VIDEO TRANSCRIPT: THIS TRANSCRIPT WAS GENERATED USING AN AUTOMATED SERVICE SO WE APOLOGIZE FOR ANY TYPOS AND SPELLING ERRORS.

The labor part deux

[00:00:00] Hello people. It's Wednesday. I've been at the hospital a lot and now I'm back. We're gonna see if I can get a quick nap in before I go back. Just wanted to show you, this is my ID from when I was younger. I refuse to give it up just cuz I think it's a funny, looks like a mafia crime boss picture. Okay, let's talk. 

This is part. . What happens when you go to the hospital and you're in labor? And this is literally, I'm gonna try to remember like the step-by-step things that happened just because a lot of patients recently have said like, we can't go with the tour. We can't, we dunno what's gonna happen. Can you walk us through it? 

Because they're used to hearing more details I think when they go on the tour. So this is gonna be. As granular as I can think of about what's gonna happen when you go in. So yesterday's part one, we talked about when to call your doctor. Again, if you're my patient, I say if your water breaks, if you're bleeding, like a period, if you're not filling the baby move or when your contractions are rock hard, painful every three to five minutes and you can't even talk through them anymore. 

That's what we tell first time moms. [00:01:00] Second time moms, water breaks bleeding, baby not moving. Regular painful contractions that are six to eight, eight to 10. Any kind of regular pain that seems like contractions just have a low threshold to call us. Okay, so you get to the hospital during the covid. What happens at our hospital, which is pretty Ty typical for most hospitals, I think. 

throughout the country. Now they'll ask your doctor is you walk in, you as the patient are gonna go into labor and delivery. At our hospital, you do not go through the emergency room. I suspect most hospitals are the same because they try to avoid the emergency room. You go into labor and delivery after calling your doctor, Hey, what should I do? 

They'll tell you, go to the hospital. Typically they'll call the hospital to warn the nurses. This patient's. When you get there, the nurses will swab you. At our hospital, it's the nasopharyngeal swab, meaning that Q-tip that goes up your nose and your partner will wait in the waiting room until the covid test comes back. 

And in our place it takes about 30 to 40 minutes to come back [00:02:00] during which the nurses are getting you ready. So they're starting your iv. Someone might come and do an ultrasound to peak at the baby's position. Because we are a teaching hospital, we have residents who are doing an intake. They're finding out how you are. 

They're checking your cervix to see, you know, are you in labor? How far are you in labor? What's gonna happen now if you're far enough in labor? Then you might get an epidural. Far enough is a very nebulous answer, and it depends on you and your doctor, meaning some doctors will still say, wait until you're at least three to four centimeters, till you're really in what is considered active labor. 

Other doctors will base it on your level of pain. Um, I myself, because I got my epidural early with my only vaginal delivery, I'm a proponent of if you're in bad enough pain and you want pain medicine, and if you don't want pain medicine in your IV like morphine, then I would give you the epidural. 

There's a big dilemma. Big question. Does it slow down labor? Most of the data [00:03:00] indicates that it does not statistically, significantly slow down labor, and most of us agree that even if it seems to slow down labor sometimes anecdotally, we can kind of beat that by using Pitocin. If you feel that you don't want any intervention or you'd like to try to avoid intervention, then by all means, if you feel like you can go without the epidural, wait as long as you can. 

A common thing that happens to patient. that I hear is they'll say things like, I'm just so scared of a needle in my back. To which my response is, if in that moment your pain does not supersede your fear of the needle in your back, then you don't need the epidural. But like me, you might say, I am in so much pain. 

Please stick the needle in my eye or anywhere you could do it, because I just want pain relief. So I urge you. Worry about your fear. Please don't even use that word, but fear of needles. Like I said, if you in that moment still are like, Ooh, the thought of a needle, my back is freaking me out. That means you can handle your pain because there might come a point [00:04:00] where you feel like fear is gone. 

Give me the pain medicine. So again, you're gonna come in, you're gonna get covid tested, you're gonna get your iv. Doesn't mean you need to have IV fluids running again at, at least at our hospital, you have the IV line put in so that the nurses have access to be able to give you fluids because there are times we're in an emergency, we really need to make sure that you're hydrated. 

Otherwise, they will hang IV fluids if you don't mind. If you don't want it and you wanna be super mobile and walk around and drink clear liquid. By all means you should do that. You are not allowed to eat at our hospital once you're in labor. Some hospitals, it seems, from what I hear, are starting to allow that. 

Most are not, because the idea is that you're there on the off chance that you need surgical intervention, right? So if you need to have a C-section, we need your stomach to be as empty as possible. We know that you might have just walked in having eaten a cheeseburger, but once you're there, you're not allowed to eat. 

So you're progressing in. Now, here are some things that might happen. You [00:05:00] might progress at a steady clip, one centimeter an hour, one to two centimeters. Every two or three hours you might be progressing, progressing. Every time they check you, every couple hours, your cervix is more and more dilated. You get to fully dilated, you push for an hour and the baby comes out. 

That is a beautiful delivery. And if it's your first pregnancy and your labor is under 15 hours and under two hours of pushing, while that sounds like a long time, that's amazing. What's very common is your labor could. 24 hours, you could push for three, sometimes more hours, and that's exhausting. But if your doctor is there and understands that you are continuing to progress in a way that makes sense, meaning when she checks you, the head is actually making dissent as you're pushing, then she may allow you to push even more than three hours because it depends on what our likelihood of thinking the baby is gonna come out, um, or what we think is the likelihood of the baby coming. 

And then we sometimes let patients push more than three hours. We used to have very strict [00:06:00] criteria as to when you've fallen off the labor curve and if you fell off the labor curve, then you would have a C-section. We would check every two hours, no change C-section. We've luckily, to a degree, change the mindset where we allow patients to have a longer period of time before we kind of throw in the towel and decide to do a C-section. 

as you might guess, if you follow me for a long time. I feel mixed about this. There are definitely patients where us having waited made sense and then they've actually delivered vaginally and it's been a beautiful thing. There are other patients where we've waited and waited in the hopes that it would turn out vaginal despite the fact that our clinical suspicion. 

was that it wasn't, and we've then been a little bit more behind the eight ball when we've needed to do the C-section because of things like bleeding or infection. So I really think if I could urge you guys to do anything, please talk to your doctor and listen to your doctor and have a good collaborative relationship. 

Your doctor really is there to help you. I really doubt that [00:07:00] anyone is there. Cut you and do a C-section at five o'clock so they can get home for dinner. I don't know many obs who get to be home for dinner. So I really hope that we don't continue to perpetuate that idea because that's just not really how any of us operate, or at least the people that I know don't operate that way, literally or figuratively operate that way. 

Um, that said, your doctor's been doing this probably for a long time and she or he might really suspect. This labor is not going to progress and produce a vaginal delivery. And the earlier in the process that that is thought about, sometimes the better off you are. But it depends. It depends on how you feel, how they feel, what's going on with the baby. 

There's a lot of parameters. There's no right answer, which is why I always say the best thing you can do is go into this with an open mind and say to yourself and maybe verbalize it to your doctors. I'd love to have this baby vaginally if that works. It. . If that doesn't work and I need a C-section, that's great too, because I keep hearing that they are both good for different reasons. 

So as long as me and the baby are happy and. , we'll [00:08:00] be happy and we'll get through this. That does not mean that there might not sometimes be drama. So some of the things that might transpire, for example, you're ploting along. You're either in spontaneous labor or you're needing Pitocin. If your contractions have petered out and all of a sudden the baby's heart rate might drop really precipitously to the point where five people run into the room, they put oxygen on your face, they flip you around to try to get the baby's heart rate back up, because sometimes that means the umbilical cord was. 

And then everything's fine. The heart rate's back up, or the heart rate stays down. They decide to do an emergency C-section to make sure that the baby's okay, and those babies almost always come out. Okay. I don't know why the heart rate drops. We do an emergency C-section, we get the baby out quick. Lo and behold, the babies come out crying. 

It's always a kind of crazy thing, but that often happens. That doesn't mean the baby didn't need to come out, but it means that those babies often are okay, but in that moment, The drama can feel very nerve-wracking for patients and it can feel very, um, like truly there's no control. And they feel almost like they're in this other [00:09:00] place, like out of their body, they describe, and afterwards they tend to sometimes have some ptsd. 

So these are the times where if that's happened to you, as soon as it happens within the couple hours or certainly a couple days, try to have a good conversation with your doctor where you guys kind of review what happened because your perception of what happened is sometimes very different than the. 

Perception or what actually was transpiring. And as much as we try, and some of us, we think, we think we're good communicators and we're just not always communicating as well as we would like, or we think because there's a lot of presumption. We assume that you understood this and you understood that. 

And again, we're not always great at this part, so let's collaborate and we should be very good about proactively kind. After the fact telling you, Hey, this is what happened. Let's just review the the situation and why we did what we did. And if you guys feel like you're not sure, ask them. Because it's always good for both sides to understand each other better. 

So that's one thing that might happen if the nurse feels like she cannot. Get the baby's heart rate as accurately on the [00:10:00] external monitor, then there's a chance that she is gonna ask the doctor or the resident doctors to put in an internal monitor, a fetal scalp electrode, which is almost like a baby ekg. 

So instead of just sensing the heartbeat from the outside, it's a teeny little wire. I know that sounds kind of barbaric, but it gets screwed into the baby's scalp, not into. The skull apart, just the skin. It doesn't hurt the baby in any way. Um, but it's a much more accurate way of noting the heart rate because those heart rate changes can kind of be a signal to us as to whether or not the baby's getting enough oxygen or not. 

Interestingly, there's a lot of controversy about electronic fetal monitoring where we monitor the baby in labor because many studies have shown that it's only served to increase the c-section. Without necessarily improving baby's outcome. As obs who have all trained in the got in the umbrella of using these, it's really hard to grasp that. 

that said, that is what the data shows, but it's still widely accepted throughout the country, so there's no hospital I know of that would abandon electronic fetal monitoring at this point. [00:11:00] The other monitor you'll have on the outside of your belly is also gonna be a contraction monitor. It is only sensing the change in shape. 

of your uterus. So as your uterus contracts and changes shape, this little monitor will change. And then you'll see on that piece of paper what looks like a sine wave with contractions. As your uterus changes shape and then comes back down, patients will often look at that monitor and go, God, I'm having big booming contractions. 

And the entrance is, no, it's really only telling us the frequency of your contractions. Meaning no matter how big these mountains look on the paper, It doesn't tell us anything about the severity or intensity of the contractions. So sometimes just like the scalp electrode that's inside, they will put in an intrauterine pressure catheter, which is like a teeny little straw that goes inside the uterus and senses the change, the actual change in pressure, and then we can quantify your contractions. 

We would need to do that sometimes just because we wanna match it to the baby's heart rate to make sure when the baby's heart rate might be changing compared to the contractions. Or we would do it in order to kind of really make sure, are we giving you adequate enough contractions? And if [00:12:00] so, and your cervix is still not changing, maybe that's a sign that your uterus just doesn't want this baby to come out vaginally, which is okay. 

What has to happen for labor? Well, we don't know what triggers it, but your uterus has to contract, your cervix has to thin out, dilate, so efface and dilate, and then the head has to at the same time go down what we call the station. And then once you get to fully dilated, you have to. at a certain clip to get the baby out. 

All of these things have to be coordinated in work. Sometimes your contractions are not enough on their own, so the Dr. May either induce you with Pitocin or augment you with Pitocin. There's no way to prove whether Pitocin is stronger than your regular contractions or not, and I've heard. people say, oh my God, Pitocin is so much worse. 

I have to be honest and tell you that I don't think that's true. I think you need a certain level of contractions in order to be in labor and in order for your cervix to change. And the Pitocin is only one part of that, meaning the Pitocin will make you have regular contractions. So your perception might [00:13:00] be, I see an iv, it's dripping medication. 

Oh my gosh, I'm having contractions. These must be worse than if I was having them on my own. But the fact. , whatever level of contraction you need to get your cervix to change, whether it's your own oxytocin or the medical pitocin, I think those are gonna feel equal. No one can prove this. There haven't been studies on this, but just so you know, I don't want you to walk in with fear ever, or anxiety about how tough the Pitocin contractions might be. 

I have so much more to say, but I only have one more minute. So these are my parting words about. Labor is an unpredictable process. We can try to figure out what's gonna work, what's gonna help. Will this baby come out vaginally, will it not? But there are a lot of different factors that we cannot always predict. 

So the best thing I can do, and I've asked you guys this before, is urge you to have a good relationship with your doctor or midwife and collaborate and talk, but remind yourself you haven't done this for years and she probably has. So you need to collaborate, but you need to trust her. If you don't [00:14:00] trust her, then the answer is, Question her to death and doubt what she's saying and go against what she's saying. 

The answer is find a practitioner that you do trust. She and you need to work together collaboratively. You and the nurses need to work together collaboratively, collaboratively. So if that's not working, , then the whole system is not gonna feel as good whether or not the baby comes out vaginally. I have had some of the most challenging C-sections where patients absolutely feel, felt and heard, and everything was okay, and occasionally we have a very easy vaginal delivery where the experience just isn't as good if the patient doesn't seem to have faith in us and we have a good relationship with them if they don't have faith. 

Sometimes it's our fault. Sometimes it's because we haven't imparted faith, but sometimes it's the patient's mistrust. So again, the most important thing you can do as the patient is find a provider that you feel comfortable with. Okay, I'm gonna go take a nap. Bye.