Childbirth, My Labor, and Endometriosis

For many of us endo-ladies, we’re so transfixed on the possibility of getting pregnant that we rarely stop to think about the part that inevitably happens at the end of the sought after pregnancy: childbirth. I know for me, I didn’t start really thinking about it until maybe half way through my pregnancy. Up until then I assumed I would go to the hospital and attempt a natural birth there, otherwise I didn’t like to dwell too much upon the inevitable “doom” that was coming. 

However, over the course of a few months I flipped my views and decided to have a homebirth, attended by two midwives, and even during the labor itself had a few big realizations. Namely that birth is hard, and birth from an endo-perspective may actually be harder (but not always). No one told me this, so of course I’m compelled to pass on the information to all you lovely ladies :) Plus, I received numerous requests to talk about my labor, so here ’tis.

 3 days before I gave birth. that belly has to go from this....

3 days before I gave birth. that belly has to go from this....

 to that.

to that.

First off: What is labor exactly??

Ok, don’t laugh if you’re reading this and know exactly what labor is. See, I didn’t understand the nuances of it at all, and at the age of 31 had be explained to that a 30 hour labor didn’t mean unending hours of pushing. Stupid sex ed class. So for the novices like me, here’s the scoop, and it’s important to understand for the rest of this post.

dilation-effacement.jpg

The first stage of labor is when your cervix effaces (goes from thick to pancake flat) and dilates (opens wide). This first stage is then broken down into 3 sub-levels: Early labor (0-4 cm dilation), Active labor (4-7 cm), and Transitional labor (8-10 cm). Everyone has different labors, obviously, but in general Early labor should be somewhat painless although perhaps uncomfortable, Active labor harder, and the Transitional part when the “Holy Bejesus” of pain kicks in. The transition is often when women throw up, want to give up, or think they can’t make it. 

During this first stage, contractions go from being spaced far apart, short, and - supposedly - mild in early labor, to growing very close, longer, and intense as labor progresses. This first stage is the longest part of that proverbial 30 hour labor. (endo might affect this, so read on)

The second stage of labor is the pushing part. Once you get to 10 cm. your body will tell you that it’s ready to push. This part can range from 1-2 pushes for a second time mom, to around 2 hours for a first time mom. This part is painful, but in a different way than the first stage… a baby coming out of your vagina way. 

The third stage of labor is delivery of the placenta, and is often mostly painless. Evacuation of the entire placenta is essential since any leftover bits in the uterus could cause infection, so your doctor or midwife will inspect it to make sure yours is all in one piece.

Why I decided on a Home Birth

When I got pregnant, I remember being scared of labor. Basically all of those movies and shows of the women screaming and writhing in pain, cursing their husbands to dismemberment, got to me. It wasn’t until I started educating myself on the birth process that I learned birth didn’t have to be full of fear and horror. I read Ina May Gaskin’s (a famous midwife, if ya’ didn’t know) book Spiritual Midwifery and which helped me calm my nerves to see contractions as “energy rushes”, and positive movements towards a healthy birth. I learned that the pain is necessary, as it forms a feedback loop in the body that releases oxytocin that then tells the cervix to continue opening. I worked on releasing my pelvic floor, squats to strengthen the pelvic floor, and walking 5 miles a day to keep my pelvic floor supple.

It was through my continued enlightenment about childbirth that I finally decided I wanted to shoot for a home birth. Frankly, this was never even a consideration even at the beginning of my pregnancy, when I truly believed birth was a medicalized activity best kept in the medical realm. After learning more about how the medicalization of birth has actually led to increased unnecessary interventions and an insane amount of C-sections, I began to question.

See, I firmly believe in the necessity of interventions when they’re needed, and am thankful at how many lives these have saved. However, I’m not impressed with the business of being born, how companies are making billions and doctors saving time by scaring women into unnecessary interventions, and how C-sections are becoming almost normal in some hospitals. When we understand the importance of vaginal birth and the baby’s microbiome, it’s important we all do everything possible to avoid C-sections for the health of our little one.

 We didn't take birth pictures, so here's a random, beautiful couple that did :) So powerful

We didn't take birth pictures, so here's a random, beautiful couple that did :) So powerful

Moreover, the more I understood that fear is one of the main barriers in the progressions of a healthy, natural labor, the more I realized a home birth would better suit me. That’s because - frankly - hospitals and doctors cause me undue stress. Since growing up with a separate auto-immune condition, then endometriosis, and dealing with doctor after doctor that seemed to set me back rather than empower me, I decided staying a way from a hospital would benefit me to no end. And if things weren’t progressing properly, we’d simply throw in the towel and make our way to the hospital then. Not beforehand. 

And for anyone out there that still thinks a midwife shows up on horseback with a bag of herbs that’s, well, not exactly true :) My midwives are skilled nurse practitioners with lots of hospital experience. They are trained in all hospital techniques of infant resuscitation, and come equipped with ALL the necessary equipment to save both Mom and Baby’s life. If labor isn’t progressing appropriately they will be the first to say “Get thee to the hospital”. During my own birth, these women were my modern heroes. They never made me feel like I couldn’t do it. 

All of this education and decision making made me feel empowered. I lost my fear, and felt that I was ready for labor. What I wasn’t prepared for was how endometriosis may have intervened…

** The point of this is listen to your heart and chose where you feel safest for birth. If you feel safest in a hospital setting, that is where you should give birth! Also, many other places have birth centers near hospitals, so you can have a homebirth-esk setting but close enough to medical help should you need it. Never let anyone else persuade you to do something you’re uncomfortable with because your body will give in and release where it alone feels safe. I personally felt safest away from doctors, but close enough we could drive to the hospital in case of an emergency.

And, if you’re pregnant and looking for some empowering resources, these three books were my biggest mentors during my pregnancy and helped re-frame my thoughts around labor, moving me from fear to a realm of peacefulness. All I wish is that I was more prepared for the possibility of a labor like mine, or that I had a chance to rectify it beforehand.

 best books to pump up your labor conifdence. you can do it!

best books to pump up your labor conifdence. you can do it!

My Labor, and how endometriosis may have affected it, movement saved it, and the importance of an awesome birth team

My Stage I: Dilation, Effacement and Endometriosis

My early labor began on Saturday morning at 2:30 am in the form of really bad back pain during mild contractions. The bonus was they didn’t hurt when I stood up, only when I laid down. This bonus was soon rectified as a definite minus, since I then had to remain upright all morning, afternoon, and well, what seemed like forever.

But Saturday was still mellow. I walked 5 miles with a friend, ate a lot of nourishing food, timed my contractions and watched them very slowwwwly get closer together. This was part of early labor for me, long. But as night approached they started to get even closer and I knew this was my time… which was definitely terrifying and exciting all at once. Such an overwhelming feeling to know sometime in the very near future you’re going to meet your baby. Just have to get through this labor.

At midnight we called my midwife, since contractions were 5 minutes apart. Mine were also very long, 2 minutes long, whereas average contractions are usually in the 30-60 second range. Yay. Lucky me. And yes, this lasted the entire birth.

By the time my first midwife arrived I was definitely feeling it. Early labor pain had faded into what I would consider active labor pain, which is why I was amazed and very very saddened that my midwife told me I was close to 2 cm and only 50% dilated, but not even quite there yet. Excuse me??? Nearly 24 hours of early labor, intense contracts, and not even 2 cm???? I tried not to be devastated, but the feelings were so intense already that I couldn’t believe I wasn’t near Transition yet.

But on the labor went! Turns out it doesn’t ever stop to give you a breather ;) About 30 minutes later my water broke and that’s when my contractions became almost unbearably painful. Before I was pregnant I remember wondering how endo pain compared to labor pain. I can here say that if my previous endo pain was on a scale of 1-10, childbirth pains were now on a scale of 1-50. I was throwing up after every contraction because of the pain, which is the type of pain most women have during the Transition phase. This is why I was officially devastated when I was checked again around 5 am and was only at 4 cm. Just barely at what was considered Active labor. 

But on the labor went! And this is why I’m so glad I decided to have a home birth: at dawn my labor had stopped progressing. It actually was regressing early in the morning because I was so utterly exhausted and fighting the pain rather than leaning into it. Turns out you must request more pain in order to request your cervix to dilate. Stupid cervix.

**Below I talk about how I personally believe endo contributed to this, as is important to understand before labor (like, I really wish I knew)

Here my midwife ordered me out of my horizontal world of bed and into the vertical world or standing. Not just standing: walking. Around the yard. She said I needed to wake up my labor, so I did as she said as the sun rose over the horizon and my insanely calm/caring/devoted/guardian angel of a husband held me up through it all. 

I’m sure that if I was in the hospital that would have been my turning point: pitocin to speed up the labor, then an epidural to calm the contractions made extra intense by the pitocin, to being forced on my back because of the epidural (can no longer walk), to probably a C-section because in the end I needed to be very very active for the pushing part of labor. 

But the combination of making to to 4 cm (officially active labor) and walking outdoors did it, the labor sped up with the contractions intensifying and growing closer together. At this point my labor was kicked into light speed as I moved into the active and transitional phases within a few hours, and was finally fully dilated around 10 am. The thing is, the pain never got more intense throughout the process of dilation, it just seemed to peak around 2cm (I’m guessing when my water broke) and stay there the entire rest of the way, so I never knew when I was in transition at all.

How Endo can affect early labor in this way, and how you may be able to prevent it!

Many women asked me before birth if I was worried about having a home birth because of endo. I said no, since I felt like I had beat the monster disease in so many ways and have been asymptomatic for over 2 years now. Well, turns out old scars can present new problems when it comes to labor, and it’s very important for endo-warriors to know this before going into labor-battle. Especially since it may be possible to avoid it!

 cervical scarring can be hidden within the tissue and only felt with a finger as "hard"

cervical scarring can be hidden within the tissue and only felt with a finger as "hard"

Here’s the deal: cervical scarring can cause a reallllllly long and more painful early labor. This is the type of labor I had, where your contractions are strong, close, and at transition level pain, but you’re barely dilated or effaced. And in the hospital setting this would most often be seen as a “failure to progress”, with a C-section to follow.

At improvingborth.org they followed a group of 18 mothers who had C-sections labelled as Failure to Progress and found “Seventeen had an obvious long, prodromal labor pattern. They also ‘seemed’ to be having transition-like labor, but were only 4-6 cm dilated when arriving at the hospital.” They go on to say that “The majority of these women also went on to deliver anywhere from just a few minutes after the scar tissue was resolved by the doctor to two hours after. In all cases, the labor progressed quickly”

 your cervix has to open wiiiiiiide to give birth. If you have scarring, it acts as a sort of needle and thread that has sewn your tissues together.

your cervix has to open wiiiiiiide to give birth. If you have scarring, it acts as a sort of needle and thread that has sewn your tissues together.

Some signs during labor that you may have cervical scarring include: stall in dilation, high effacement/low dilation after many hours of contractions, strong contractions with no dilation, mom has transition-like pain but with little to no dilation, waters breaking after much early labor, and an overwhelming desire to push with low dilation. I had all but the last.

bellybelly.au says: “A woman in this situation often becomes extremely fatigued and discouraged. She might try many different positions, take a bath or shower, walk or lie down – yet nothing changes. At some stage, her ability to cope with exhaustion and the pain of contractions will reach a limit. She might try pain relief, or her care provider will decide augmentation is needed (artificially stimulating contractions with medical or mechanical methods). However the cervix can’t open, and these methods will generally lead to more pain and tiredness, with the likelihood of distress to the baby. A c-section is inevitable”

What can cause cervical scarring? Endometriosis! Bet you didn’t know I was going to say that ;) Not always, of course, but in my own health history I had a partially obliterated cul-de-sac in 2012 that was “cleaned up” using the cauterization method (the surgical equivalent to slash and burn). Additionally, I had a small endometrioma found on my cervix in 2014. Combined, you can imagine that ‘ol cervix of mine may not have been “ripe” for the opening.

And, FYI for your endo-less friends, other things that may cause cervical scarring are IUD’s, cervical scraping (for HPV), or D&C. Spread the word to prevent unnecessary C-sections!

So here’s the other deal: if you know or suspect scarring beforehand, you may be able to get rid of it beforehand, and thus prevent a potentially long and more-painful-than-necessary labor. The way to do this is get it massaged … sounds relaxing right? Perhaps not :) But cervical massage by your health care practitioner - while very uncomfortable - can help break up scar tissue and adhesions on your cervix. Your health care provider can do this while you’re in labor to help open things up. You definitely need to speak with them beforehand, though, so they know what’s up.

Stage II: Pushing and how movement saved the day

 why position is important, especially for those of us with narrow hips. squatting allows the entire pelvic outlet to widen naturally.

why position is important, especially for those of us with narrow hips. squatting allows the entire pelvic outlet to widen naturally.

Ok, on to pushing! Believe it or not, pushing was the easy part. Never did I ever think I’d say that, but after 11 hours of transition-eske contractions it finally gave me something to do. Pushing is the complete and utter urge to bear down (i.e. go poop) during contractions. There is no other way to describe it. But then, during contractions, you feel like you finally have a purpose: to bring that baby on out.

Since my long-winded fingers have already written way too much for a succinct blog, I’ll just say I tried pushing in a bunch of different positions to no avail. My midwives thought baby might be in an odd position, combined with the fact I was kind of stuck at 9.5cm rather than being at a full 10. (Often this is okay and the cervix will pop open with decent, but in my case not so).

 this is how incredibly active pushing can be if you have full use of your body.

this is how incredibly active pushing can be if you have full use of your body.

I was ordered back outside, this time to do lunges, on the stairs, while doing a “hula” rotation with my hips, then squatting really deep. Yah, I wouldn’t say this was fun for my exhausted self, but I was determined to get this baby out. You know what? It worked, and once I got into a very odd, very active position I felt baby boy start to drop down. So we went inside to recreate what I had been doing on the porch: squatting with one foot higher than the other on a stair (we improvised with a box) while holding on to a birthing rope we had installed in the bedroom. 

By pulling the rope with all my might during the contractions, while bearing down, while squatting with one foot slightly higher than the other, I finally gave birth to my beautiful baby boy. I wouldn’t have been able to do this a) on my back, or b) if my legs and arms weren’t strong enough or c) if I hadn’t so diligently worked on my squat throughout pregnancy, which is why I’m such a huge proponent of keeping your strength up during pregnancy. For me, natural movement saved the day again.

Stage III: The placenta is boring so I’ll talk about this importance of a birth partner and supportive birth team

For my birth we only wanted us (being my husband and I) and our midwives. Everyone has their own preference for who they want, but for us we wanted to keep it our solid family unit. I’ll just say that I don’t know what I would have done without my husband, who never left my side throughout the entire process. Having him as my partner throughout the birth made me able to endure what I did, because after each contraction he was still by my side, never doubting me, always feeding me strength in words, in touch, and through sips of water.

I say this to bring home the importance of a strong birth partner, be it your husband, wife, partner, mother, doula, or friend. Someone who will be there by your side through the greatest journey of your life. I didn’t realize I would need so much support, but when that time came I was so thankful it was there for me.

 my husband, my knight in shining armor, and reef, our baby's newest guardian (truly, he's taken it apon himself to guard the baby night and day).

my husband, my knight in shining armor, and reef, our baby's newest guardian (truly, he's taken it apon himself to guard the baby night and day).

My midwives were equally important though, and this would do for any supportive birth team be you at home or in a hospital. My midwives continually monitored both me and baby for signs of distress or anything that would be a serious issue. Although they saw the pain didn't match the dilation, they continually ensured me this everything else was normal, no one was in danger, and that it was hard but I could do it. They never once made me feel like I couldn't do it, that I needed an epidural, or should go to the hospital. Having them be so confident kept me from being fearful.

And a last note on why pain is actually okay, and why you too can do this without fear

Although my birth was somewhat mentally traumatizing and it took me a few days to clear my head of it, I came out feeling like a warrior. Like, a true, bad-ass warrior who could handle anything. I read these words a few days later and it brought home for me just how exceptional the process of the birth is, and how sometimes we must die a little to be re-born:

“During birth a woman goes into a battle for her soul. I have heard so many women say, especially during unmedicated birth, ‘I’m dying!’ Everything she has learned about herself falls away…. A woman who is allowed to experience birth in a safe way, making her own choices, following her own urges, can connect with the universal, primal, wild part of herself. The animal part. The wildest part of her is the only part of her that can go to battle for her deepest spirit, love, and intention. It does feel like you’re dying. Because it is a chance to be reborn."
 Elias, we waited for you for a long time. so glad we did. 

Elias, we waited for you for a long time. so glad we did. 

I truly love the thought that we have a metamorphosis throughout labor and are reborn, because you do arrive at the other end of the tunnel a new person: a mother. It’s an intense experience, but even after my own elongated and painful labor, I am so glad I was able to face it head on and win. At the end we received a beautiful baby boy who has filled our hearts more than we ever knew possible. There’s no better reason to “battle for your soul” than this.

Now go get your cervix checked

Which is why if you’re expecting, or wanting to be expecting, I urge you now to speak with your health care provider and ask him/her about how they can help you in this situation. Scarring may not be visually apparent - even a tiny bit of scarring the size of a grain of rice can cause the situation I spoke of above to arise - so make sure they do an internal exam. And remember, if you're already pregnant, you'll have to wait until your labor starts naturally to have this procedure performed :)