As a childbirth educator, there are a couple of topics that fill me with dread when addressing a group of soon-to-be parents, and one of them is circumcision.
If you’ve spent any time at all on the internet as it relates to parenting, you may have noticed that this topic can spark some very heated discussion, so much so that it can be hard to wade through the rhetoric to find solid information. Folks hold some strong opinions on this topic—and for good reason! The decision whether to circumcise or not will carry into every day of a boy’s life. So, how to give accurate information that will help parents decide? Here’s how I do it:
There are basically 3 things for parents to consider in deciding whether or not to circumcise their baby boy:
Religious or cultural reasons
On this point, I don’t figure I have too much to contribute as a childbirth educator, though occasionally I have helped Jewish clients who did not want to circumcise to explore the idea of holding an alternate ceremony (known as a brit shalom).
These usually fall under the headings of: “wanting him to look like Daddy” or “wanting him not to be bullied in the locker room.” Again, I don’t feel that I can speak to one person’s sense of what looks right or wrong, and I particularly don’t need to know which of the fathers in my class were circumcised or not. But I can note that since the rate of infant circumcisions performed nationwide in the US is around 55%, there is a high probability that there will be another boy in the locker room whose penis looks like your kid’s, whichever route they choose to take.
Health benefits and risks
Since I work very hard to research and present information based on current research evidence in my classes, this final category is the one to which I can really speak. And it can be surprisingly hard to sift through the claims that are out there about risk and benefit!
The American Academy of Pediatrics has been equivocal, to be sure. Their current statement on the one hand seems to endorse the practice, and on the other hand it doesn’t. This statement can be found on their website for parents:
“The American Academy of Pediatrics believes that circumcision has potential medical benefits and advantages, as well as risks. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it, however, existing scientific evidence is not sufficient to recommend routine circumcision.
Therefore, because the procedure is not essential to a child’s current well-being, we recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician, taking into account what is in the best interests of the child, including medical, religious, cultural, and ethnic traditions.”
Their longer policy statement can be found here and the very detailed and long article from the task force behind the policy statement is here.
So, according to the AAP, the benefits outweigh the risks, but not so much as to become “essential to a child’s current well-being.” Which leaves us where, exactly?
I did my best to dig for solid numbers, and came up with this handy chart to compare benefits and risks. Let’s work our way down the list together, shall we?
Yes, Circumcision is painful
First off, circumcision is painful, and medical professionals recommend adequate pain relief both during the procedure and during the healing process (which takes about a week). The choice to circumcise your baby means he will feel pain, and there is always a small risk that he will have an adverse reaction to the pain medication.
Complications can occur
Further, the choice to circumcise means incurring the risk that there will be complications to the procedure. It is basically impossible to get hard numbers on this, since there is no universal reporting standard on complications. The numbers in my chart are a good guess. Mild to moderate surgical complications include: irritation of the glans, infection, excessive bleeding, painful urination, or scarring of the urinary outlet. The much more rare severe surgical complications include: hemorrhage or having too much skin removed. Some babies will need to have the procedure redone, either because the first attempt was inadequate, or because the skin re-adhered while healing.
For a small number of babies whose parents chose to leave them intact, they will develop a medical reason (often phimosis) that will require circumcision in adolescence or as an adult.
Perceived benefits of circumcision
Now we get to one of the benefits of infant circumcision: the reduction in risk of UTI. It is important to note that most UTIs in males occur in the first year of life, but overall incidence is still low at 1%. Baby boys who are circumcised do have a three to ten-fold reduction in risk of contracting a UTI in the 1st year of life.
Sometimes a reduction in the risk of penile cancer is mentioned as a benefit of circumcision, but the overall incidence of this type of cancer is so low, that the slight reduction in risk for circumcised men is barely statistically significant.
Finally, the other major purported benefit of circumcision is the reduction in the risk of contracting HIV and some other STIs. There have been several high quality studies done in Africa that show significant reduction of these risks. Whether their findings can be generalized to the population of American men is debatable.
It is important to note that rates of contracting sexually transmitted infections are affected to a high degree by socio-cultural influences. For example, the rates of circumcision in Northern Europe are much lower than the United States, but their STI rates are much lower as well. Regardless, the reduction in risk for circumcised men would not be completely protective. In other words, parents would need to teach their sons to wear condoms.
And on the somewhat uncomfortable topic of considering one’s baby boy’s future sex life, it is debatable whether adult men who have been circumcised experience diminished sexual satisfaction and function. I’m not sure whether this could ever be definitively proven, but there are certainly plenty of people who like to argue this point.
And that’s it. The risk/benefit ratio for circumcision as it regards to health concerns. You can see why the AAP has had a hard time making a definitive recommendation in favor of circumcision. It is, as they wisely put it, a decision that parents must weigh for their own sons. If you want to read more science-based conclusions, check out The Informed Parent: A Science-Based Resource for Your Child’s First Four Years.
This guest post was written by Stephanie Spitzer-Hanks. Stephanie gave birth to her first child in the Netherlands, where the nurturing and encouragement she received from so many women there inspired her to become a doula. Now she strives to give unconditional support and evidence-based education to families so that they can be confident in making the choices that are right for them. She is an ICEA certified childbirth educator, an Evidence Based Birth® Instructor, a DONA certified birth and postpartum doula, a StillBirthday certified bereavement doula, and a certified lactation counselor through Healthy Children’s Center for Breastfeeding. On the side of all of that, Stephanie is an ordained minister in the United Church of Christ, and she serves as a chaplain at a hospital and writes and speaks about birtheology when she gets the chance. You can find out what she is up to at www.revdoula.com.
Advancements in technology, industry, and business have brought about many changes within the last century. Society has likewise evolved both for better or for worse. Among these evolutions has been a big shift in the standard process of childbirth. Back in the day it was fairly normal to live near extended family and close friends, so it was very natural to have many of them support a woman during labor and delivery. As we have changed over time, it is now more common to live far away from family and delivering in the hospital has become the norm. A side effect from these changes is that mothers have lost the standard support team of women around them while they labor. A possible replacement for this lack of support is to hire a doula. Despite the myriad of positive benefits of a professional doula, only a small percentage of women utilize them. Many newly pregnant women often wonder if a doula is a worthy investment.
Benefits of having a doula
Many studies have been conducted that show the positive effects of doula support, although currently only about 6% of women use one. These benefits include, but are not limited to: decreased labor time; and a lower rate of epidurals, c-sections, pitocin administration, and instrumental assistance during delivery. A Mother who hires a doula also tends to have a much more positive view of her experience. When she feels safe and protected, she lets go of fear (which interferes with progression). Stress levels decrease, and natural oxytocin levels rise, thus encouraging labor advancement. After babies are born, they are more likely to have higher apgar scores (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 2013), and there is an earlier initiation of breastfeeding as well.
Do I need a doula?
There are many known benefits of doula support during labor, but do you really need one?
The large majority of women deliver babies in a hospital and are left to the care and attention of a medical team. A staff may be concerned and aware of a mother’s physical and emotional needs, but they are often distracted by their duties as part of hospital procedure and policy. A nurse, midwife, and doctor all have their own specific tasks to complete—monitoring the baby’s vitals, reading charts and logs, making sure mom is hydrated, and has good stats, etc. They are preoccupied with the safety of mother and baby and are also overseeing a large number of other laboring women at the same time. They will be in and out of the room constantly, and even monitoring moms from machines in the hall. Think of all that is going through the minds of these healthcare workers during delivery.
Making sure baby’s position is optimal, providing perineal support, trying to prevent tearing, coaching mom how to push, monitoring baby and mother’s vitals, assisting the baby when it emerges, making sure the baby is breathing, checking apgar scores, cleaning things up, performing sutures, baby care, delivering the placenta, avoiding hemorrhaging, and keeping things sterile. They have so much going on mentally and physically that although they may be sympathetic to the mother’s needs, they cannot be too preoccupied with them. Plus they have other patients simultaneously.
A Doula’s Purpose
Conversely a doula’s primary purpose is to provide emotional, physical, and informational support for the mother for the entire duration of labor, and afterward. She will be solely focused on you and at your side continually. But what if you have a partner, sister, mother or friend with you? It is highly recommended to have support from people you love and trust. Yet keep in mind that your support group is not always specifically trained in how to care for a laboring woman, no matter how much they love you, whereas a doula is. In order to become a certified doula, a candidate must meet many qualifications. DONA International, “the international leader in evidence-based doula training, certification, and continuing education,” requires that a doula meet the following criteria:
- have a minimum of 28 hours of labor support time logged
- read several required textbooks on labor and birth
- attend at least 3 births and be evaluated by a doctor, nurse or midwife, and the mother.
This knowledge and skill set put into practice is truly invaluable in knowing intuitively how to support a laboring mother.
Doula Services Prior to Delivery
A doula will usually meet with a client about two times prior before the mother goes into labor. During these meetings, she will get to know you a bit, get a feel for what your birth vision and preferences are, and help with a birth plan. She can address any concerns and fears you have about birth, and offer educational materials to review. She can learn about your personality and what calms you, as well as what gives you a boost when you are tired, and how you best anticipate needing support.
A good doula will also be well connected to the birth community for additional support and education. This can be a great resource for women wanting to gain more childbirth education and to get involved with other moms and resources in the area.
Doulas Stay With You the Whole Time
The best thing about doulas is that they are usually available as early as you’d like them in the process, even from the first few contractions. They can come to your home and be with you while you labor there, then transfer with you to the hospital. One of the main advantages to hiring a doula is that you meet her and know her before you go into labor, whereas your nurse and perhaps the doctor on call at a hospital can be complete strangers. Having your doula with you can help you feel more at ease when you arrive. Another advantage is she will stay right with you whereas doctors and nurses, and sometimes even partners will be in and out throughout the process.
Doulas Support Your Partner Too
Doulas are also valuable resources for birth partners. A doula does not replace a partner’s support; rather she assists both parties. She can allow the partner the main role of offering words of encouragement and emotional support while she provides some physical support, and vice versa. She can offer suggestions of what a partner can do to help mom. She can also support the partner should he start to feel anxious or overtired. In one recent study, it was recorded that on average, doulas touched the laboring mother 95 percent of the time, as compared with less than 20 percent by male partners. This in no way discredits the helpfulness of a partner, but rather sheds light on the fact that a doula and a partner have different primary roles. In the end she will be able to read signals from mom and partner of what their needs are in the moment.
A doula’s job is to be there for the mom and to encourage a safe and satisfying birth experience. She provides three kinds of support—informational, physical, and emotional.
Physical Support from a Doula
A doula draws upon her knowledge of many different labor positions and offers suggestions to the laboring mother to help ease discomfort and keep labor progressing. She can offer massage or counter pressure, adjust mother’s temperature with blankets or cool washcloths and fans. She can help to implement breathing and relaxation techniques, and will offer verbal reassurances. She can offer ice chips, drinks, and food if the hospital allows it. She remembers things mom might not think of like to use the bathroom frequently. She knows mom’s preferences and will guard the atmosphere so it remains as calm and peaceful as possible. This is invaluable, especially when the mother is focused and does not want to be bothered with details.
Doulas Offer Informational Support
A well-trained doula will be aware of the hospital policies where the mother is delivering, and will know what kinds of things are allowed and/or prohibited. She can offer advice and information if the mother has concerns or questions. A doula can be a liaison between the staff’s medical jargon and the procedures that are happening. Should unexpected complications arise, a doula can offer extra information, advice and encouragement for big decisions.
Emotional Support from Your Doula
Should some unexpected things arise during the course of the labor, a doula can offer emotional support and encouragement, especially if a c-section or epidural is ordered. She can help to ease fears and guilt and allow a mother to process her potential anxiety or confusion.
Keep in mind that a doula is not only valuable for mothers planning a natural birth, but for all kinds of deliveries. Birth can be an unpredictable event. Even if you plan on getting an epidural or having a planned c-section, a doula can offer tremendous emotional guidance during the process. She can help to aid in your comfort level both physically and mentally. She can be aware of the details that are happening while you are “in the zone.” If a lot of information is being thrown at a mother all at once, and she is already overwhelmed, it can be hard to process and remember what is being said. A doula can be a valuable second set of eyes and ears to absorb information and help answer your questions.
Postpartum Doula Services
Many doulas will offer care for postpartum mothers and charge an hourly rate. Their tasks can range anywhere from breastfeeding support, emotional support, physical care and healing of mother, to cleaning, cooking meals, or taking care of the baby so mother can rest. They will usually offer services up to a certain amount of time (like 4 hours), and some will even offer to sleep over and help with night feedings for an extra fee. The postpartum period can be a difficult time, especially for brand new moms, and the aid of a doula can be very valuable, so it’s something to consider. Even knowing the option is available can put one’s mind at ease.
An Example of a Positive Doula Experience
Elaine Stillerman of Massage Today tells of her positive experience with a doula.
“I called Ilana when I became pregnant. She came to my home to interview me and my husband about our hopes for the big day. Ilana took copious notes in the attempt to get to learn my likes, dislikes and what would be most helpful during labor. She gave us a realistic list of items I would need to make my labor more comfortable. Since then, I have provided my clients with that invaluable list and offer it in my textbook.
When the day came, Ilana had just returned from another birth she had stayed at for 13 hours. She had been home for two hours when I called. “Don’t worry,” she said, “I’m on mommy time.” My water broke and I went into active labor within minutes. The contractions were coming one after the other. She asked to hear a contraction. Did this mean put the phone on my abdomen? Or did she want to hear the sounds I was making? By this time, all rational thought was out the window. “What?” I asked. “Let me hear a contraction,” she repeated. Mine were silent. “I’ll meet you at the hospital.”
Once there, she directed my husband to get a different nurse and a private room for me. She disappeared for a few minutes and came back with a pile of waterproof pads and clean gowns. She opened her bag of goodies and asked if I was hungry or thirsty. And she held me. She massaged me. She danced with me. When the pains got intense, she took my face in her hands and said, “Give me the pain. Give it to me.” And the pains lessened.
When I felt I was losing strength, she told me to relax my feet and let Mother Earth’s power help me. She stayed by my side for 19 hours, encouraging me, honoring my efforts and nurturing me. And when my son was born, she told me how magnificent I had been. A week later, Ilana came to my home for a visit, bringing lunch, gifts, pictures and my birth story. We shared a life-affirming experience and I wasn’t going to let her out of my life since she had been such an important part of it.”
If this sounds like an experience you’d like to have, it is worth looking into hiring a doula.
How to find a doula
There are a few resources to help with finding the right doula for your specific needs. You’ll want to read reviews, choose several options, and then interview them to get a feel for the right fit for your personality. Here are some places to look.
- Dona.org – Doulas of North America
- Cappa.net– Childbirth and Postpartum Professional Association
- Alace.org– Association of Labor Assistants and Childbirth Educators
- Birthcenters.org– National Association of Childbearing Centers
- Doulamatch.com– online database of certified doulas, where you can search by state, years of experience, and price.
Doctor or Midwife Office- many offices have a list of doulas in the area or that they have personally worked with before. This is a great sign that the office is mother-centered and practices evidence based birth!
Hospital—Similarly, some hospitals have doulas on staff full time that they offer to laboring mothers.
What does a doula cost?
A doula’s services can range anywhere from about $300-$1800. They will usually charge a down payment upfront and then collect the rest after delivery. Many doulas are willing to work with you on price if you are not able to afford their fee. Some believe that every woman has a right to have the support they need. Don’t rule someone out just because their fee is high. Check with them first and see if it is flexible, or if they would accept a payment plan. Many insurance companies are now helping to cover the cost of doulas as well, so check there to see if you qualify.
Having a baby is in itself a monumental accomplishment. A doula can provide the additional physical, emotional, and informational support a mother needs to navigate labor and delivery more easily. A mother’s birth experiences are some of the most significant she will have in life. Consider enlisting the aid of a doula to make it the most positive experience you can.
- Bolbol-Haghighi N, Masoumi S, Kazemi, F. “Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial.” Journal of Clinical and Diagnostic Research. 10. 9 (2016):QC14-QC17. Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial-PubMed-NCBI. Feb. 2017. https://www.ncbi.nlm.nih.gov/pubmed/27790526
- Stillerman, Elaine. “In Honor of a Doula.” Massage Today. Dec. 2008. Massage Today Digital Issue. Web. Feb. 2017. http://www.massagetoday.com/mpacms/mt/article.php?t=38&id=13902
This guest post was written by Austyn Smith.
Whether you have a planned or unexpected cesarean section birth, the recovery can present challenges for any woman and being prepared for certain possibilities can help relieve you of added stress. After all, this is major abdominal surgery affecting nearly one-third of women in the United States and even higher numbers in some other countries; c-section prep and recovery are definitely worth thinking about and planning for, no matter what kind of birth you have in mind.
In Hospital Cesarean Recovery
If you know ahead of time that you will have a c-section, here are some things to bring and what to expect of your stay after delivery.
What to bring to the hospital
Aside from your normal hospital bag, these few extra items might be helpful.
- Nice shampoo and lotion. Your favorite shower items can be a nice way to treat yourself.
- Clothing. Definitely do not pack anything restrictive that could cut into your incision area. Maternity pants, sweats, and robes are all good options. These high-waisted panties have great reviews for c-section comfort and a bit of support.
- High fiber snacks. Many women report some degree of GI pain and discomfort following surgery, and constipation is not uncommon. Having some fibrous foods on hand to eat during your stay can aid in normalizing your bowels. Pack some easy snack items to munch on between meals. Apples, oranges, pears, berries, nuts, and dried fruit are all good options. Remember to drink as much water as you can!
- Slip-free shoes. Slippers with rubber soles or flip flops will be handy when you go for laps around the floor and to the bathroom. It may be difficult to regain your balance post-surgery because you use all those core muscles that are currently on the mend. So make sure your shoes have good grip.
- Fabric wrap for your waist. Purchasing a belly band or bringing some stretchy fabric to wrap snugly around your waist can really help with added support when you are moving around post-surgery. Even coughs and sneezes can be quite jarring to your incision area, so having that core stabilization is nice. It also helps to encourage your abs to come back together after separation during pregnancy (diastasis recti). Holding a pillow tight around your stomach when coughing or sneezing can also help ease the pain, but having a wrap or belly binder allows you to have support and free up your hands for holding your new baby.
What to expect post surgery
Hospital policies vary but a three or four day stay is most common. Recommendations for getting up and walking will vary based on the type of anesthesia you were given as well as how your body responded to it, but it’s not uncommon for the staff to have you up and walking around after approximately 12 hours. If 12 hours post-op falls in the middle of the night they will probably keep the catheter that was placed for surgery inserted and wait until the next morning. Some hospitals don’t suggest getting up to walk until 24 hours following surgery. This is something to discuss with your doctor to decide what is the best course of action for you personally.
Mobility After Cesarean Birth
The reasoning behind getting you up and moving as soon as is safe is to encourage good blood flow to your extremities and prevent clots. Walking will also help with digestion, but will likely wear you out, so don’t overdo it. Taking a lap around the floor every couple of hours is probably sufficient.
While you’re still in the bed you’ll likely wear cuffs around your lower legs that occasionally pump up with air and squeeze tight. These compressions lower the risk of blood clots when you are less mobile.
Some women may feel very gassy and bloated. This can make it uncomfortable to try to pass gas as well as cause discomfort to your incision area where the muscles used for bowel movements are still healing from surgery. Answering questions about whether you’ve passed gas or had a bowel movement yet can be embarrassing but the staff needs to know your GI tract is back up and working to ensure you don’t have any complications there.
Your first bowel movement can be a nerve wracking event. The act of pushing can be painful to your healing muscles so you’ll be given stool softeners beginning right after surgery to help minimize the amount of pushing required. Many women report the anticipation of pain during a bowel movement was much worse than the actual pain experienced while some women do experience severe discomfort.
Anesthesia, surgery, narcotic pain relievers, and decreased mobility can all contribute to constipation so it’s important to take the stool softeners regularly, drink plenty of water, eat wholesome fiber rich foods, and be as mobile as your energy and pain level permits to help alleviate possible GI issues.
Following all types of birth the uterus needs to contract in order to expel any remaining blood or tissue inside of it. Some women report no noticeable afterbirth pains (the uterine contractions that occur after baby is born), while others experience such strong ones that they equate them to labor pains.
Whether yours are mild or strong, they serve a purpose. It’s important for your uterus to begin the process of shrinking back down to its pre-pregnancy size. The nurses will need to assess the size and firmness of your uterus but palpating your abdomen. This is typically a fairly uncomfortable assessment whether you’ve had a cesarean or vaginal delivery. They have to press down hard to accurately assess the size of your uterus as well as how firm it is.
A shrinking, firm uterus is what they are looking for, whereas a ‘boggy’ uterus could indicate a problem requiring medication to help it contract more. The act of pressing down on it through your abdomen can help it along as well, and while they don’t usually have to press down very long it can be painful. The nurses will use this time to assess your level of bleeding as well. We recommend this afterbirth tincture.
Many women are surprised to learn that following a c-section you will still have very heavy vaginal bleeding, just like vaginal deliveries. This lasts for about 4-6 weeks and the protocol is the same—no tampons allowed, only big absorbent pads. Your caregiver will likely provide some large mesh disposable underwear to use after delivery. These are a great option for the first few days following birth as they typically don’t irritate your incision site or put any pressure on that area the way some underwear elastic can—basically they are glorious! Stocking up on these as well as large overnight pads (these are our favorites) is a good idea since you’ll be changing them frequently the first couple of weeks.
Passing some heavy clots is fairly normal. The rule of thumb is generally if you pass a clot smaller than your fist, it’s okay. Anything larger—call your doctor.
Cesarean Incision care
Following surgery, your incision will be covered with a bandage that usually isn’t removed until the next day. Your incision will either be closed with sutures (dissolvable or non-dissolvable), staples, steri strips, or surgical glue on your abdomen. Staples and some types of sutures will need to be removed by your doctor a few days after you’re discharged. Before being discharged you will be given incision care instructions specific to your type of closure.
Keep in mind that your incision will look very different immediately after surgery than it will eventually. Most incisions will shrink down considerably and flatten to a thin line. Itching and tenderness around your incision is normal but annoying, anything more severe than that would warrant a call to your doctor. Try this spray or salve for expedited healing and scar reducing.
Advocate for Yourself at the Hospital and Home
Recovering from surgery, adjusting to new motherhood, getting the hang of breastfeeding—the first few days after a cesarean can be stressful and overwhelming. It’s important to make your needs known to the staff. If they don’t know your wishes, they can’t follow them. It’s your job to advocate for yourself and your new baby. Be open and clear with the hospital staff and expect the same from them—you’ll both benefit from respectful and clear communication. Never be afraid to request a new nurse if you aren’t receiving the care you feel you need or even if your personalities are not meshing well.
You never get the first few days with your new baby back again and they’re too precious to have marred by having someone around who puts you on edge, this goes for visitors and family as well. While well meaning and excited for you, visitors and family often end up putting more strain on mom than support. If friends want to come see the new baby make them earn the visit! Have them hold the baby while you take a shower or nap. Fold a basket of laundry while you chat. Fix some lunch or start a freezer meal in the oven for you. Have older kids? Ask friends to take them to the park for a hour and let them peek at baby when the come to pick them up.
You might be surprised at how eager people are to help when given specific tasks! But if the thought of a house full of people fills you with dread then don’t put yourself through it. Ask your partner or a supportive family member or friend to spread the word that you aren’t ready for visitors yet but appreciate everyone’s well wishes and put a sign on the door with the same sentiments.
Breastfeeding after a Cesarean Section
The first few days, your breasts produce a nutrient-dense, antibody-rich yellow liquid called colostrum. Colostrum is nature’s first perfect food for baby and provides all the nutrition, immunity, and vitamins your baby needs. Colostrum usually transitions to mature breast milk within 2-6 days of delivery. It’s not unusual for milk production, or ‘coming in’, to be delayed following a cesarean due to the use of IV fluids and other medications such as Pitocin. Once this occurs your breasts will be much larger and you may experience some engorgement. The best remedy for the discomfort of engorgement is removal of milk from the breast by the baby. Your baby will signal the amount of milk she needs your breasts to make and your supply will normalize. There are wonderful breastfeeding resources to be found here.
Some women have no additional difficulties breastfeeding following a cesarean than after a vaginal delivery but some find positioning difficult while their incision area is still tender (we love this breastfeeding pillow for keeping off your incision). Utilize the lactation consultants at the hospital as much as you need them while there. It’s a great idea to have an outpatient lactation consultant’s contact info saved already prior to delivery in the event you need more assistance following discharge. Ask friends who have had fulfilling breastfeeding relationships with their children for references to check out before you’re home with a new baby, sleep deprived, and probably pretty emotional.
The International Cesarean Awareness Network has some great info available regarding breastfeeding after a cesarean that can be found here. Kellymom.com is a great breastfeeding resource website in general and wonderful article about breastfeeding after cesarean can be found here.
Recovery at home after Cesarean Birth
photo via @littlewhale3
Bringing a new baby home is an exciting time for everyone, but don’t forget to take care of yourself as well. Your baby needs a cared for mother as much as she needs to be cared for herself. Accept offers of help! People love to feel useful but may not know how best to help or are hesitant to step on toes. Give them direction and don’t be afraid to set boundaries when it comes to having people over. Physically, you’ll need to take it easy for a while. It’s often recommended that you not to lift anything heavier than the baby or drive for 2 weeks. After that, follow your body’s cues and rest as much as possible.
The best way to encourage a speedy recovery is to allow your body the time it needs to heal. Rushing the process can result in setbacks that will only prolong it. Once you feel up to it, which will vary for every woman, light exercises like walking can be beneficial.
Medication After C Section Birth
The types of medications prescribed for pain will vary from doctor to doctor and patient to patient. Ask someone (like your partner) to keep track of what time you take your medications as trying to remember on a sleep deprived brain is probably not the best plan. Many people recommend taking the meds on a strict schedule the first few days regardless of whether you’re in enough pain to feel you need it yet. This is suggested to prevent the pain getting ahead of you and then having to wait for the meds to kick in. Some people prefer to begin a slow weaning process off of the meds sooner if they don’t like the way they feel on them.
Pay attention to your reaction to the meds and to your pain level and make the best decision for your body. Don’t hesitate to call a nurse or doctor if you are concerned about any symptoms. There are many post-surgery symptoms that while totally benign, can alarm you if you haven’t experienced them before. Reach out for information when you need to.
Some women report referred pain in their shoulder during recovery. Not all women experience it, and it seems to be worse for patients who had general anesthesia vs. spinal anesthesia. The pain is due to irritation of the diaphragm, and trapped gas. Anti-gas medication and walking will help. The more regular you can get with your bowels, the sooner the pain will subside.
Bed comfort for Cesarean Mamas
Keep that wrap handy for when you get in and out of bed, to help with support. Wrapping before you get up and lay down provides stability and a little bit of comfort. Feel free to even keep it on for a while so you don’t have to constantly adjust it. Some women find it difficult to get up from a flat lying position in bed. Roll on your side first and push up with your hands to prevent straining your abdominal muscles. If this is still too uncomfortable try putting several pillows behind your back and rest or sleep in a reclined position. Your pelvis will be working to get back in its pre-pregnancy position and can ache after delivery. Try sleeping with a special pillow between your knees and ankles to help alleviate some pressure.
There are lots of hormonal changes that take place right after delivery, and your body is also getting rid of a lot of excess fluid it carried while pregnant as well as any intravenous fluids given before, during, and after surgery. All of these factors combined might have you waking up at night to find the bedding and your clothes completely soaked. For the first couple of weeks, some women sleep on an extra sheet folded in half, or a towel so they can remove it midway through the night to have clean linens beneath them. Others suggest having clean pajamas handy for a quick middle of the night change. Remember to keep drinking a lot of water. It sounds counter-intuitive to replace excess fluid you are losing through sweat, but remember how much water is going toward milk production, so it’s necessary to keep things functioning well, and restore balance.
Mobility After A Cesarean Birth
For some women, stairs prove to be tiring and awkward to navigate the first couple of weeks. If possible, you might consider setting things up at home so that all the supplies for baby and for yourself will be mostly on one floor. Then stay in that area most of the day minimizing the need to navigate the stairs repeatedly. For other women the lure of being in their own bed on the second floor is enough to make it worth it. Just don’t hesitate to ask for help going up and down, even just having someone walk along beside you can be reassuring.
Keep in mind that your center of gravity has drastically changed and your body is still adjusting to that as well as healing from surgery. It’s not uncommon to feel off balance and it’s better to have help nearby just in case. Consider having pillows handy on both floors should you need to squeeze one against your abdomen while coughing or sneezing. Plan to give yourself plenty of time to recover, should it happen sooner than you planned—it will be a pleasant surprise! Be gentle with yourself. All women are different. There is no ‘right’ amount of time for recovery. There are no hard and fast rules for a healing timeline. Listen to your body, introduce things slowly back into your routine, and ease into motherhood.
photo via @chan_askins
Emotional Recovery after Cesarean Birth
Take time to evaluate your feelings about your cesarean experience. Mothers with planned cesareans have the opportunity to consider this beforehand but may still find themselves overwhelmed with conflicting emotions after the fact. Mothers who had an unexpected cesarean may feel blindsided and it’s important to take stock of all of these emotions and know that they are all valid.
It’s ok to feel disappointed in the way your baby was born. If you had planned for or envisioned things going differently, it’s completely normal to be sad it didn’t work out that way. This does not take away from the love and joy you have for your child. You can be deliriously happy that they are here and still be upset about how they came. Birth trauma may sound like a dramatic way to describe it but it’s not uncommon for women to experience varying degrees of trauma after a cesarean birth whether it was planned or unexpected, or especially if it was an emergency situation.
Your Feelings Are Your Own
Birth is a highly emotional experience and any emotions you have towards your child’s birth are valid and you are not alone in feeling them. Perhaps your cesarean was calm, you felt respected, and things went smoothly—this is the hope for all women experiencing a cesarean. Many women feel at peace with their sections and might not understand why others are seemingly devastated by theirs. Other women are deeply saddened by having had a section and cannot fathom why someone would choose to have one unless necessary.
When speaking with other mothers or mothers-to-be, be respectful of others’ experiences and perceptions of their experiences. Just because you loved your c section doesn’t mean another woman is wrong for disliking hers. Just because you hated your experience doesn’t mean another woman is wrong for liking hers. Evaluate and process your own feelings towards your cesarean and reach out for help.
Find others who can be supportive of your journey of processing your cesarean. The International Cesarean Awareness Network provides support, education, and advocacy for women experiencing cesareans and interested in VBAC (vaginal birth after cesarean.) ICAN can be found online here as well as on Facebook and Instagram. They have local chapters across the world which can be located on their website. Many of their chapters have individual Facebook groups and hold in person meetings for support. Talking to other women who have experienced a cesarean is an invaluable resource for processing your experience as well as planning for a cesarean section or a VBAC.
Birth is hard. Birth is beautiful. Birth is transformative. Take the time to take care of yourself and be proud of what you’ve accomplished and experienced for your new baby.
This guest post was written by Austyn Smith and a very special thanks Laura Shawver and Elizabeth Quinn who provided lots of great information while writing this post.
- Hamilton BE, Martin JA, Osterman MJK, et al. Births: Final data for 2014. National vital statistics reports; vol 64 no 12. Hyattsville, MD: National Center for Health Statistics. 2015. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf
- Althabe,Fernando; Belizán, José M.; Betrán, Ana P.; Gibbons, Luz; Lauer, Jeremy A.; Merialdi Mario. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report. 2010; Background paper, 30. Health Systems Financing. World Health Organization. 2010. [January 22, 2017]. http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf
- Basar, Birsen; Cift, Tayfur; Olmez, Fatma; Ustunyurt, Emin; Yilmaz, Canan. Shoulder Tip Pain After Cesarean Section. Journal of Clinical and Diagnostic Research. Ausust, 1, 2015 [January 22, 2017]. Bethesda MD: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4576593/
Your Intuition, Your Gut, Mama Instincts — Whatever You Call It, Listen to It
Pregnancy, labor, and birth are monumental, life changing events. Doing research, educating yourself, being fully prepared, taking proper precautions, and trusting your OB and/or midwife are all important. However, keep in mind that women have been going through this since the beginning of time. Our bodies are engineered to create, sustain, and bring life into this world. Birth does not always go as planned, or as “textbook” as we’d like. There are times when preparation, education, and practitioner’s advice take a back seat and a powerful voice comes into play. Your intuition. A mother’s intuition is an important voice to pay attention to, and the more prepared and educated you are up front, the more you will be able to trust that your gut feelings are coming from a vital place, rather than from fear and panic. Below are some powerful accounts from women who paid attention to what their body was telling them, and the positive outcomes that followed.
Mamas Who Are Glad They Followed Their Intuition
“With my second baby’s birth, I had been 3 cm dilated for over two weeks and having contractions on and off, too. The night before my son was born (1.5 weeks after my due date and the day before my induction), I told my husband, that we needed to call my dad if I had three strong contractions and/or my water broke, because I just felt it would be a quick labor. At 2:30am I had those strong contractions, 3:00am my water broke and at 4:27am my baby was born! If I hadn’t had that feeling of things going quickly after a slow buildup, Sullivan may have been born in the car or even at home!” – Jesica Boro
“…My son was turned. I was feeling nauseous from not eating for so long. The midwife was trying to turn him and couldn’t so they wanted to get a doctor to help. I could feel it was coming time for me to have an emergency c-section. Before the doctor came into the room, I got on my hands and knees which [made me] throw up and that caused my son to turn so I delivered him naturally like I wanted. – @Celeste2401
“A week after i had my daughter in June, I was terribly ill. At a time when I was supposed to be mending and enjoying my new baby, I was so sick that all I could do was cry. My friends and family told me it was just after birth cramping and that I was still healing, but I finally decided to call in to the midwife and let her know what was going on. She advised me to go to the ER right away, and hours later I was having an emergency d&c for a retained placenta that was hemorrhaging. I am so glad I listened to my body. If I had waited any longer it could have been a much different outcome.” — Jamie Van Nuys
“I was laboring in the labor tub. I had only been in for 15 minutes and was just checked 30 minutes prior and only 5 cm. My intuition told me to get out and go lay in the bed (they don’t let you deliver in the tubs). I was standing up and felt the urge to push. Two pushes later and about two minutes later my son was born.” — Brittani Fink
“When I was in labor about a month ago, we were waiting for my mother-in-law to come watch our two older children. When she was about 40 minutes away, I got the feeling that we had to leave for the hospital NOW. My husband was a bit skeptical because I had only been in labor for about two hours. But, he went and woke up the neighbors in the middle of the night and we left. Our baby was born about one hour later. If we had waited, I would have had him in the car!” — Nicole Kavanaugh
“After three cesareans and no natural births I was told by my doctors that my body “wouldn’t know how to labor” so I decided to get a private midwife, not step foot in a hospital again for the rest of my pregnancy, and set my mind on a homebirth. Everyone gave me their unwanted opinions about it all and only my husband stood by me. After about 100 hours of labor, I gave birth at 42 weeks + 1 day to my biggest baby ever (all 9 lbs 10 oz. of him) in a pool in my living room! THE best feeling ever! I’m now 39 weeks with baby number 5, I have the same midwife as last time, and I cannot wait to give birth to this baby. I never believed for a second my body was broken, and I proved all the doctors and midwives at the hospital wrong. I did it.” — Rose McMurrie, Liverpool UK
“After the birth of my son last Thursday I was over the moon…but something kept telling me something was wrong and after the experience I went through I will never doubt my intuition! Three days after birth I knew something was wrong when I had been experiencing severe edema, painful headaches that wouldn’t go away, and sky high blood pressure. I decided to go to the emergency room and the doctors then told me I had developed postpartum preeclampsia. I was immediately admitted, I was at high risk for seizures, a stroke and even the possibility of going into a coma. After four very long, emotional, rough days I am finally responding to medication that is maintaining and stabilizing my blood pressure. I am back home with my baby and my fiance and most importantly I am alive and well…If I didn’t rush to the emergency room when I did, the signs I was showing could have been fatal for me. I appreciate my life so much more.” — @Ox.vs
“My first birth, I was in labor barely an hour when I told my husband to call the midwife. I had to push before she even got there. She didn’t even check me, but when I said I had to push she called the backup and got set up and my daughter was born 20 minutes later. So glad I didn’t fall into the thought that first births take a long time, or else I would have been birthing unassisted. Very glad to have planned a homebirth from the get go! Though my midwife training would have come in handy!” — Meganne Odile Coyle
“My baby’s bilirubin levels were high. Day three of life, the pediatrician made the assumption I wasn’t producing enough milk. “The baby will eat it if it’s there,” he said, and told us we needed to supplement with formula. I asked for a pump and made them weigh him before and after a feeding as well as pumped after. I was producing more than enough and wouldn’t you know it, his chart was being read wrong and he had been back to normal levels on day 2. Still breastfeeding like a champ nine months later.” — Marji Taylor
“At 38 weeks 5 days pregnant with my first son, I woke up in the middle of the night and found myself bleeding. I called my midwife who immediately recommended that I go into L&D and she would meet us there. Upon arrival at L&D the attending doctor recommended an induction and suspected that I was likely experiencing placenta abruption (i also had a low lying placenta). My partner and I decided to wait on the induction and the hospital admitted me for observation and told us to let them know when we were ready to be induced. But somehow, I felt that my son wasn’t ready to come. The bleeding eventually subsided, and after 17 hours of being observed, after one doctor after another came in telling us we needed to be induced, and braving through judgemental looks and fending off their repeated push to have an induction; against doctor’s orders, we decided to check ourselves out and go home. A day later, I went into active labor. After 9 hours, in the safety and comfort of our small apartment, with my partner and midwife by my side, my son was born at home. It was the home birth that we had wanted. I listened to my body and my son. My partner stood by my side and although it was very scary to leave the hospital, it was the best decision we made that day.” – @Bbmee
“The nurses wanted to check my dilation when I arrived at the hospital. I told them not to bother—I wasn’t fully dilated yet but was in transition and it would be soon. I told them my second stage is always under 5 minutes. They didn’t believe me. When I felt a shift I told the doctor I was ready to push and baby was coming. She checked and said, “No, you’re only at an 8.” She stood up and walked to the sink, and I called to my husband (who always catches our babies and who was ready), “She’s coming, catch her! “I heard his calm voice reply “I’m here, I’ve got her.” And she was born into her father’s hands at that moment, with no assistance from others. Which was exactly as I had wished.” — Elisabeth
“After 26 hours of non-medicated labor with a baby who had his head turned sideways and was in no hurry to come out, I decided to transfer from the birth center to the hospital to get an epidural. I knew that even if I did dilate all the way, I wouldn’t have enough energy to push my baby out on my own. After the epidural, I was able to get a few hours of sleep and when I woke up I was fully dilated and ready to push! I truly believe I was able to have a vaginal birth because of the sleep I got after the epidural! I am happy that I listened to my body and I have no regrets! My birth was hard, but that is what it was. My birth.” — Kristi Merideth
“I was on hour 6 or 7 of my twelve hour homebirth when I began to hyperventilate. I was in the birth tub facing away from everyone, so I don’t think they knew I was starting to lose it. I hadn’t dilated much at that point; how little, I don’t know. But I sensed the air of concern. I didn’t want to go to the hospital. That was my greatest fear. I began going down the “what if” spiral of doom and lost control of my breathing. Just then my intuition kicked in and told me to look up and open my eyes. A birth affirmation my friend made me came into view. It said: Think strong. Feel strong. Be strong. I began saying that over and over in my mind, pushing away the fear. My breath calmed, my outlook improved. I could do this. I would do this. At the next check, I was fully dilated!” — Katie Bunten
“When you reach the end of what you should know, you will be at the beginning of what you should sense.” ― Kahlil Gibran, Sand and Foam
Pain Medication Options in the Hospital Setting From a Nurse’s Perspective
During labor, there are two options for pain medication in the hospital setting: IV medications and/or an epidural. Oral pain medications (pills) are usually only given in the postpartum period.
When you are admitted to a labor unit, your doctor or midwife initiates an Order Set. These are the same universal orders for each patient, with some choices that can be added on or removed. The option to have IV pain medication or an epidural if desired by patient is included in these orders. Your nurse, and occasionally your doctor, will work with you to discuss if and when these should be given.
IV Medication options during labor
First let’s talk about the IV medication options. There are two different IV medications that may be given for pain (please note medications may vary at different hospitals but these are pretty standard). One is called Stadol and one is called Fentanyl. They are small liquid doses that are administered through your IV site. There are usually half and full doses available, and you can usually repeat the dose again after a period of time. For example, Fentanyl may be ordered as 50mcg (micrograms) or 100mcg, every X hours, as needed for pain. And Stadol may be ordered as .5mg (milligrams) or 1mg, every X hours, as needed for pain. Both of them have a maximum amount that can be given. That means, if you’ve reached that amount, you can’t have anymore.
Benefits of IV medication
These IV pain meds can be helpful for taking the edge off. I tell patients they might knock the top off of the contraction mountain. The sensations are still there, but not as intense. Maybe mom will even get a short nap. She may be able to rest and regroup and get back in the game of coping with contractions. This is good for someone who is looking to avoid an epidural but is having a hard time. It’s nice to have something, and IV pain meds can be a useful tool in the “coping with labor” toolbox. The effect of these drugs in your system can last anywhere from 20 minutes to 60 minutes. On a side note, sometimes we see moms in triage having days of looooong early labor. We can give them these same IV pain meds, some IV hydration, some monitoring to watch baby during this, and usually they take a great nap. Often times they go home afterwards.
Potential Side Effects of IV Medication administered during labor
IV medications go into your bloodstream. Therefore they cause systemic effects, like mental changes. They’re narcotic drugs. They may make you feel loopy and out of it. You may not have a lot of experience feeling loopy and out of it or tipsy (especially since you’ve been pregnant for 10 months!). You may not like the way this makes you feel at all. The good news to that is that these are short acting drugs, so the effects (both good and bad) will be over quickly.
Will Baby Feel the Effects?
Since the drugs are in your IV and bloodstream, that means they are also in baby’s bloodstream. You will have to be continuously monitored with the belts around your abdomen during the time these drugs are in effect – the monitors are listening to and graphing baby’s heart rate as well as your contraction pattern. They sedate you, but they also sedate baby. Baby’s heart rate pattern will appear similar to what it looks like when they are sleeping. We would not be able to administer these drugs to you if baby had recently shown us any reason to be concerned about their wellbeing. Baby’s usually metabolize these drugs faster than you, and we see baby’s sedation wear off relatively quickly on the monitor.
How Long Can You Wait to Get IV Meds?
We also would not want to give you these drugs if delivery was imminent (meaning 8cm or more dilated for a first time mom, or a second + time mom who is dilating quickly). We would not want baby to be born with these drugs still active in their system, since they may make their responses to extrauterine life not as vigorous. We want a baby alert and crying (hello apgar scores!), not sedated. To be clear, these two IV narcotic pain medications and their doses are chosen for their use in pregnant women because they are safe to cross placenta to baby’s bloodstream. That’s why they aren’t very awesome and magical and pain relieving for you (those would be IV pain med drugs such as Dilaudid or Morphine), because that has to be balanced with safety for baby as well.
Alternatives to IV meds
Of course, all non pharmacological pain relief options are alternatives to IV pain meds. Additionally, if you don’t like the idea of your baby being exposed to short acting narcotic pain meds in utero, an epidural is a great option (more on that next!).
Reality & My Opinion as an L&D Nurse
I usually see IV pain meds administered as sort of a prelude to an eventual epidural. I usually don’t see IV pain meds alone. If you’re looking for that sort of relief/release, you will usually eventually have an epidural. Patients ask for some IV pain meds after either exhausting all of the non pharmacological coping strategies the doula or I have suggested (shower, walking, swaying, hip squeezes, distraction, birth balls, calm voices, encouragement…), or as a means of prolonging the time until they get an epidural (“I want to be 6cm before I get an epidural”). Probably an equal amount of times people are happy with the effects and take a spacy nap, vs feeling like ‘yuck, I hate feeling this out of it.’ And, for what it’s worth, I prefer to use Fentanyl for my patients because there seems to be less of the yuck.
Epidural Relief during Labor
On to our next pharmacological method of pain relief: the epidural. Epidural is not the name of the drug; rather it is the name of a space in your spinal column. That’s where the small flexible tube that will administer medications is placed. Think of it like your IV: we use a needle to get a small flexible plastic tube into a place, and then we remove the needle and tape the small tube in place. Medication drips continuously into this space and numbs the pain sensations of the nerves below it. The drug cocktail that makes up an epidural is a mix of Fentanyl and Bupivacaine.
When a patient says “I want an epidural now,” it takes about 45 minutes from that statement until you start to feel relief. Let’s suppose you already have an IV. I start giving you a whole bag (one liter) of IV fluid really fast. I let the anesthesiologist know that you want an epidural. Where I work, there is always an anesthesiologist or a nurse anesthetist in the building. I get all the materials anesthesia needs to perform the procedure at your bedside. I help you cope with the contractions that keep coming, because usually these last ones feel really intense. Mentally you have decided on the epidural, so you are ready for these contractions to be over. They may not actually be stronger, but they feel stronger because your coping has lagged.
Procedure for administering an epidural
When anesthesia arrives at the bedside, we sit you up on the side of the bed with your legs dangling. We sit your support person down on a stool right in front of you to help squeeze your hands and talk to you and distract you and just generally be up close in awe of how tough you are. We discuss what’s going to happen. It’s all about positioning, so we coach you into the right position. Think of the cat pose in yoga, or pushing your lower back out in slouchy posture. Maybe a pillow helps you round over your belly, chin to chest, shoulders relaxed. Anesthesia cleans your back, places a sterile drape over your back, touches your bony spine to determine the spot they are going to place the epidural. They numb your skin with lidocaine – which burns! That’s usually the worst part. But everything burning and tingling is getting numb. After that you just feel touch.
Positioning for Getting an Epidural
We help you get in the ideal position with rounded back. Having a rounded back makes the spaces between the bones of your spine bigger. They use a needle (that large, long needle everyone talks about, but your eyes will never see it) between two of your lower vertebrae almost like a dart. Then they thread a long, soft, flexible skinny straw into the space, and pull the needle away. It takes just moments. The needle does not stay in your back. We test and make sure the tube is in the right place by giving a tiny bit of medication first. We would know instantly if it was in a wrong place such as a blood vessel. Your heart would race, you would have a metallic taste in your mouth and a ringing in your ears if this happened. I’ve seen it happen twice. The amount of the drug is so small those side effects are over almost immediately, and anesthesia fixes the placement of the catheter.
Do Epidural Meds go to Baby?
It’s important for us to determine that the tubing is in the right place because we only want the epidural to be in the epidural space of your spinal column. That’s where the medication stays. The medication does not go in your blood stream, and does not go to your baby. I’m anticipating some comments here about studies and evidence to the contrary, but the point I’m making is that compared to IV pain meds, epidurals do not “drug” your baby at all. Your baby does not know you have an epidural, and your uterus doesn’t know you have an epidural.
Dosage of Epidurals
Then we tape the tube to your back really well and connect it to the pump that gives you medication constantly. Epidurals don’t run out—we continue the medication until it’s no longer needed. You are usually quite comfortable initially because you get a loading dose, and then afterwards you have a remote button that you can press and give yourself a little more. I tell my patients if they are ever making the wincing ouch face again, it’s time to press the button. The button is totally optional.
We lay you down flat to let the medicine settle evenly across your whole pelvis. The contractions fade away like a sunset, rather than a light switch. The first couple feel shorter (even though they’re not) and then eventually you don’t realize that you’re talking to me through a contraction without noticing. We monitor your blood pressure closely. We place a catheter in your bladder to drain urine since you can’t walk to the bathroom anymore. This does not usually hurt.
Moving Around After an Epidural?
Once you have an epidural you can no longer bear weight on your legs, and it’s not safe to stand up. I don’t know what people are talking about when they request “walking epidurals.” You are bed bound. You’re not totally numb in a panicky “I can’t feel my legs” way. You are able to help us change your position every hour or so from side to side. You don’t generally lay on your back for the same reasons we tell you not to do that when pregnant – bad for blood flow to uterus. I like to keep a peanut ball or a folded pillow in between your knees to keep your hips open. It’s important to remind your care team to do that if it’s not being done. Epidurals take away pain, not pressure, so you may still have awareness of your belly getting hard with contractions, and ideally you still feel vaginal and rectal pressure with contractions when it’s time to push. If you’re getting close to the time to push and you are really really numb, I’ll suggest not pressing the button for awhile.
Benefits of an epidural
You’re able to sleep. Many of the epidurals I am apart of are for therapeutic rest, and not for an inability to tolerate painful contractions. You’ve been awake for days or even just all night (especially with the long early labors that are notorious in so many first time moms), and the epidural is a valuable tool to allow rest, relaxation and regrouping for pushing and early parenting.
Maybe mentally you’re in your own way. Fear, anxiety, and interpreting pain as suffering send your body “fight or flight” messages. Adrenaline overpowers oxytocin, and can stall labor. You need to feel safe as an animal to give birth. Your body needs to relax in order to release, surrender, and dilate. Sometimes the relaxation of an epidural is exactly what that body needs to dilate.
You remain numb throughout the rest of dilating to 10cm and throughout the one, two or three hours it may take to push baby out (if you’re a first time mom) or the maybe 20 minutes of pushing if you’re a repeat mom. We turn off the epidural pump after the placenta is delivered and any possible repair to your perineum (aka stitches) is completed. We take the tube itself out an hour or so later when we get you up to try walking to the bathroom. You might complain about the tape coming off your back and won’t notice the sensation of me pulling out the tiny tube.
Potential Side Effects of an Epidural
We need to monitor baby and contractions continuously, so you’ve got those belts on from now on. We also need to monitor your vitals pretty regularly (aka the annoying blood pressure cuff stays on, sorry). The most common side effect of an epidural is a blood pressure problem. It can drop low. We try to prevent this by giving you all that IV fluid first. If it drops it can make you feel sweaty, nauseous, light headed, and gross. That’s what low pressure feels like. But baby doesn’t like it because they’re used to the glub-glub-glub of your blood pressure chugging along nicely. If we see this we will intervene quickly to raise your blood pressure back up and correct baby’s response to it.
Let’s talk about the Cascade of Interventions. Yes, if your contractions space out from every 2-3 minutes to every 5-7 minutes, and your cervix pauses in its dilation progress, your doctor will recommend augmenting with some pitocin. That means giving you an IV version of the drug pitocin, which is modeled after your own hormone oxytocin, which causes uterine contractions. We would also suggest this to you if these same conditions were present in labor without an epidural, by the way. Yes, if you get an epidural in early labor, you will have an epidural for a long time (first time moms take about 1 hour to dilate 1cm…and we’re going to 10cm = 10 hours at least, usually 16-24 hours), and interventions will likely be offered to you.
Reality & My Opinion as an L&D Nurse
We don’t have “rules” about getting epidurals only after 4cm and only before 8cm, but ask your nurse or doula to help you cope with contractions until you’re in active labor. And once you have an epidural make sure you are turning from side to side every 1-2 hours, and keeping knees and hips open with peanut balls or pillows. If you have an epidural you will not be able to take advantage of gravity efficient birthing positions such as squatting, so it may take you some time to learn how to push, and you may push for one, two or three hours. My advice: use the mirror!
The same rules apply to interventions whether you have an epidural or not: always be an empowered and informed healthcare consumer. If an intervention is offered and discussed it is totally ok to ask:
- What are the benefits?
- What are the risks?
- What are the alternatives?
- What if we wait an hour?
- What if we do nothing?
Other side effects to note in an effort at full disclosure: maybe it takes several tries to get it in the right spot, maybe it works better on one side of the body than the other, maybe there is a hot spot on your belly where you still feel discomfort, maybe you weren’t as numb as you wanted to be, maybe you’re too numb when it’s time to start pushing. Your nurse and anesthesia provider will work to troubleshoot these problems. Before they start placing an epidural you will need to sign a consent form whereupon are all other possible known risk factors and serious side effects of having an epidural. The only serious side effect I’ve seen in my career is when there is an error in placement and a couple days later (usually when you are still hospitalized on the postpartum unit), you end up suffering from a terrible postural headache. That means you are fine when laying down, but feel awful when sitting up. It has to do with the levels of fluid in your spinal column and gravity. It is treatable.
Reality & My Opinion as an L&D Nurse
I feel like patients with epidurals are divided between women who know they want an epidural eventually and it’s just a matter of when (my job is to help steer them towards being in active labor first); women who maybe want an epidural but are afraid and anxious about getting one (my job is education and emotional support); and women who are getting epidurals for therapeutic rest after fighting long hard battles with natural labor (my job is emotional support).
The ebb and flow of popularity for different trends in obstetrics is interesting over time. We are currently in a natural parenting surge, which is great. I sat down to write this article after breastfeeding my 3.5 year old. I get it. I just want people to remember that access to an epidural was once a women’s rights cause, and women marched in the streets demanding access to them. I completely reject the guilt, shame, and “mommy wars” hostilities that women place on each other for their childbirth and parenting choices, especially the choice to have an epidural or not. You do you! I did not have an epidural with either of my deliveries, but oh I was talking about it. I had put in some good hard time (naked, moaning, out of body experience), and if my midwife would have said “You’re 5cm” I would have said “Epidural.” Done. But it just so happened that she said “You’re 8cm” (and with second baby, “You’re 10cm”). The thought of being close to the end was reward enough to keep going, and soon after those babies were here. I may be biased, but I think most pregnant L&D nurses and obstetricians (at least all the ones I know) operate on a pretty similar and effective “Birth Plan” for their own deliveries: use whatever you need if you need it. No shame, no guilt!
This guest post was written by Maureen Hodges, BSN, RNC-OB, LCCE. Maureen has over ten years of Women & Children’s nursing experience. For the past seven years she has been a Labor & Delivery nurse at a very busy hospital in the Austin area. She teaches private, hospital, and online childbirth classes. She has two children, aged 1 and 3, and a husband who knows all her L&D pep talks verbatim from listening to her answer every pregnant woman’s questions at dinner parties, on airplanes, and on the phone in the middle of the night. She has attended the deliveries of everyone in her book club. She could not pick any of their vaginas out in a line up. You can find her on instagram at @empoweredbirthatx or on facebook at Empowered Birth Austin.
- We want to see your poop.
- You’re getting an IV.
- Take a class or a tour.
- Your first labor & delivery is the longest.
- Get a doula.
- Let go of control.
- It’s only one day.
- Are you with the right doctor?
- Say something.
- How to thank us.
We want to see your poop.
Let’s get this one out of the way first because it’s my favorite. Everyone who comes into L&D to have a baby is worried about “pooping on the table.” They think that they are going to try and push a baby out, and the baby will stay inside their body, and instead a huge poop will come out and it will be mortifying. Wrong!
When you are completely dilated (10cm) the only thing holding your baby in is your pubic bone. Pushing is the act of bearing down to rock baby under your pubic bone and stretch/make space for your baby in your vagina. When you are doing a great job of pushing, if (big IF!) there happens to be stool (medical term for poop) in your rectum (medical term for butt) at that time (and maybe there isn’t because diarrhea sometimes happens in earlier labor), a little smear of poop might come out with pushing.
Nurses think this is a great sign that you are pushing effectively! We like to see this! We are usually quite good at keeping this discrete. I keep a “poop drape” towel tucked under your bottom and folded up to hide your bum. We change these towels often, and chances are you will have no idea if there was a little bit of poop or not. Ditto for any support people in the room at the time.
You’re getting an IV.
Please don’t write a birth plan that says “No IV unless medically necessary.” You’re all getting IV’s. Think of an IV like buckling your seatbelt when you get in a car. It’s for safety. It’s for just in case. There are people who say “telling moms they need IVs in case of emergency is hospital fear language and negative because it implies there may be emergencies.”
There are people who say “can’t you just start an IV if there’s an emergency?” These people have obviously never started an IV and have never been in a true medical emergency. It’s not always easy or quick to start IVs, so we like to place them soon after arrival to the hospital. An IV is a tiny plastic straw inside a blood vessel. The needle we use to get that straw under your skin doesn’t stay in! Lots of people fear IVs because they mistakenly believe a needle is going to stay inside them. Wrong, it comes right out immediately!
The straw (catheter) is connected to a small access port. We can connect that access port to a longer strand of tubing and use it to infuse fluids or medications. If the straw and port are not connected to the tubing, it’s called a “saline lock” or a “hep lock.” But the IV part remains the same. Please don’t write a birth plan that says you want a “saline lock instead of an IV.” That doesn’t make any sense. If you don’t need to be connected to fluid or medications, we will disconnect the long tubing so you will have more freedom of movement.
If you don’t think you need extra fluids and you aren’t requiring medication at the time, it’s always ok to ask for your IV to be saline locked. Requiring patients to have IV’s isn’t a thing that’s going to change anytime soon in the hospital setting. If this is really a big deal for you, look into giving birth at a birthing center or at home.
Take a class or a tour.
If you took a childbirth preparation class, you would have already heard that pooping pep talk, and heard that you’re getting and IV, and had the chance to ask a birth professional anything you wanted! Classes are amazing for lessening anxiety and fears, building confidence, empowering you to make informed decisions about your health care, even teaching you the anatomy basics. I started teaching classes because I couldn’t believe how many times I would be holding a woman’s dilating cervix in my fingers talking to her, and she had no idea what that was or its very important role in labor. Get informed!
At the very least, take the tour of the hospital’s birthing facilities. It’s packed with information, tips, and you get to ask the nurse leading the tour any and all questions about policy or procedure.
Your first delivery is the longest.
Your first labor and delivery usually takes the longest time of any pregnancy you will have. Be patient. Be more patient than you ever thought possible. It can take days or weeks for your cervix to soften, efface and start to dilate. Then it takes awhile to dilate to 4cm (awhile = hours or days). Then it takes about a centimeter an hour to go from 4cm to 10cm. And then it takes anywhere from 20 minutes to one, two, or three hours to push your baby out.
While we’re on the topic of things you should know: know that your doctor won’t come push with you until the very end, like the last several pushes. You could push with your nurse for two hours, and the doctor two pushes. Might as well tell you all of it: it might not even be your doctor. It might be one of your doctor’s partners.
The active labor portion of this whole experience (where contractions are strong and require all your coping attention) can start at any time of the day or night, so maybe you end up being awake for a long time. Even if you are planning on having an epidural, you must come prepared to cope with strong contractions. We will help you cope of course, but it’s naive to think it’s possible to feel nothing.
Many of the epidurals I help administer to patients are for exhaustion, not inability to handle pain. We call it “therapeutic rest” and is very common for first time moms.
Coincidentally, the time when most women think they want to try and have a baby without an epidural is the first time they are pregnant. It’s like if someone tried running for the first time and found out the course was a marathon. Some people might reasonably decide, well running isn’t for me. I sure would. The problem with this is that the second meeting of the running club is just a 3 mile loop around your neighborhood. Your second, third etc labors are much faster! Like, hours and hours faster! Once strong labor contractions start your cervix can dilate to 10cm very fast.
We joke that we don’t trust those moms for a minute. They could “go complete” (-ly dilated) at anytime and push that baby out in minutes. My point is, don’t beat yourself up if you thought about not getting an epidural with your first delivery and you ended up having one. Maybe try it with your next delivery, or…
Get a doula!
If you are a first time mom and your goal is to deliver epidural free in a hospital setting, think about getting a doula. When you are in the hospital, a doula and I aim to do basically the same thing for you, with one catch. The doula only has to do it for you. Sad but true, I may have another patient I am taking care of at the same time as you in the early part of your labors. Additionally, your doula usually starts caring for you at home in early labor. This can keep you home for a longer amount of time than if you were laboring alone.
Constant, reassuring, expert bedside support is crucial for managing natural labor. Doulas can be expensive. If you can’t afford one, make sure that when you first arrive as a patient in Labor & Delivery, you ask to speak to the charge nurse and request a nurse who loves working with natural labor patients (we all are capable of doing this, some just have a special passion for it).
Let go of control.
There is a huge spectrum of normal in Labor & Delivery, and you can’t plan it all out in advance. You just can’t. Trust your support team and your providers to give you good advice and expertise, ask the right questions, and pay attention to your intuition. Breathe. Think of this as your initiation into parenthood. Anyone who’s been around kids knows “control” is not a word used to describe the experience of raising young children. More like: “SURRENDER”, “LET GO”, “WHAT WILL BE WILL BE”, “BE OPEN TO THE EXPERIENCE”, “RIDE THE WAVE.” Coincidentally those are great birth mantras. Another one of my favorites: “Let go or be dragged.” Breathe. It will be ok.
This is only one day.
Ok, maybe it’s two or three or four days, but your time being in labor and delivering a baby is relatively short. It can be an empowering, life changing, positive experience, but it is still only several days. Parents spend so much time preparing for (and worrying about) this portion of the experience (where you will have a constant bedside presence of a supportive L&D nurse or doula), and neglect preparing for the postpartum period (where you will be sleep deprived at home with another sleep deprived person as your companion and a confusing tiny new member of the family who you love in a terrifying way).
Labor is one experience. After your baby is born, breastfeeding is an experience that is going to happen every three hours for almost the next three months or longer. Breastfeeding is natural, but it doesn’t come naturally. Babies and moms have to learn those behaviors. Take a breastfeeding class; identify three friends who have breastfed successfully that you can text with questions; and get the name of a good lactation consultant in town. Most breastfeeding issues come up after you’ve been discharged from the hospital. Not breastfeeding? No judgment here, fed is best.
Make a postpartum care plan (great book). Put just as much effort into that care plan as your list of birth preferences. Identify a new moms group you can go to, an online community, or a postpartum doula service to come love on you at your house if needed. Make a plan for postpartum mom not being the person solely responsible for dealing with household chores, cleaning, cooking, laundry, etc. Make a plan to have friends drop off dinner. Key words: drop off. You’re not hosting people to dinner every night. Drop off food and leave, thanks. People who understand this are the best kind of people to include in your postpartum plans.
Be kind to yourself. Let your house be a mess. Just a total mess. The default position is on the couch with a baby skin to skin, feeding when needed, next episode on Netflix starting in 12 seconds. Be kind to your postpartum body. Don’t say mean things to it or think mean things about it. It’s beautiful. You’re beautiful. You just did a beautiful thing.
Postpartum depression is real. Postpartum anxiety is real. Weepy is normal. Feeling hormonal and overwhelmed is normal. It’s ok to feel like you should be so happy but you’re just not. If this lasts longer than three weeks or you have thoughts about harming yourself or baby call your doctor or midwife immediately and get an appointment to see them in person. If you feel traumatized by your birth experience, talk to someone. Partners and friends can help, but don’t be shy to talk with your providers. And ideally, if you were delivered by a different provider in that practice, make your follow up postpartum appointment with them. Maybe they can help you work through and process some decisions and emotions from that day. You’re not alone. Seek out postpartum mental health support group or alliances in your town.
Some of you are with the wrong doctor.
We scratch our heads over this one all the time. Let’s say Doctor A and her partners are the group at our hospital who have the highest volume of pain med free deliveries (what a lot of people call “natural” childbirth), and the lowest rates of interventions (inductions, C-sections etc). Doctor Z and her partners have the highest rate of epidural deliveries and highest rates of interventions, with all the other practices that deliver with us having A-Z variations in between.
It is always perplexing to us nurses when patients with goals and philosophies similar to Doctor A group (and usually quite adamant about their desires) show up but are patients of Doctor Z group. You’d be better matched with another doctor, but our hands are tied. When we are meeting you, you are already in labor or showing up for an induction. We can’t, and we shouldn’t, tell you then to switch doctors. We can only attempt to navigate you through the maze of possible interventions. This is a finely honed art of professional relationships between the doctor and the nurse.
Our job is to advocate for you and your preferences. Your job is to do your homework. Don’t just choose a doctor because they are popular or your friends go to them or they are already your doctor who’s been prescribing your birth control pills and doing Pap smears for a couple years. Spend some time thinking about your birth philosophies and preferences, ask friends about their births and their providers, and know that it’s ok to interview OB’s before choosing a practice.
You’re the consumer. Say something!
If you have a bad experience in a hospital setting, say something. Not to your friends, not to the internet, say something to the hospital administrators themselves. All hospitals call you in the postpartum period for a follow up survey. This is your chance to tell us the things we got right, and what areas we need to improve. Be specific. If you didn’t get this call, or you didn’t realize you could speak so openly during that call, call the hospital back. Ask to speak to the unit manager or director. These days, patient voice and satisfaction is everything in health care. Almost to a frustrating degree, hospitals will listen to what patients say more than what the nurses say. Upset about some of practices you encountered in L&D that you don’t feel are evidence based medicine? Let them know.
Here are some possible suggestions, wink wink: strict restrictions on eating and drinking in labor, nurse to patient ratios in labor, baby remaining skin to skin with you in the first hour of life, enough staff for breastfeeding support.
How to thank us…
We love to eat still-hot Tiff’s Treats cookie delivery and a baker’s dozen Einstein bagels and cream cheese, but we can live off a genuine thank you note for weeks. I still have every one I’ve ever received, and they are among my prized possessions. Oh, but if you’re going for food we also like breakfast tacos, pizza, coffee…
This guest post was written by Maureen Hodges BSN, RNC-OB, LCCE. Maureen has over ten years of Women & Children’s nursing experience. For the past seven years she has been a Labor & Delivery nurse at a very busy hospital in the Austin area. She teaches private, hospital, and online childbirth classes. She has two children, aged 1 and 3, and a husband who knows all her L&D pep talks verbatim from listening to her answer every pregnant woman’s questions at dinner parties, on airplanes, and on the phone in the middle of the night. She has attended the deliveries of everyone in her book club. She could not pick any of their vaginas out in a line up. You can find her online at @empoweredbirthatx or Empowered Birth Austin on Facebook.