Labor lasted 27 hours so you're damn right it's a two-part post

One tends to hear a lot about pregnancy--the morning sickness, the swollen feet, the constant bathroom trips--but much less about labor and birth. In part this is because birth is a private act, while pregnancy is performed publicly, but in part it is because falling birth rates and delayed childbearing reduce the exposure we have to women giving birth.

In academia, with its further fertility delays, these effects are exacerbated. I was in my late twenties before any of my close friends or relatives gave birth. At the time we got pregnant, I had perhaps heard more about the problems of fistula in impoverished African women (thanks, Nick Kristof!) than about the process of giving birth in upper middle class America.

After I gave birth, I discovered that many of my friends really wanted to know details, but they were sometimes reluctant to ask. Commonly, a group of labmates would hover until someone managed to ask the question--"Did you have an epidural?"--and then all heads would swivel, waiting for the answer. I think both the curiosity and the reluctance to ask are symptoms of how little many of us hear about this basic physiological process. Mainstream depictions tend to focus on the pain, often (e.g. Kirstie Alley movies) for comedic effect.

During pregnancy I found women's stories as reported in a few birthing books (Birthing From Within; Ina May's Guide to Childbirth) to be more helpful than the more clinical presentation of, say, What to Expect When You're Expecting, or the (truly awful) Your Week by Week Pregnancy. As Birthing From Within author Pam England puts it: Millions of women have given birth; how can there be only one right way to do it?

So here's my version, for Arlenna, for other pregnant readers, and frankly for anyone who would like a little demystification of this secret act. Consider it the happy finale to the IVF series.

The first surprise was that it was early. Conditioned by friends and relatives that first babies are generally late, I was expecting an early September arrival for our late August due date. (One nice benefit of IVF--you don't waste time speculating about the accuracy of the dating!) One week prior to the due date, I was happily planning an upcoming week of analysis. As I left work, my advisor called out, "It could be any day now!" and I laughed at him as I walked away.

So that night, while eating the zucchini, tomato, and pancetta pasta that Dr Hyde had prepared, I was nonplussed to feel some cramps. Unlike Braxton-Hicks, the painless if sometimes intense contractions that had been constant companions in the third trimester, these cramps were mildly painful, like minor menstrual cramps, and reached all the way around both belly and back. "Just early contractions," I thought, "probably irregular and will go away." Regular contractions spaced five minutes apart is considered the threshold for visiting the hospital, but most women start out with irregular contractions 10-15 minutes apart.

But after dinner, just to see, I started timing them. Six minutes from the start of one to the start of the next. Then six minutes for the next. Six minutes. And, hmm, six minutes. I called my doulas.

A doula is a woman who accompanies you throughout the process of labor and childbirth. Unlike a nurse, midwife, or doctor, she will not leave when the shift changes; nor will she (necessarily) participate in any medical evaluation or treatment. Her role is to support and encourage the laboring woman and her partner. A doula's presence significantly reduces the rate of Caesarean birth, epidural anaesthetic, prolonged infant hospitalization, rate of forceps/vacuum usage, length of labor, etc. etc. [1, 2, 3]. (Also, more breastfeeding [4].) In other words, doulas are good for women and babies.

Our hospital offers volunteer doulas, pending availability.However, I wanted to meet a doula ahead of time and make sure I liked her. How to find one?

There are websites where you can search for local doulas, but I found mine in an unorthodox manner. The woman sitting next to me on the bus one day had a bag with the name of a doulas' organization on it. I asked her about it and it turned out that she was not a doula, but had a friend who was. She put us in contact, and Dr Hyde and I went to interview her.

Doula S and her partner Doula D were so awesome that I decided not to interview anyone else. They were both midwives as well, so if I wanted to labor at home for a while before going to the hospital (which I did), they were qualified to evaluate my progress. Most important, they were clearly committed to helping me have the experience I wanted, and not imposing on me their vision of how labor "ought" to be.

During several prenatal visits they spent an hour or more answering our questions and asking us some too, to establish our preferences. Were we seeing a midwife or an obstetrician? How did I feel about epidurals and other forms of pain relief? What painful experiences had I had, and how had I handled them?

Eventually the plan we settled on was this: I switched from obstetric to midwifery care, once it was clear that the pregnancy was going normally. At our chosen hospital, this meant that I could labor in the midwife-run birth center, which has big tubs and is generally cozier than the standard OB-run labor & delivery ward. If at any point I decided to have an epidural, or if something was not going well with the labor, I would be transferred a couple of floors to the regular L&D. Also, with our doula/midwife help, I would labor at home for as long as I felt comfortable doing so. The idea was to delay an epidural as long as possible, and perhaps even avoid one.

Why this route? Epidurals typically provide pretty good pain relief, but they're not without drawbacks. Epidural anesthesia requires an additional IV line for fluids; in addition to the numbness produced by anesthesia, this keeps the woman tethered and less able to stand or change positions. Epidurals slow down labor and increase the chance of vacuum, forceps, and Caesarean deliveries. The greater risk of infection and fever increases the usage of antibiotics, and therefore the likelihood of thrush. A urinary catheter is also normally required, again with associated risk of infection, antibiotics, and thrush. (Why this emphasis on thrush? A woman in my breastfeeding group had it and said she'd rather go through labor a second time than have thrush, the pain was so bad.)

At the same time, I certainly wasn't ruling out the magic epi. The prospect of being in a lot of pain for 24 hours was daunting, to say the least. My philosophy was that I'd never given birth, nor even seen someone else do it, and that it would be presumptuous for me to declare ahead of time how things would go. The last thing I wanted was to set up an expectation of unmedicated childbirth that would make me feel like a failure if I chose an epidural after all.

So the official position was--default no epidural, try to use the hot tubs to get through it; but easy access to Plan B if and when I changed my mind.

After I let my doulas know that contractions had started, around 9 pm, we sprang into action. That is, Dr Hyde did the dishes and went to bed; I had a beer and went to bed in the guest room. The beer took the edge off and helped me relax, so I was able to doze between and even through the continuing contractions. Around 2 am I got up and took a lovely hot shower, which helped ease the pain a bit. An hour or two later, I decided that misery would like some company, and woke up Dr Hyde.

The next eight hours or so were not terribly unpleasant. I moved around the house, rocking during contractions and groaning or humming as the mood took me. The nice thing about much of labor is that the time between contractions is calm and painless. If you've ever hiked a steep mountainside, contractions are like the switchbacks, while the intervals are like the straightaways where you regain your breath and appreciate the scenery again.

Around 5 am Doula D came over, freeing Dr Hyde to go out for food. Midwives and doulas will usually encourage you to eat and drink in labor, on the theory that you need to keep your energy up over the long haul. Labor & delivery wards, by contrast, often have no-food policies. The concern is that a woman may require emergency Caesarean and that under general anesthesia she is at risk of aspirating her own vomit. Truly emergency Caesareans--the sort where you don't have time to put in an epidural/spinal catheter if there isn't already one in place, necessitating general anesthesia--are fairly rare (Wiki cites as 5% of all C-sections, so perhaps 1.5% of all deliveries in the US?) While it's understandable that the L&D ward wants to err on the safe side, in practice this means that the other 98.5% of laboring women are denied food.

I'm a good eater, and I get cranky fast if I don't eat for ~6 hours. So I knew I would want to eat during labor (another reason to labor at home or in the birth center, which permits this). Accordingly, Dr Hyde picked up some food, including, on my request, raisin bread. I don't know why I was intent on raisin bread. Normally I eat it perhaps twice a year. But raisin bread I demanded! Must have!

So throughout the labor, I snacked on eggs, fruit (cold grapes were a magical godsend--something about the high water content, mild sweetness, and ease of consumption--I ate them nonstop), peanut butter, and of course, raisin bread. This strategy worked well for me. Some women vomit during labor as a physiological reaction, whether to pain or some other aspect, but I noshed like the high-metabolism lady I am and it all stayed down.

Much of the morning (around 8 am - noon, 12-16 hours into labor) was spent in the bathtub. You enjoy a hot compress for muscle cramps? Labor is just like that, times 10. I grew bored in the bath, so Dr Hyde sat in the bathroom and read Harry Potter 7 to me. We were both rereading it at the time because we'd just seen the movie of HP6, and now I will forever associate Harry's peregrinations in search of the Elder Wand with labor. Occasionally I dozed between contractions, then made Dr Hyde reread whatever section I'd slept through.

At some point, my doula checked my cervix and said I was around 5 cm. I was pretty chuffed. "Halfway there," I thought, "and this is totally manageable. I am fantastic! I am champion!" Those of you who have been through labor, feel free to start laughing.

Around noon, I started feeling like I wanted to get to the hospital. Contractions were still livable, but I was starting to feel a shade of panic, an urge to be In The Place. We called the hospital to verify they had an open room in the birth center, packed up, and headed over.

to be continued