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Ten Tips for First-Time Moms: What to Do in That Last Month!

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Take everything we say in this post with a grain of salt. Most of it has minimal medical basis and maximal learn on the job-type tips. Pregnancy can be amazing and awful all at the same time—yes, we just said awful and pregnancy out loud together!

When you head into the home stretch, the physical pain usually gets worse, as does the anticipation and anxiety, especially if it’s your first time at the rodeo. First, all the emotions you are feeling are totally NORMAL. We totally give it up to Brooke Shields, who broke barriers by sharing her postpartum experiences. It’s important to know that joy is not the only emotion you’ll be feeling at the end of pregnancy and the beginning of mommyhood…

Here are our top 10 pre-delivery tips.

  1. Get groomed.
    While we are not telling you to run from the nail place to the waxing place and back to the hair salon, we are telling you to treat yourself! Make time for you before the baby arrives. A spa visit and some good R&R is the best way to do it. Besides, who doesn’t like to be pampered?
  2. Make a delivery playlist.
    Labor is not called labor because it comes and goes in the blink of an eye! Much to the chagrin of the family members camped out in the waiting room, it can be a LONG process—especially for your first! We recommend bringing along some good music, downloading some good movies, and maybe even packing a good book. Nothing takes your mind off things like laughter and light tunes.
  3. Plan a dress rehearsal.
    It’s never a bad idea to map out the best route to the hospital. Know where you are going and how to get to the labor and delivery floor. While it may seem silly to make a dry run, it will likely ease anxiety when game time comes. On that note, it’s also not a bad idea to have your “costume” (a.k.a. overnight bag) ready to go. The last thing you need when those contractions start is to be searching for your favorite sweatpants!
  4. Breast milk vs. formula.
    We are NOT here to pass judgment or tell you which is better for you or the baby. In our opinion, what works best for you will work best for your baby. But if you do think that you want to give this breastfeeding thing a whirl, make friends with a good breast pump, and a find a good lactation consultant (or someone in the know). This will help you prepare for what’s to come and increase your chances of getting the milk flowing.
  5. Bag the birth plan?
    We get it…you know exactly what music you want to be playing, exactly where you want your partner to be sitting, and where the baby should be placed right after delivery. And while having a birth plan is important, be FLEXIBLE with your bullet points. For sure know if you want an epidural, if you want a doula, and if you want a vaginal delivery or a C-Section—but unfortunately, labor and delivery don’t follow a plan. Be prepared for things to deviate from the script…the show will still go on!
  6. Know who you want to be there at the final push!
    Who you want to hold your legs and wipe your forehead is a very personal decision. Don’t be bullied by parents, your in-laws, or your friends—only people you want in the room should be there. It’s okay to want privacy during your special moment.
  7. Eat your heart out!
    While we want you to be careful about how many pounds you add during your pregnancy the night before you go into the hospital (if being induced, having a C-Section or as labor is starting), we recommend going all out in the food department. Treat yourself to a decadent dinner with your significant other. You will not only need the energy to push, but you will also want to enjoy the last moments of being kid free.
  8. Be mindful of unsolicited advice.
    Everyone is an expert when it comes to all things pregnant, and they are not afraid to share it. While most mean well, the advice can become moderately annoying. Listen to what you want to, and shut out what you don’t want to hear. Your doctor and medical team have probably done this several hundred times; they have got you covered and know what’s best.
  9. Accept the unacceptable.
    So many times, we hear women saying through tears and sobs, “This is not how I planned it. I feel like such a failure.” Unfortunately, no matter how hard you try to control what happens on D-day, you can’t. Nature doesn’t care if you dreamed of delivering in a bathtub in the dark with classical music in the background—if your baby’s heart rate drops, you’re having an emergency C-Section under the bright lights, no questions asked. The number-one priority is your and your baby’s safety; trust us, when you hold that baby in your arms, the plan will be nothing more than a moment in the past.
  10. It’s ok to want to quit—at least several times a day.
    Motherhood is the only job you don’t get to call in sick to, you don’t get to resign from, and you don’t get fired from. You can’t clock out, and you don’t get a paycheck. But even with all the exhaustion, the frustration, and the anxiety, it is the most amazing experience you will ever have. Labor is TIRING. Pushing is HARD. But quitting is not an option—you are stronger than you know.

When to Cut the Cord

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While we can’t tell you how long your kids will hang on to you for support, we can talk a little bit about when to cut the umbilical cord! Delayed umbilical cord clamping has become all the rage these days—almost as popular as those fidget spinners!

What’s all the buzz about delayed cord clamping, and what does it mean?

After your baby is delivered, the umbilical cord (what connects Baby to the placenta, an organ that feeds Baby while inside Mom) is often clamped and cut soon after delivery, usually around 15 to 20 seconds afterwards.

However, studies have shown that blood is still transferred from the placenta to the baby during those first few cries after delivery. As long as Baby is doing okay after delivery, those extra few ounces of blood can give your newborn a leg up on iron and blood stores.

In pre-term babies (those born before 37 weeks), this can mean a better transition to life on the outside, fewer blood transfusions for low red blood cell counts, and a smaller chance of a few other complications of prematurity.

For term babies (those born after 37 weeks), waiting to clamp and cut the cord can also increase iron stores and decrease your baby’s chance of having anemia (low red blood cells) in the first few months of life. Giving your baby a few more red blood cells post-delivery may increase his or her chance of needing therapy for newborn jaundice (think those UV lights newborns are sometimes under), but that chance seems to be small, based on the studies so far.

So, delayed clamping seems to be great for Baby, but what about mom? Mothers seem to do just fine, with no increase in bleeding or postpartum hemorrhage (see our post here) in studies.

How long is long enough? It seems 30 to 60 seconds should be good. Some people like to wait until the cord stops pulsating, but it seems most of the benefit from delaying clamping happens in the first minute of Baby’s life.

Now, what if something happens during your delivery and you can’t delay cutting the cord? Remember, the main goal is a healthy mom and baby. If Baby needs some extra attention from the pediatricians after delivery, that may mean you can’t wait to clamp and cut!

Think of it as one of the first of many compromises you make as a parent. While, of course, we always want to give our kids the best of everything, sometimes we can’t always do things by the book.

Doing It at Home: Labor and Delivery in Your Bedroom

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When most of us think about the birth of our baby, we ask questions like Who do I want in the room? Which doctor/midwife do I want at the delivery? and Will I have a bowel movement while pushing (don’t stress if you do; it’s super common)? Until recently, very rarely did the question At home or in the hospital? cross our minds. However, over the past few years, home birth has gained some serious followers.

More and more women are opting to deliver their baby in their bedroom rather than in birth centers or hospitals. In fact, rates of home birth were up from .79% in 2004 to 1.3% in 2012. Fear of C-Sections and the medicalization of birth (monitors, medications, and modest autonomy) have collectively driven women out of hospitals and into their homes. While there are certainly benefits to home births (minus the cleanup factor—labor can be quite messy), there are some major downsides as well. Here’s what to consider if you are considering a home birth.

First, deciding to deliver at home is a BIG, BIG, BIG decision that should not be made alone. While we get that women have been delivering babies for centuries, things can still go wrong, very wrong and very fast. That’s why it’s super important that you speak with a medical practitioner (OB/GYN or midwife) to make sure that you are a good candidate for an at-home delivery. According to the ACOG, the following women are on the no-fly list when it comes to at-home births: a previous C-Section, babies who are not head down (medical term: fetal malpresentation), and multiple gestations (more than one baby in their uterus at one time). It is just way too risky.

Second, if you are good to go for it at home, make sure you are not alone. Seek out a midwife who is licensed and experienced in doing home births. You want to make sure that this is not their first rodeo. Knowing when to throw the towel in and trek over to the nearest hospital is essential.

Third, have a good idea of your surroundings. And while we aren’t referring to the nearest grocery store, we are referring to your local hospital. Being close to a medical facility can be the difference between a horrible and heroic outcome.

Why do we care so much? Well, we care about you and your baby’s safety—big time. And although most home births go off without a hitch, when compared to hospital deliveries, home births carry a significantly higher risk of bad outcomes. A large study that was recently published in the JAMA (the Bible of all good medical research) showed that death, neonatal seizures, and neurological impairment were nearly 2.5 times more likely to occur when babies were delivered at home as opposed to in the hospital. Additionally, mothers who delivered at home were more likely to need a blood transfusion. But to be fair, the data wasn’t all down on home births. Women who delivered in a hospital were way more likely to have their labor augmented (a.k.a. enhanced with drugs like Pitocin) and have a C-Section.

As doctors, we have opinions…lots of them. Most of these are rooted in research, data, and years of medical education and training. But despite our degrees, we are not dictators. We are, in many ways, nothing more than trusted advisors. Therefore, while we can give our advice and render an opinion, we can’t tell you what to do. That’s up to you. You take the information we give you and with it make an educated and informed decision.

But we’re not going to lie; on this issue, we side with the ACOG and truly believe that the safest place to deliver a baby is in the hospital or in an accredited birth center. In our opinion, the potential downsides of the at-home birth far outweigh the potential downsides of the hospital birth. And while bad things can happen anywhere, we would rather you go where they happen less.

We also get that the labor and delivery of a child is one of the most intimate experiences in one’s life. You want what you want. We know; we were patients, too. Our advice is to find a practitioner (OB or midwife) whose vision for labor and delivery is close to yours. While on D-Day what you expected while expecting and what happened may be very different, at least you are staring from a place of togetherness.

Labor is as unpredictable as the weather in the tropics. Things can change faster than you can imagine. Get ready to roll with whatever rolls in…it will allow you to weather the storm safely. Make sure you have a life jacket and safety net (a.k.a. good medical practitioner on your side) should the seas get rough.

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

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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?

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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!