also, having a fun activity will help you pass the time in early labor. My friend the midwife tells her families to call her when they start burning the cookies. That’s because while early labor is a time of distraction, when you can usually continue with your normal activities during contractions, active labor is a time of concentration, when you may well forget the cookies in the oven.
During early labor try to follow your normal routine, alternate rest with activity, and keep eating and drinking. As long as you are at least thirty-seven weeks along (three weeks before your due date) it’s best to ignore mild contractions for as long as possible. Of course, if you are not yet term, you would want to call your midwife or OB if you suspect labor. It is often not obvious when early labor begins, but as the contractions keep coming, and get longer, stronger, and closer together, you will be increasingly confident that labor has started. As long as you are term, you’ll do the same things if you’re in pre-labor or early labor.
When you talk to women about their labors, you may notice that many seem to emphasize either how long or how short their labors were. Part of how you get in the short labor club is by ignoring the early contractions. If it’s night time, try to get back to sleep. Even if each contraction wakes you up, you may have ten to twenty minutes between contractions when you can drift back to sleep. No one ever got to pushing and regretted sleeping too much in early labor! While I used to dream when I was pregnant that I had slept through the birth and my baby was next to me in the bed, you can’t actually sleep through active labor. When your contractions require your attention, you’ll know. If you find you can’t get back to sleep, try getting up, going to the bathroom, having a snack, and then lying down some place else, like the couch or a guest bed, and trying again. Even if you can’t sleep there is benefit in resting.
During the day you could continue with your normal activities, take a walk or a nap, or watch a movie. It’s important not to drive yourself in early labor, since you don’t know when the contractions will get more intense. It’s also important to regularly empty your bladder, since your baby and your full bladder can compete for space. Most activities that you do to relax after a stressful day are available to you in labor; you can walk, take a bath or shower, cook, eat, snuggle with your partner or your pet, listen to music, do deep breathing, have a massage, watch tv, nap, etc.
Labor is driven by the hormone oxytocin, which both you and your baby secrete in spurts in your brains. When you release oxytocin, you also both release endorphins, which help with pain. Since the hormones come together, as the contractions get longer and stronger and closer together over time, you will also have natural help to deal with them. So try to relax and experience what early labor is about for you. You are creating the beginnings of what will soon be your unique birth story.
Julie Brill, CCCE, CLD is the author of the doula anthology Round the Circle: Doulas Share Their Experiences. She has taught thousands of childbirth students over the last twenty-four years and is currently offering independent childbirth classes and workshops for childbirth educators and labor doulas.
- What is my fantasy of the perfect birth experience? Do you want to squat to push out your baby in your bedroom? Labor in water? Get an epidural in the hospital parking lot? While no one can predict how your labor will go, thinking about your ideal will help you make decisions now and in labor. It’s important to choose a provider with a similar philosophy to yours. Find out what his or her intervention rates are. Creating a birth plan and discussing it with your doctor or midwife prenatally will help you learn if you’re on the same page. If the gap seems too wide, meet with other providers in your area to try to find a better match. Take an independent childbirth class to find out what your options are.
- If I went into labor tonight (at term) what would I want to know? This bottom-line question will help you find out what you most need to learn. Do you have questions about comfort measures and contraction rituals? What supplies to have on hand during labor? The best route to the hospital or birth center and where to park? How to know if you’re in labor and how to time contractions? Taking a quality childbirth class, touring your place of birth, and talking with your provider should help you clarify your questions.
- How do I relax after a stressful day? Most techniques women use to relax are great tools for them to use in labor. The more relaxed you are, the shorter and easier your labor will be. Adrenalin blocks oxytocin, the hormone that drives labor, some keeping stress levels low makes it easier for your labor to progress. If you take a bath after a hard day, you may enjoy laboring in the shower or tub. If you relax by exercising, you might want to walk in your neighborhood in early labor, and up and down the hall once you are active. How we relax is personal, but if you are soothed by listening to music, smelling lavender, using affirmations, slow dancing, or getting a massage, then try those techniques in labor.
- What is my definition of the difference between pain and suffering? Answers to this question vary, but generally people see pain as being a shorter duration and more physical, while suffering is pain that goes on too long, has no purpose, and has a mental or emotional quality to it, as well as physical. Being around people you love and trust, eating and drinking in labor, and using the comfort measures discussed in question 3 can help you keep your labor pain from transcending into suffering.
Julie Brill is the author of doula anthology Round the Circle: Doulas Share Their Experiences. She mentors childbirth educators and doulas for CAPPA, teaches private childbirth classes in Bedford, MA, and provides breastfeeding support as a La Leche Leader. She offers Prepare for Cesarean Birth, Heal Faster workshops over the phone. She is a homeschooling mom to two teen daughters.
To register for a childbirth class or train to be a childbirth educator or labor doula with Julie visit WellPregnancy.
- Help her stay in the moment while you plan ahead.
A laboring mom’s job is to take one contraction at a time. But the partner can help by thinking ahead. Maybe you’re slow dancing together, and all is well. It’s helpful for the partner to think about what to suggest when mom is ready to move on. Maybe she’d like to try the shower, sit on the birth ball, go for a walk. We measure time during labor with contractions, so rather than suggest walking for fifteen minutes, suggest trying it for five contractions.
- Monitor input and output.
Once she gets to active labor, a woman should be drinking a glass of fluid an hour to keep up with her hydration. Fill her class with juice, coconut water, or broth every hour and remind her to take sips between contractions. Prompting her to pee every hour will help keep her bladder empty. A full bladder can compete with the baby for space.
- If you are transitioning from home to a hospital or birth center during labor, help her get back to doing what was working for her before.
The car ride, answering questions, meeting new people, being in the place where she’s going to have the baby, can cause your partner to secrete adrenaline, which slows down labor. Help her find her rhythm again so the contractions can pick up. If she was laboring in the shower or tub at home, help her get back into water. If she was walking, help her get out of the room and walk the halls.
- Make positive suggestions.
If you see her tensing a part of her body during contractions, gently remind her to relax or release that area. (Don’t say: “don’t be tense,” that just reinforces what you don’t want). I love you is usually a nice thing to hear in labor. If the OB or midwife says something encouraging, try repeating what he or she has said.
- Don’t make changes during contractions.
During contractions don’t turn the lights off or the music on, don’t ask a question, don’t chat with the nurse. If you’re not actively helping, try to be as still as possible.
- Don’t take anything personally.
If she rejects your suggestion or gives you a direction, try to take it calmly and move on.
- Remember to take care of yourself too.
Take bathroom and snack breaks when you need them during early and active labor. You are probably a calmer, more patient person when your needs are taken care of. Expect to be with her all the time during transition and pushing, which are the most intense times for most women. Eat bland foods so you don’t smell like you’re lunch, since women are sometimes nauseous in labor. Pack a sweater or sweatshirt, since mom’s are usually hot in labor the room will likely be cool. If you take an over the counter headache medication, have some on hand for yourself, just in case.
- Turn off your phone so you can give your partner your complete attention.
- If she has written a birth plan or has specific requests, help her communicate that to the birth team.
If an intervention is suggested, ask questions about benefits, risks, and options between contractions. What would happen if you did nothing? Remember that most situations are non-emergencies, in which case there is time for a second opinion.
- If you have concerns or questions, discuss them with your doula, nurse or midwife.
She is there to support you, and help you support your partner.
Julie Brill, CCCE, CLD specializes in natural, VBAC, and refresher childbirth classes in the Boston area and via Skype. She also offers Prepare for Cesarean Birth, Heal Faster workshops over the phone. She trains childbirth educators and labor doulas for CAPPA and is the author of the doula anthology Round the Circle: Doulas Share Their Experiences.
Our new scientific understanding of the microbiome and epigenetics is helping us to understand how babies who are fed human milk, and those who are fed formula, are inhabited by different microbes. Our comprehension of why babies who aren’t breastfed are more likely to have health issues is deepening. One reason is there is a difference in the way their genes are activated. I think it’s fascinating! Stream the documentary Microbirth for a better understanding of how we create our baby’s gut health during pregnancy, birth and breastfeeding.
Breastfeeding is what makes humans mammals, and in some ways is the most natural of acts. If you’ve ever seen a mom breastfeed her baby while she keeps up with her toddler at the playground, you know that. But breastfeeding is also learned. And for most of us, because we haven’t spent our lives surrounded by nursing moms, that learning curve can be steep in the first few weeks. It usually takes three to four weeks before the first time mom can talk on the phone, eat dinner, and nurse at the same time. Setting aside the first few weeks to learn to nurse and to recover from labor and birth makes sense. See my post on doulas and other tips for making postpartum easier.
“I believe, like with any journey, the preparation phase is the most important aspect of breastfeeding.” Christy Jo Hendricks, an International Board Certified Lactation Consultant (IBCLC) from Birthing and Breastfeeding told me. “When a mom receives evidence-based information prenatally, she is equipped with knowledge and power. Most moms make their feeding choice prenatally, so diving into the discussion early is very advantageous. Those who educate themselves rarely fall for scare tactics, and are prepared for stages of lactation. Moms should have confidence in their bodies and understand the basic anatomy and physiology of lactation.”
Learning about breastfeeding while you’re pregnant will make it easier to do when your baby comes. Take a breastfeeding class and read the Womanly Art of Breastfeeding. Understanding breastfeeding position and latch before you start will help you from developing sore nipples postpartum. Include your partner in your educational process. When the other parent is on board with breastfeeding, and understands how it works, mothers breastfeed longer and are less likely to supplement.
I asked Lucia Jenkins, RN, IBCLC, the Executive Director of Baby Café USA, what advice she offers pregnant women. She told me the “first thing to do is find a Baby Café, La Leche League group, or other breastfeeding support groups where you can watch women breastfeed. Being able to observe a newborn latch is particularly important. A photo or video pale in comparison to seeing it in front of you.” Christy Jo says agrees. “Moms can find their support group before they deliver so if any issues arise, they have a built in sounding board that will offer advice and support.”
“Remember babies breastfeed, moms don’t.” Lucia reminded me. “A baby on his or her side will be disorganized, but if he or she is on top of the mom in a laid back position, you’ll be amazed at how capable he or she is.”
“The best thing for pregnant moms to do to prepare for breastfeeding is to learn about the importance of skin to skin and laid back breastfeeding,“ Laurel Wilson, IBCLC, the owner of MotherJourney told me. “Skin to skin is not just for the first hour after birth. It is a way of being with your baby in those early days and weeks that helps you extend that connection you felt during pregnancy. It keeps baby close for breastfeeding, keeps them calm and nurtured, and regulates his or her temperature, breathing and heart rate. It is the key to the best experience possible after the baby is born.” Lucia agrees, saying “Skin to skin is not an event, it’s a place for your baby to transition over the first few weeks. Plan on doing lots of baby wearing with your baby just in a diaper.”
Lucia Jenkins, IBCLC, the executive director of Baby Cafe USA, shared these suggestions with me. “Learn to hand express some colostrum. Around the eight month moms start to be able to do this. Try to find a hospital that is Baby Friendly. Make sure you do immediate skin to skin for at least an hour. The baby’s bath and weight check can wait. They aren’t important. What’s most important is that baby has mama. Your baby’s vernix is extremely protective.”
Plan to keep your baby with you postpartum. Known as rooming in, babies who sleep in their mothers’ rooms are happier and cry less. Studies show that moms who room in get similar amounts of sleep to moms whose babies sleep in the nursery. Learning to read your baby’s early hunger cues and nursing him or her frequently initially helps to get breastfeeding off to a good start. Understand the risks of your baby having even one bottle of formula in the hospital.
The choices you make for your labor and birth can affect your breastfeeding experience in the beginning. Common pain medications, pitocin, vacuum delivery, and cesarean birth can all increase the learning curve in the beginning. Even something as simple as an IV in labor, can result in over hydration for you and your baby. A mom who is over-hydrated will have swollen breast tissue which makes it more challenging for her baby to latch. A baby who is born over-hydrated will initially have excess fluid, which increases his or her birth weight. This can cause the baby to lose more weight (greater than 10%) of his or her birth weight, which can result in formula supplementation. Using the twenty-four hour weight, rather than the birth weight, is more accurate in this situation. Labor interventions are sometimes necessary, and moms can go on to successfully breastfeed afterwards, but breastfeeding should be seen along a continuum that includes pregnancy and birth. If you know you will be giving birth by cesarean, discuss with your doctor prenatally breastfeeding and holding your baby skin to skin in the operating room.
When interviewing pediatricians, ask how they will support you during breastfeeding. Pediatricians don’t learn much about breastfeeding in medical school, so expect that they will refer you to an International Board Certified Lactation Consultant (IBCLC) if problems arise. IBCLC is the gold standard when it comes to lactation support. They are usually available for consultation in the hospital during the postpartum period. You can also find an IBCLC who will visit you at home.
Check with your HR department to make sure you will get pumping breaks and a place to pump that is not a bathroom when you return to work. Federal law protects these rights. If you are in the military you can get support through Breastfeeding in Combat Boots.
A common concern that many moms have is breastfeeding while taking medications. Most meds are compatible with breastfeeding, or there is a similar one that is. Discuss the safety of the medication with your pediatrician, not the prescribing doctor. Call the Infant Risk Hotline for specific information about the safety of your medication.
Some of my fondest memories of my daughters’ early years are of breastfeeding. But I also remember the steep learning curve in the beginning, and some very long early nights when I wondered why people kept talking about how fast those first years go by. Now I see that while the days (and nights!) can be long, the years are short. Preparing for breastfeeding during pregnancy will make those first days easier.
Julie Brill, CCCE, CLD is a childbirth educator, labor doula, and breastfeeding counselor. She also trains labor doulas and childbirth educators throughout New England. The homeschooling mother of two teenage girls, Julie is also the author of the doula anthology Round the Circle: Doulas Share Their Exeriences. She offers private childbirth classes in the Boston area.
Imagine a woman giving birth. What position do you see her in? If, like most people, your views on birth have been shaped by what you see on tv and in the movies, you likely imagine her lying flat on her back in a hospital bed. Traditionally birth took place at home, and people formed their impressions by direct experience. When birth was largely institutionalized in the United States in the first half of the last century, most people no longer witnessed births, except those of their own children, and so media images came to replace live ones. For more information on the way that media influences our perceptions of birth, I highly recommend the documentary Laboring Under an Illusion.
Lying flat on the back, also known as the lithotomy position, turns out to be one of the hardest positions there is to give birth in (short of standing on your head!) It can cause non-reassuring fetal heart tones and more pain. The more upright the laboring mother is, the more gravity will help her baby to descend. I tell my childbirth classes that labor is the one time in a woman’s life when gravity is her friend! Very few un-medicated women would ever choose to labor on their backs. In labor we get important signals from our bodies about what positions are best. Women who labor in the positions of their choice experience shorter labors than those whose movement is restricted.
Squatting gives the baby the most room to descend. The female pelvis is thirty percent bigger when squatting, than it is when lying flat. Thirty percent is a lot! Because of that, when women squat their babies descend more quickly, with less pressure. Squatting is called the midwives forceps. Midwives don’t actually use forceps, but the idea is that when the mother squats with the midwife’s encouragement, the baby comes as quickly as if she had.
In many places in the world where people live without cook stoves or toilets, they squat frequently. Because Americans over the age of three or four rarely squat, getting reacquainted with the squat during your pregnancy is worthwhile. You can do a free squat, hold on to someone or something, or squat with your back against the wall. Place your feet far enough apart that you can get your heels flat on the floor.
Hands and knees, or knee chest, is an excellent position for back labor, because it helps to move the pressure off the mother’s back. Back labor is often caused by the back of the baby’s head, rather than her face, being against the mother’s spine. This position can often cause a longer labor, because the baby usually needs to rotate to be born. Knee chest helps to rotate the baby into an easier position. For information on how to prevent and handle back labor, Spinning Babies is an excellent resource.
A position to try when labor is slow is lunging. If lunging on a side feels neutral, try lunging the other way. Often one side will feel really good. When a baby is acinclitic (crooked) his head is disproportionately on one side. Lunging will feel good because it opens the pelvis to relieve some of the pressure, while also give the baby room to rearrange her head.
A good childbirth class will give you the opportunity to practice these positions and learn more as well. Understanding them is not enough. It’s important to experience them prenatally and use them as tools if needed in labor.
Julie Brill, CCCE, CLD has been teaching childbirth classes in the Boston area since 1992 and mentoring childbirth educators and labor doulas since 2003. She specializes in natural, VBAC, twin, and refresher childbirth classes. Julie is the author of the doula anthology Round the Circle: Doulas Share Their Experiences. To register for a childbirth class or a childbirth educator or labor doula training visit www.WellPregnancy.com.
Julie Brill, CCCE, CLD, IBCLC
Julie (at) WellPregnancy.com