Labor and Childbirth: What You Need to Know with Dr. Salena Zanotti

Podcast Transcript

Intro:

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Molly Shroades:

Hi, and thanks for joining us for this episode of the Health Essentials podcast. My name is Molly Shroades, and I'll be your host. Childbirth can be described as a miracle, and it's truly miraculous when you're holding your little one in your arms for the first time, but it's also a lot of hard work. That's why many parents find out that it's really is labor. Today, we're joined by Dr. Salena Zanotti to learn all about labor and childbirth. Thank you so much for joining us.

Dr. Salena Zanotti:

I'm glad to be here.

Molly Shroades:

So just as we get started, let's talk a little bit generally about labor. I think a lot of us have this image in our heads that has been planted by TV and movies. I have feeling that hasn't really prepared us for this. Tell us a little bit about it.

Dr. Salena Zanotti:

It's funny. I always tell patients that too, like it's not like on a TV show where it's all so clean and quick and the baby comes out and everything works out perfectly. There's a lot that goes into labor. The important thing is that every single person's labor can be different. So there's a large variation. I think that's where people either get surprised or confused because no one's labor is exactly the same.

Molly Shroades:

Absolutely. It's the most unique experience that also everyone else is going through.

Dr. Salena Zanotti:

Exactly.

Molly Shroades:

Can you walk us through a little bit of those stages of labor and what to expect as you're going through this journey?

Dr. Salena Zanotti:

Probably the stage that has the most variation is that first stage of labor. That first stage is when your body's really starting up with contractions and having change. That first stage is actually divided into two stages actually, or two phases, I should say. One is called latent and one is called active. The latent phase is the one that can be very long for some people. It may last a few hours to a couple days, which is what's really hard.

When you hear about those women saying, "I was in labor for days," they were in the latent phase of labor that whole time. Then there's the active phase and the active phase is defined by how dilated you are. So when we're talking about dilation, it's how much your cervix opens up. When a woman's not pregnant, a cervix is closed. Then when you're ready to push your baby out, you're 10 centimeters. So what we call the active phase is usually around six centimeters. That 6 to 10 tends to go a lot quicker for women.

If you haven't had a baby, it might be anywhere from 5 to 10 hours, depending on how things are going. If you have had a baby, it might only be a half an hour to a couple hours. So that's the shorter phase. That latent phase is that long one that you hear about with everybody.

Then the next part is that second stage of labor. That's when you're pushing that baby out. Again, that's not like TV, that can take a little bit of work, especially for first time moms. It's not uncommon for it to take anywhere from one to three hours to push that first baby out. So when you've had one baby, it tends to be quicker. Each baby gets a little bit easier. So that second or third one might only be five minutes. It might be a half an hour. So those do get a lot easier.

Then after the baby's born, that's not the end. There's the third final stage is when that placenta needs to come out and then everything else needs to be cleaned out of that uterus and taken care of. Those are the main stages of labor.

Molly Shroades:

So this can be anything from a couple hours to days?

Dr. Salena Zanotti:

Definitely and that's just spontaneous labor. When you're talking about an induction, that can even be longer. But real natural labor can be hours to days.

Molly Shroades:

Wow. Now rewinding back to even before labor really kicks off, I think a lot of first time moms have a hard time recognizing when the whole party's getting started. Can we talk a little bit about signs that labor might be getting ready to get started and then maybe a few ways that people try to start labor?

Dr. Salena Zanotti:

Labor by definition means you're having some contractions that are causing your cervix to make change. A lot of women will have contractions for weeks. Some don't have any till the end. So that's where it gets confusing for women. They're not sure when do I call, when do I not? How do I know it's real? The thing about labor it's having consistently strong contractions that are getting closer and closer together. If you're only having one or two an hour, you're not in labor. What you're looking for is that they're getting stronger and closer.

What we'll tell most women, if it's a normal pregnancy and no issues is you're waiting for your painful contractions to be every four to five minutes apart for a good hour. You'll sometimes hear people call it the 511 rule. So if you're having contractions every five minutes, they last a minute and that's gone on for about an hour, it's probably the real thing. But we tell everyone, call your provider, especially with your first baby. We don't expect you to know. So we're going to help you figure that out.

But that's a large variation again of what people feel. For some people, their water breaks. For some people, it doesn't. So that can be confusing to women too. So again, we often tell women, "If you think your water breaks, you're not sure, call us. We'll evaluate things from there."

Molly Shroades:

I'm wondering too, even as you say that every woman feels this differently, those contractions, I've heard them explained as heavy cramps or a really bad period or even extremely painful. Is there a wide spectrum of what those can feel like and where you can feel them on your body?

Dr. Salena Zanotti:

In the beginning, they're often like menstrual cramps. When I have women calling me saying, "I'm having cramps." I usually say, "It's your uterus waking up. It's starting to do what it needs to." That's often the prelude to the real thing. When it's real labor, you'll get tightening either of the full front or maybe of your back that holds for a good 30 to 60 seconds and goes away. For most women when it's real labor, they're not talking through those contractions. So you need to stop, take a breath. You might be very quiet. Every woman has a different pain threshold. For some women, it may not be as bad. But with real labor, I mean, it's a pain that you have not had before.

Molly Shroades:

Got you. Now let's talk a little bit about those anxious weeks when you are waiting for labor to start and nothing's happening. I know people try all different kinds of things. Let's talk a little bit about those and maybe some things your doctor might help you with like stripping your membranes is what one I've heard of.

Dr. Salena Zanotti:

It's always fun because that's always a common question. What can I do to get this going? Truthfully, there's a lot of things that can make your uterus contract. But if your body's not ready to go into labor, they don't do anything. We'll have women ask about, "Should I keep walking or exercise or go on a bumpy ride, have sex." That's a common one. Those things are all fine to do. If you have a normal pregnancy, they might make you contract. But if your body's not ready for labor, it's really not going to happen.

One of the funny ones that people used to do a long time ago, but every once in a while we have people do is try castor oil or things to make you cramp. All castor oil does is make you have some diarrhea, but your uterus contracts. Maybe some people go into labor because they're ready, but the vast majority are just uncomfortable. So we recommend against doing that. With stripping your membranes, that is something a provider can do in the office. We usually wait till your at least 37, 38 weeks, so you're full term.

What that involves is when we're checking your cervix again, your cervix needs to be open like we talked about and you're separating that bag of water from the cervix. What that does is release something called prostaglandins, which sometimes can trigger labor in women. Again, if your body's not ready, your baby's not ready, it may not do anything. But if you're on that cusp, it might give you that jumpstart that you need.

Molly Shroades:

Sounds like baby's a bit in charge at this point.

Dr. Salena Zanotti:

They are even after they're born. It continues.

Molly Shroades:

Absolutely. Now speaking about the birth itself, I know there's several ways that can go. Can we talk through a few of the different options for childbirth itself?

Dr. Salena Zanotti:

Definitely. There are a lot of different kind of childbirth experiences. Everyone who comes in the door or I should say majority of women who come in the door want to have a normal vaginal delivery. That means they just push their baby out without any assistance. A lot of women want to do without medication. A lot of women are very honest and want medication from the second they walk in the door. So those are two of the different ways of having a vaginal delivery.

If you want to go naturally, there are a lot of tricks to help women. It really depends on the women's tolerance of pain as well how her labor course is going. If it's really long and drawn out, it's harder to do it naturally. If things are going faster, a woman might be able to. We have lots of tricks to help them. A lot of women labor in water, in a tub or in the shower or on a ball. A lot of women will use different birthing techniques like hypno birthing to help them work through that.

But for some women it's still just hard and that's okay and we have these options. We have a lot of different options for medication or ways to help with pain. Most women have heard of epidurals and that's something done by an anesthesiologist where they put a catheter in your back around the area where your spinal cord is. It's not going into your spinal cord, but they give you medicine that makes you numb from basically the waist down. That takes away the pain from contractions. That's our most commonly used form of analgesia. There are also IV options that women can get until the end of their labor course.

Then the last option we have, which a lot of women may or may not about because we used to use it years ago and then it's made a comeback in the last several years, is nitrous oxide or laughing gas. A lot of dentists use it and women can use that to help take the edge off their contractions. It doesn't wipe out your pain, but it sometimes gives you enough control that you can get through it without anything else. So those are our three main options for a medicated kind of labor.

Then the other thing I think you brought up, there's different kinds of labor processes if you go in on your own or if you need to be induced. Again, our goal is to not induce somebody, but sometimes there are reasons we need to. There are medical reasons and sometimes the mom might want it to be done later in pregnancy and if it's appropriate. Those are the labors that can be a little bit longer if your body's not ready for it, especially a first time mom.

Those are often the ones you hear when a woman's in the hospital for two or three days getting induced and that is a long process. So we try not to do it unless there really is a reason, but that changes oftentimes the labor course and the pain. It's not as quick as natural labor, especially in a first time mom. Those are the major types of vaginal deliveries that are on their own or spontaneous.

Sometimes we have assisted deliveries. I don't know if you've heard of like forceps or vacuums and they always scare people. People call the vacuums a suction cup and the forceps, the spoons. They've been around a long time and providers do them very safely. They have a lot of experience if they're doing it. Most providers are only going to offer it if it really needs to be done. They're going to be offered if it's going to be the safest, quickest way to get your baby out. They're not options for every single person. It has to be the right situation. But again, that might change your delivery as well.

Then lastly, there's C-sections. I think everybody knows what they are and everyone's afraid of them. They're done safely. Unfortunately we do a lot of them, but they're usually indicated reasons. That's where we make an incision obviously, and remove the baby through your abdomen. I think I covered every kind of delivery we could do.

Molly Shroades:

Awesome. Obviously these are indicated by your preference and your medical history and what's best for you and baby, right?

Dr. Salena Zanotti:

Exactly. It's going to be more medical indication. C-sections are done for reasons like your baby might be in the wrong position. So feet down or butt down. Or the most common reason is a woman's been in labor a long time and things just don't keep progressing. That might be because the baby's too big or the pelvis isn't big enough. So those are indications where they might happen. There may also be placental issues or things that indicate it. So those are the reasons that it'll happen.

Molly Shroades:

Now, if there's an emergency situation where let's say you start off as an all natural vaginal birth and then something starts going wrong, what happens and how quickly does that happen?

Dr. Salena Zanotti:

That's a really good question. There are a lot of things that can happen. Most women, they don't go into it thinking about it and we don't talk about it very much. They might see something on TV once in a while, but most providers and most hospitals prepare for these things. Emergencies can happen very quickly, which is why we do believe the safest place to have your baby is in a birthing center or in a hospital and not at home. Because although these emergencies are infrequent, they do happen and you want a rapid response.

We recommend if there's any kind of true emergency and a C-section needs to happen, it should happen within 25 minutes. That's sort of the standard of care. Most hospitals like ours, I think our average is 10 to 12 minutes from the time we call it to the time the baby comes out, but not every hospital has those facilities. So they may take longer. But usually within 25 minutes is our goal if it's a true emergency.

Molly Shroades:

Awesome. So let, let's go back to, in a traditional vaginal birth where everything is going well and not complicated, who are the players in the room? Who might you run into or interact with during your experience?

Dr. Salena Zanotti:

Again, every hospital's different. Without a doubt, our nurses are our biggest heroes in this. They are the ones that are with the patient the most from the time of admission and the time of delivery. So you'll always have one, maybe two nurses. Then your provider might be a physician or a certified nurse midwife. They both are trained to deliver babies, midwives for normal uncomplicated deliveries. So it depends on what you choose in the facility you're in. If you choose to have anesthesia, there are anesthesia team members that might be there.

If you're at an academic center, you may have residents who are learning as well as medical students. So there are a lot of people. But your core group is going to be your provider, which is the midwife or doctor as well as your main nurse.

Molly Shroades:

Wonderful. So your body's changing a lot during all of this. During all of pregnancy it's like a roller coaster of change here, but let's talk a little bit during this final phase. What kind of big changes are happening to your body?

Dr. Salena Zanotti:

Towards the end, I always tell people, I divide it up into the trimesters. The first one you're getting used to being pregnant. You're a little nauseous, tired, anything could happen. Second trimester, you feel great. Usually your energy level's good. You're not that big. Third trimester, your uterus is growing and your body's getting ready for those changes. So you'll often have more low back pain. You can have hip pain or pelvic bones or a pubic bones start separating a little bit. So some women might notice that a lot more. They'll have a lot of pain because your pelvis is trying to make room for this baby to come down.

Right before labor happens, some women notice a change in their bowel movements and that can happen because of some of the hormonal changes. So those are probably the main things. You'll often hear women talk about their mucus plug and that's something that they'll call you about. We always tell them, "You don't have to call me at three in the morning for that." But sometimes women will have a large clump of mucus or pieces of mucus come out. It does not mean the baby is coming imminently. It just may happen several days, even a week or so before labor's going to start. But those are some changes women might notice.

Molly Shroades:

Got you. Great. Now you mentioned earlier about pain, but I know it's a question on a lot of people's minds leading up to the big show, right? They want to know how painful is labor?

Dr. Salena Zanotti:

Again, everyone has that different pain threshold. It may be the worst pain of your life if you're going all naturally. Some women have it in them and they can do it and I think it's amazing when they do. But even with an epidural, I think it's amazing when they do it. You'll still feel some pressure. Even when you have those anesthesia options, you'll feel pressure as the baby is coming out. Some women feel a lot of burning around the vagina is everything stretching. So that's what they'll remember, but it can be very intense until you get some of those pain control options in.

But like I said, some women they can handle it and they do really well with it.

Molly Shroades:

Speaking about the all natural option here, are there any perks to going all natural and what are some of the myths around pain management for labor?

Dr. Salena Zanotti:

The biggest perk to doing it all naturally is really how you recover afterwards. Because you're able to move around. Actually you're able to move around throughout labor because your legs are not numb. So that is a benefit. You can stand in the shower, walk around your room if you're going all naturally. As well as after you deliver, you can get up and walk around immediately. A lot of women will say their recovery is a lot better because they don't have that delay.

When you do have an epidural, before you're up and about, we need to make sure your legs are back and you can have all your sensory feeling back. So that can be the little bit of delay after delivery. Some of the myths with epidurals are some people think epidurals increase their chances of having a C-section and that's not true. A lot of studies have looked at it and a woman who has an epidural does not have an increased risk for a C-section.

There can sometimes be a little increase in the length of your labor after you get an epidural. So sometimes we need to add medication to help augment your labor like Pitocin. But that again, does not increase your risk for any complications. There's no long term risks for your baby either. So epidurals can be done very safely.

Molly Shroades:

Awesome. It's really just doing what's best for you once again. Right?

Dr. Salena Zanotti:

Yeah. I always tell women, everyone's going to tell you their stories, don't listen to them because you're going to have your own story. You're the only one who's going to know what it's going to be like.

Molly Shroades:

Absolutely. I mean, every new mom has her birth story and they're all completely different even though the result is usually the same. So speaking of concerns here, what are some of the biggest concerns that you hear patients say when they're in the office, when they're getting ready for childbirth?

Dr. Salena Zanotti:

The one you've touched on the most pain. Women, especially their first babies, it's scary because you don't know what it's going to be like. Again, no one can express their pain to you and you can't express what your pain is like to them. So they're most worried about that. They're often worried about if they tear. A lot of times that women have a vaginal delivery, especially first time moms, you get some degree of tear in the area between the vagina and the rectum. It's called a peroneum. So women are very afraid of that.

We do a lot of things to help minimize those risks, but they can happen. So we try to reassure women about that. Some women just on the lighter side are always worried about pooping in labor. They find that to be the most embarrassing thing, if it happens and it happens and it's okay. Nobody in your room remembers that you did it. So it's okay.

Molly Shroades:

It's funny that you say that because my next question was literally, that people get nervous about asking if they're going to poop during labor. I feel like that's something that everyone is worried about, but doesn't want to ask.

Dr. Salena Zanotti:

It's an anatomic thing that happens. If you happen to have stool in your rectum, you're pushing the same way... we tell people when they're pushing their baby out, push like you're having a bowel movement. So if there happens to be stool there and it comes out, you're pushing in the right spot and it's not going to happen the whole time. There's only going to be a little bit and it's perfectly normal and nobody is bothered by it. Unfortunately just the patient often is. But hopefully once they see their baby, they forget all about it and it's okay.

Molly Shroades:

Definitely one of those things you just brush out of your mind, right?

Dr. Salena Zanotti:

Yes, exactly.

Molly Shroades:

Great. After are your baby's born, I know your focus shifts completely to your baby as the new mom, but that's not the end of birth as you said earlier. Let's talk a little bit about that next stage, the after birth part and what happens when that placenta's out.

Dr. Salena Zanotti:

So the baby comes out and most of the time babies go right directly on mom. We're all for skin to skin contact. While the mom's starting to have that bonding experience with their baby, the providers are working on everything else down there. Like you said, the first thing is getting that after birth placenta out. They can be delivered anywhere from a few seconds after delivery up until 20 to 30 minutes after it can take for it to separate. Once it comes out and this is what often can scare some people, especially their partners, you have a lot of bleeding and that's normal because your uterus has to get everything out.

So your providers are working on helping control that, bleeding, getting that placenta out. Then if there's any kind of repair to do, that's the time that a repair is done.

Molly Shroades:

I've always heard that the uterus has to shrink back up after pregnancy. Can you talk a little bit about that in the aftermath of giving birth?

Dr. Salena Zanotti:

I personally think the uterus is the most amazing organ. Because if you ever see a pregnant woman, it is huge. It is amazing how large it is. Right after you deliver, it can be three or four finger breaths below your belly button already. So it shrinks. Goes from this big down to really small. Then as time goes on in the next few days, it really shrinks a lot more. As it's shrinking or contracting down, women will have cramps, that's normal and they'll have some bleeding. Then it'll go back down to being its normal size.

Molly Shroades:

Awesome. Now, one thing I remember seeing from recovery was the either nurse or doctor pushing on your abdomen and then the gush of blood what's happening when that happens?

Dr. Salena Zanotti:

So what they're doing is trying to help your uterus contract. So you're massaging your uterus and getting all the blood out of it. Because sometimes uterus's can be a little bit lazy and they don't contract on their own. We often give women some medication afterwards to help them contract, but we really press on that uterus to get all the blood out. Because if it sits and collects, it increases the risk for more bleeding and potentially a postpartum hemorrhage. So oftentimes you'll see the nurses really pushing hard on that uterus making sure everything is coming out and that the uterus is getting really firm.

Molly Shroades:

Got you. Now what happens to the placenta afterwards?

Dr. Salena Zanotti:

So most the time the placenta is just discarded. If someone's had some kind of issue in their pregnancy, maybe an infection or diabetes, a whole list of things, it might get sent to pathology to be studied. Sometimes women want to take their placenta's home, which we're fine with if they want them and we don't need them for some reason. So they have that choice. But most of the time they're just discarded.

Molly Shroades:

Got you. Wasn't there a thing in the past of making pills or things like that out of them?

Dr. Salena Zanotti:

There are people that still do that.

Molly Shroades:

Interesting.

Dr. Salena Zanotti:

They make vitamins out of the placenta claiming that it might have some benefits that haven't really been proven by any studies. When women ask me about it, I tell them, "There's no harm if you really want to pay the money to do that. Studies and data haven't shown it reduces any risk significantly. But if you want it, you can have it." Every once in a while you have someone who takes it home and wants to plant it under a tree or something just to have it. That's fine too. You can do whatever you want with it.

Molly Shroades:

Got you. Now I was wondering about birth plans. I think everyone loves to be prepared and you want to develop this perfect birth plan you think it's all going to go like that. But reality doesn't always end up working out the way you plan out on paper. Talk to us a little bit about why you should or shouldn't do a birth plan and how much to hold on to that idea.

Dr. Salena Zanotti:

Birth plans are funny. They really came into play in the 80s when obstetrics was changing a lot and everything was about medication and controlling things and it wasn't as natural. A lot of the things were just procedure oriented. I think a lot of birth plans really grew during that time period. I think the idea of thinking about what you want your birth to be like is really important. Every detail need to be put on paper, not necessarily.

What we often see and I think most providers would agree with me, when a woman writes everything down and and I'll go through some of the things they write down, if it doesn't go that way, you're in such an emotional situation. Often even though you know you don't want to feel this way, you feel like a failure when it doesn't happen. Like it's supposed to be on your piece of paper. So we see it really can often be detrimental to a person and their experience. How I look at them, I talk to women and I say, "Let me know, what are the things you think you want that are different?"

Because 99% of the time, they're the things we do normally. The common things people write down, "I don't want to have a C-section." We don't want you to have a C-section, but sometimes they happen. "I don't want an assisted delivery." A common one is, "I don't want an app episiotomy," which is when your provider might make a little cut in that perineal area to help the baby come out. Back in the 70s and 80s, episiotomies were cut very routinely and we've learned in obstetric practice that we don't need to do that.

Oftentimes a natural tear might be better. There are a few instances where we'll cut them, but they're very rare now. So I try to tell patients, those are things again, we don't do routinely. So it's important I think to bring these things up with your provider, but again, the common things are, "I want the baby to stay with me or be skin to skin," which I think most institutions do in the US.

A common one is, "I want to have the core delay clamps." The umbilical cord needs to be cut at some point. Years ago we used to cut it immediately. What we've learned is, it's worth waiting 30 to 60 seconds. So those are sort of things that are more of a standard that we do. So I often tell women if there's something you think that you want's a little different, let me know. I make note of it in the chart. I will make sure people know in your labor.

But do I think women need to have a completely typed out birth plan? Not necessarily, unless there's something you think that's very special or different.

Molly Shroades:

It's definitely important to be flexible to change, I imagine

Dr. Salena Zanotti:

Definitely. Especially in labor, like we've said, no one can tell you how it's going to be. It's a hard situation because you don't have control. Most women, we want to have control of our bodies and our situation and labor is one that you cannot. So I think it's important to think about it and know the different scenarios that can happen and to talk about them and address them, but to be open to what might happen for sure.

Because I often will have a woman who says, "I don't want anything for pain." Then when they get there, it might be a little bit harder than they thought and they want something. They honestly feel disappointed in themselves, which is really sad because they're doing an amazing job. So I think it's important to be open to everything and to discuss it with your provider too.

Molly Shroades:

I'm just curious, do second time moms tend to come in with as many birth plans as first timers?

Dr. Salena Zanotti:

Not at all. Nope. Second time moms are way more relaxed, completely different ballgame.

Molly Shroades:

Got you. You know what to expect the second time.

Dr. Salena Zanotti:

Exactly. Again, that's it. We like to have control and by writing it down and saying, "This is how I want things." It might help you process it, but usually not necessary.

Molly Shroades:

Great. Now, as we wrap up today, I'm just wondering if you can give us a few words of wisdom for moms that are about to enter into this new adventure in their lives and have this experience. Just a few things you can tell them as they get ready for this.

Dr. Salena Zanotti:

Every woman's different in how like to prepare. There are some women who want to read as much as they can, some women want to watch as many videos as they can or talk to people and some don't want to talk about it at all. But I think it's important to tell women that every individual's labor and delivery is going to be different. To be open to everything and to ask for help and let your providers know how you would like things to be or how you're feeling.

If you have that open communication, it's going to be a better experience for you. There is no right or wrong way in doing this. As we talked about, there's many different ways to have a baby and the way you do it is the right way for you. I think that's the most important thing for women, to enjoy this as much as they can. It's a very stressful situation. So just trying to be as relaxed and open to things I think can help reduce that stress.

Molly Shroades:

That's fantastic. Thank you so much for joining us and sharing your insights today.

Dr. Salena Zanotti:

Oh, you're very welcome. It's my pleasure

Molly Shroades:

To find an OB/GYN or to schedule an appointment with Cleveland Clinics Women's Health, please visit clevelandclinic.org/women.

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