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When There Is More Than Your Plus One in Your Pelvis

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain.  However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

  • Increased risk of miscarriage.
  • Preterm delivery and labor.
  • Abnormal fetal position.
  • Fetal growth restriction.
  • Placental abruption.
  • Labor dysfunction (and the need for a C-Section).
  • Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

I Am Ready to Race Again; Is It Too Soon? Pregnancy Interval

For any of you who have competed in a long-distance competition (be it a run, a swim, a hike, or a bike), you know what it feels like to cross that finish line. Total euphoria—combined with a fair amount of exhaustion, pain, and lots of blisters! The first thought that runs through your head, after the “I can’t believe I actually made it” moment is either “When can I do it again?” or “I am NEVER doing that again!”

The first group is already planning their next race, mapping out their training schedule, and thinking about how they could have done it better. While the “Okay, I can check that off my bucket list group” is looking for the nearest bar, a bath, and a bed. In many ways, pregnancy, labor, and having a newborn is very similar to the training and racing of a long-distance competition.

While the “Yes, let’s do it again” and the “No, I am so out” camps in pregnancy and parenthood are more fluid than the participants in long-distance competitions, (hard-core Group B members may move into Group A), people usually have a pretty set idea about how many times they want to be pregnant, how many times they want to give birth, and how many children they want.

Most of us even have a pretty good idea about how close together we want our kids to be (medically termed birth spacing). Whether you want them back-to-back or you prefer to space them apart is a personal decision. But how soon you can hop back on the baby machine is dependent on more than just your feeling ready. It also depends on factors out of your control such as if you had a C-Section or a vaginal delivery, if issues like high blood pressure or diabetes complicated your pregnancy, and if you required any additional procedures post-delivery. These all can hold you up even if your heart is ready to race again.

Regardless of what went down during your pregnancy, the time between delivery and a pregnancy should be AT LEAST 18 months. Any shorter inter-pregnancy interval can increase the chance of preterm delivery, premature placental separation (placental abruption), pre-eclampsia (high blood pressure in pregnancy), placenta previa (particularly after a C-Section), low birth-weight babies, and autism.

While the definitive reason behind why these events occur more frequently is debatable, fingers seem to point towards the “maternal depletion hypothesis.” Pregnancy and the stressors of a newborn takes a lot out of you, and your body needs time to re-fuel and re-energize before it starts the race again. Stressing the system before it is ready to function can interfere with its ability to do its job well.

Among the organs in the body that need a break, the uterus is at the top of that list, especially after a C-Section. The uterus is a muscle, and a muscle that is injured (particularly cut and sewn back together) needs to heal. Without adequate time to heal, there is a higher chance that it will open (a.k.a. rupture which is life threatening to  you and the baby) in the subsequent delivery. Furthermore, women who had a C-Section and want to try for a vaginal delivery in their next pregnancy (vaginal birth after cesarean section=VBAC) need extra-extra time to rest their uterus before it is pushed to push.

You don’t have to decide which group you are going to side with moments after crossing the pregnancy finish line (#delivery). Labor can be long and exhausting. Give it some time before you wave the “Yes, I want another baby” or “No way; I am done” flags. Even if you are raring to go moments after the race is over, give it time before you line up at the next start line. Hydrate, stretch, rest—do whatever it takes to get you ready to go again. The time off will do you good—and your next pregnancy.

Fibroid: Is This Causing Your Infertility?

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. They work their magic (or rather interfere with the magic) usually by interfering with implantation, distorting the uterus, or blocking off one or both of the tubes. They can take up prime real estate, and this can lead to miscarriage and pre-term delivery.

Depending on the block they chose to call their home (a.k.a. their location in the uterus), their impact on fertility and pregnancy may be more pronounced. Fibroids that are located within or partly within the uterine cavity (medically termed submucosal) almost always need to be evicted before pregnancy. Additionally, these are the ones that are most likely to cause true infertility. Intramural fibroids (those located in the muscle) can go both ways; how they are going to lean is really anyone’s guess. As a general rule, the bigger, the bigger pain for you and everything fertility related. They can press on important things (like tubes or the cavity) and cause problems that need to be dealt with. Last, those hanging out outside the uterus (subserosal) have almost no effect on fertility or pregnancy. Don’t even give them a second thought.

While fibroids can be treated medically or surgically, when it comes to fertility, medical options are no bueno. Most, if not all, medical options will prevent ovulation and implantation, which will prevent pregnancy, so that’s not going to work. Surgical options are really the only ones on the table, and even these “dishes” are limited.

So here is what is on the menu—myomectomy (myoma means fibroid and ectomy means removal). Myomectomies can be performed through an open bikini-cut incision, a camera (laparoscope), a robot, or vaginally. The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid(s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary. It will also in many cases, particularly when there are many fibroids, require that you to have a C-Section. The uterus is a muscle, and after surgery, it will be forever changed, scarred, and sometimes weakened. You want to make sure that you treat your muscle with tons of TLC—labor, contractions, and hours of pushing is not anyone’s definition of TLC.

And while we are talking about surgery, we recommend that you always ask your surgeon for their notes from the surgery (a.k.a. the operative report). This is super helpful to anyone else—your OB/GYN or your fertility doctor—who decides to date your uterus in the future. Knowing who has been there and what they have done will help us guide your treatment.

Two big questions come to patients’ minds and ours when considering fibroids and fertility. Are they causing my infertility, and should I treat them before I do fertility treatment? First things first, fibroids are very rarely the sole cause of infertility. If you think of a pizza pie, they are even smaller than the smallest slice (think more of like a baby bite). Usually, fibroids plus something else are keeping you on the fertility sidelines. So even if your fertility doctor diagnoses you with fibroids, they are usually not alone in making this baby thing difficult. For this reason, we always recommend completing the entire fertility work-up before pointing the finger at the fibroid.

The second question is way more complicated. When do you treat a fibroid? This question about fibroids is more controversial than religion and politics at a family dinner! However, while getting us all to agree on when to treat is nearly impossible, we can almost all agree that fibroids, which are on the outermost layer of the uterus, are outside the realm of what we need to treat. They are not causing infertility and don’t need to be treated before a fertility treatment. Exceptions to this are if they are very large causing pain and pressure of the bladder.

On the flip side, fibroids that are in the uterus (submucosal) of women who are experiencing infertility or recurrent miscarriages need to come out before any fertility treatment is started. The fibroid is like a roadblock, blocking any and all traffic. They need to come out before any cars try to pass. The trickiest ones are the ones in the muscle (intramural). It’s like our Congress—no one can really agree on what is right. For most there is a split down the aisle for which to treat and when. The line in the sand usually comes down to how big it is, where it is, and if you had previous fibroid surgery. Fibroid surgery is not something you want to double down on!

Unfortunately, of all the partners you will have, your fibroid is the least likely to leave you. Only menopause and a hysterectomy will break you two up. However, there are ways to temporize them and to temporarily remove them so that you can “attempt to see other people.” Take our advice. Tell them, “It’s not you. It’s me. I just really want to have a baby and don’t want you hanging around.” While they may reappear one day, hopefully, they will leave you alone long enough for a pregnancy to take place.

Heads or Tails: What to Do When a Baby Is Breech

Surviving OB/GYN residency is like surviving boot camp. Most of the days blur together, and when you reflect on your days and nights, you can’t believe that you actually survived it. And while you couldn’t imagine doing anything else, you also couldn’t imagine doing it all over again. Along the way, down in the trenches, you make some amazing friends, meet some amazing patients, and learn the most amazing things (how to deliver babies!). There are certain practices and procedures that are drilled into your head so many times, you could repeat them in your sleep. One such practice is checking the “presenting part” on every woman admitted to the labor floor. If this part is not a head and actually a butt or a leg, you’d better move your butt back to the operating room for a C-section, ASAP!

What is a “presenting part”? Oh hello, Doctor, I am Tommy the Tush and would like to present myself to you? Sort of, but not really. The presenting part is the anatomical part of the fetus that is leading (a.k.a. closest to the pelvic inlet of the birth canal). Most babies are going to present head first, or in OB language, cephalic. When the butt or feet come first, we call this a breech presentation. Occasionally, your child can give us the cold shoulder and present with an arm, the shoulder, or the trunk. We call this a shoulder presentation. A baby that is cephalic is most often vertex, which means the crown of the head is first. This is the easiest, most common, and ideal presentation for a vaginal delivery.

Sometimes, although a baby is cephalic he or she is not vertex; a baby can be face, chin, or even brow first. Such cephalic but not vertex presentations can be challenging. Although in some circumstances, they can be delivered vaginally, they can also require a C-section. However, of all the crazy positions a kid can get themselves into, a breech is the most common and the one that shouts “C-section” the loudest and the fastest to most modern OB/GYNs. While it’s usually just a flip of the coin for whose baby will be breech and whose will not, there are some risk factors for a breech presentation: the shape of your uterus, the position of your placenta, low amniotic fluid volume, or a previous breech baby.

Old-school OB/GYNs were no joke—they could deliver a kid headfirst, feet first, hand first, or tush first. Rotating, twisting, and rearranging the presenting part was their every day. However, because data demonstrated that breech babies who were delivered vaginally had a worse outcome after they were born, these practices fell out of favor. They were performed infrequently, and just like anything you do, without practice, there goes performance. Therefore, while the American Congress of Obstetricians and Gynecologists (the governing body of our specialty) does not “outlaw” vaginal delivery for a breech baby, they make a strong statement about which obstetricians should be allowed to attempt such a procedure. They explicitly state that delivery mode (vaginal versus C-section) should depend on the experience of the OB.

If your doctor feels comfortable going for it based on his or her experience, it should only be performed in a hospital that has a specific protocol specifying how this thing should go down (or out). Women who are game to try must have a clear understanding of the potentially increased risk associated with stepping up to the plate.

Why have times and opinions on vaginal breech deliveries changed more radically than our wardrobes? Because in 2000 a large international trial called the Term Breech Trial was performed. In this study, they compared how babies who were breech did following a planned C-section vs. a planned vaginal delivery. And what they found was so powerful that you have a better chance of finding a can of Tab than an OB/GYN who will perform an elective vaginal delivery for a breech baby. Mortality (both during and after delivery) and serious morbidity (seriously bad things happening) were significantly lower in the planned C-section group as compared to the planned vaginal delivery group. The findings in this study gave the red light to most OBs offering planned vaginal deliveries for breech singleton babies.

It’s important to mention that twins are a whole different ballgame and having two on your team will let you enter the vaginal delivery for a breech baby ballpark. Here are the rules…if twin A (the twin that will be delivered first) is head down and twin B (the twin that will be delivered second) is head up (breech) AND twin A is larger than twin B, let’s play ball. You can attempt a vaginal breech delivery for the second twin, a.k.a. twin B.

Before you get all bummed about your baby’s current position, take a deep breath. Most babies move all over their roomy apartment (your uterus) for the first five to six months of pregnancy. By the late second trimester, most babies will be head down and stay head down. In fact, only about 3–4% of babies will be breech by the end of their pregnancy. Your OB will check your baby’s position around 34-36 weeks. If your little one is head up, this is the time to talk about what can be done medically to turn things around. An external cephalic version (ECV) is a procedure that is often offered to women with breech babies who would like to attempt a vaginal delivery. It is usually performed at about 37 weeks. We wait until the last minute for two reasons:

First, we want to give your stubborn one as much time as possible to make the move for themselves, and second, if we are successful at moving the baby into the head-down position, we don’t want them to flip back up! Most women are candidates for an ECV, and while it won’t work on everyone, unless you need a C-section for another reason, you can consider an ECV. Women who have had other children, have a posterior placenta, and have a good amount of amniotic fluid are more likely to have success with the procedure. All that pushing, poking, and turning works about 50% of the time. The average success rate is reported in the medical literature at 58%, with a range of 35–86%. Some doctors may offer pain medication and muscle/uterus relaxers to not only make the procedure more pleasant but also increase the chance that it works.

However, you should know the procedure is not without risk. The baby may not like all the poking and prodding, and therefore, heart rate monitoring should be performed during and after the procedure. In some rare cases, an emergency C-section may be needed if the baby is really unhappy with the ECV attempt. We strongly recommend the ECV only be performed on a labor and delivery ward where actions can be taken in the event of an emergency.

Other non-Western medicine tricks include maternal position (forward leaning inversions, headstands, pelvic thrust), acupuncture, and moxibustion. The latter is a technique whereby an herbal (moxa stick) is burnt on an acupuncture point on the body. If your baby just won’t see the light, no matter how many tricks and methods you and your OB employ, don’t sweat it. C-sections can ensure your headstrong child enters the world safely on his or her own two feet!

Epidurals, Episiotomies, and Elective C-Sections: What Are the Essentials for a Good Labor?

From the moment you pee on the stick and see the two lines, the smiley face, or the word pregnant, your mind starts to run wild. Is this for real? Will it be good? Could this really be happening? After dropping about fifty more bucks at the drugstore by taking another three to four tests to confirm what the first showed (trust us, we’ve been there!), the idea of pregnancy and motherhood begins to settle in.

Through deep breaths and calming thoughts, you start to envision what the next nine months will look like. Cravings, nausea, fatigue (sometimes extreme), bloating, spider veins, acne, back pain, and maternity clothes…bring it on! And although you can handle almost any of pregnancy’s curve balls—and there are many—the unknown surrounding how that baby will actually make his or her entrance into this world is probably the most nerve racking. Will there be endless hours of pain where you spend every contraction cursing your labor team (gotta love the movies!), or will it be a peaceful few hours rocking back and forth to the iPod playlist you carefully selected? Whichever it winds up being, you can almost be sure it won’t be what you imagined. It will deviate from your birth plan or your non-birth plan, no matter how hard you will it not to.

Amidst all the unattractive parts of pregnancy, there will be the most attractive things you have ever experienced. You will feel your baby kick. You will listen to your baby’s heartbeat, and you will watch your baby grow. You will think a lot about your future, both immediate and distant, and try to imagine what your days, nights, and years will look like. (Spoiler: the nights will be long, and the sleep, short!) While you can’t know when or how everything will happen during labor, you can take those sleepless nights preparing for a variety of possibilities. By educating yourself (through reputable sources—shout out to Truly, MD!) and talking to your doctor or midwife, you can prepare yourself for what might come. There is a lot to learn and a lot to consider, so we will give you the abridged version.

Epidurals are not your enemy; in fact, they are sort of your fair-weather best friend. (Labor isn’t so long!) Despite all the pros, unfortunately, for some reason there is a lot of negative hype around epidurals, such as:

  • They will cause a C-section.
  • They will hurt your baby.
  • They will cause permanent back pain.

These are simply not true. While epidurals have been demonstrated to increase the second stage of labor (a.k.a. how long it takes you to push that kid out) and increase a woman’s need for labor augmentation (Pitocin), they have not clearly been linked to increased C-sections.

Data show that timing may be the issue, and getting your epidural too early (defined as < 4cm) may be what increases the risk of a C-section. So while we will do our best to coach you through those early contractions sans an epidural, in our opinion, next to the pill, epidurals may be medicine’s best gift to women. Think of any other medical situation where it would be okay for a woman to have intense pain and no pain control. We can’t think of one! So don’t try to be a hero. If the pain is too much, it’s okay to cry mercy. We promise this doesn’t make you a failure. While pain-free labor seems pretty amazing, we would be remiss not to mention that there are some negative side effects with epidurals (headache, temporary weakness/numbness, fever, low blood pressure, rash). However, in general epidurals are incredibly safe and in our opinion a total lifesaver!

Hot topic #2 on the L&D floor. Put your scissors away, because episiotomies (a cut along the perineum to increase space) are no longer standard practice. The routine use of episiotomies is sort of an old-school practice (reference to it can be found in the medical literature for over 300 years!). Historically, it was done to help expedite the pushing process, more space presumably equaling more speed. It was also thought to decrease the incidence of bad tears and future leakage (a.k.a. your dependence on Depends!). But the studies demonstrated that the proof was missing from the pudding. Most evidence showed that the benefits of routine episiotomies were sparse and in more of doctors’ anecdotal experiences (let me tell you about what I’ve seen!) more than evidence-based. Medicine moves faster than a NASCAR racer in the final lap of the Daytona 500; research is the fuel driving the process. Routine episiotomies are out of gas; restricted use is preferred and is the current practice.

Zodiac signs, numbers, days of the week, and months are all important. I mean, if you deliver a Taurus as opposed to an Aries you could be up against a bull versus a ram. But despite your love of certain signs, elective anything when it comes to labor should be carefully considered. Scheduling C-sections and deliveries to fit between scheduled appointments, commitments, and important events has become a popular trend. The “Cesarean delivery on maternal request” (the PC way to say “no medical reason to go under the knife”) encompasses about 2.5% of all births in this country (about 1.3 million births per year). Simply stated, if this is what you want you are clearly not alone. But before you go under the knife, we ask you to consider the potential downsides of this seemingly benign procedure.

While the most common surgical procedure performed on women in the US is a C-section, they are most certainly not risk-free. A C-section is still surgery. You will be in the hospital longer; your baby has a higher chance of respiratory problems. Squeezing through the birth canal squeezes the fluid out of the lungs, while taking the “easy way out” does not allow the fluid to come out, and you are at higher risk of problems in your next pregnancy. Think of it this way: when you fall and cut your knee, you usually get a scab. The area heals, but often a scar remains. As long as it isn’t on your face, you can pretty much deal! Well, when a C-section is performed and the uterus is cut, it (just like your knee) will scab and eventually will heal. But even in the hands of the best OB, it is not uncommon for scar tissue to form on the uterus. Scar tissue on the uterus may be hard to see, but trust us, it is not a pretty sight. While cosmetically, you won’t have a problem (only your OB sees your uterus!), scar tissue can negatively affect your future pregnancies in a pretty big way. Placental implantation problems, uterine rupture, and even the need for a hysterectomy can all occur the next time around.

And in this case, the motto “The more, the better” does not apply. The more kids you have, the more C-sections you will likely need and the worse the situation can become. A planned “C” will decrease your urinary leakage (cough, sneeze, laugh, oops!) in the first year after delivery, but after that, the playing fields between elective C-section and vaginal delivery are pretty much equal. (Basically, we all will be peeing on ourselves at the same rate.) So while it seems simpler, cleaner, and easier, we again remind you that it is surgery, and surgery has risks. Think before you sign up. Read, ask, consider, and investigate.

Flashing alert…we are talking about the elective-not-in-labor C-section, NOT the “I’ve-been-in-labor-for-24-hours-and-pushing-for-four,-and-this-kid-won’t-come-out C-section!” Or this baby is breech and won’t turn C-section.  Trust us, we are not knocking C-sections or those who have them; being awake while somebody is operating on your belly is more than admirable. If you wind up needing a C-section, don’t sweat it. You are no less of a woman, a mom, or a tough chick because you couldn’t push your baby out from below. It’s your voice, your body, and your baby. And as long as you are at least 39 weeks pregnant (one week before your due date or more), you can request an elective-not-in-labor-just-because-I-want-it C-section!

We’ve seen women who swore off epidurals like the devil begging for them and women who signed up for elective C-sections walk onto the labor floor 10cm and pushing. You just never know how it will go. Have an idea what you want—midwife or OB, doula or partner, C-section or vaginal delivery—but be ready to accept the exact opposite. You can print it 100 times, in color and in bold, but it likely won’t change what happens on that fateful morning, afternoon, or evening. In the words of our girl Elsa, “Let it go.” More important than the perfect story or the kickass photo ops is safety (yours and your baby’s).

Hours of painful contractions can blur your ability to reason. That’s what your trusty OB/midwife is there for. Sure, we’ve probably been up with you, but sleepless nights are par for the course for an obstetrician (coffee is our best friend!). Even the best of stories and plans often needs editing. And while chapters 1–10 may not be a New York Times bestseller, it’s the last page that matters most: a healthy mom and a healthy baby. The rest are just words on a page!