Emilly Gama—emillygama.com

Labor: Short and Long; Physical and Mental

Editor’s note: This article first appeared in Midwifery Today, Issue 126, Summer 2018.
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Webster’s dictionary defines labor as “the expenditure of physical and/or mental effort, esp. when difficult or compulsory. To exert one’s power of body and/or mind, esp. with painful or strenuous effort. The physical activities involved in parturition.” That sums up labor pretty well. It is hard work, physically and mentally.

Why are some labors so short while others seem to go on forever? Why do some women seem to breeze through labor while others have such a hard time? There is no one easy answer to this, but I will attempt to cover some of the more common important aspects that go into making it harder or easier; but realize that many less common tangents—which are beyond the realm of this article—also contribute either negatively or positively.

Labor requires much physical exertion. In our sedentary society, it is easy to “work hard” without doing more than lifting fingers over the keyboard. In order to labor efficiently, our muscles must be used for a strenuous workout. We must exercise our bodies just as much as our minds. We need not only the kind of exercise we get in a gym, but exercise in fresh air and sunshine. Many of the women we serve are deficient in vitamin D because they don’t get outdoors frequently; moreover, when they do, they slather on sunscreen, which prevents them from absorbing vitamin D from the sun. Gardening, swimming, bicycle riding, and hanging up clothes on a good, old-fashioned clothesline are all excellent ways to get more outdoor exercise. While there are exceptions, in general, members of rural communities, who have gardens and farms, chop firewood, and, in general, do hard physical work daily—much of it outside—have much easier labors than city dwellers. But even a city dweller can ride a bike through a park, visit an arboretum, or grow tomatoes on their patio.

Sometimes a malpresentation makes labor unnaturally harder. This is why it is imperative that we assure that the pelvis is well-aligned before labor. Chiropractors and midwives should go hand in hand. Dr. Jeanne Ohm, DC, (whose six children were all born at home) puts out a great magazine called Pathways to Family Wellness. She touts how chiropractors love midwives because babies born with midwives have much less birth trauma. She recommends that any baby pulled out surgically (or a vaginal breech) have a chiropractic adjustment as soon as possible. Likewise, midwives and obstetricians should always check for pelvic symmetry and recommend chiropractic care anytime baby is not in an optimal position. Gail Tully’s Spinning Babies website or the Miles Circuit (milescircuit.com) may minimize the need for a chiropractor, but there is only so much one can safely do alone. However, that limit may be much higher than we realize!

In our society, the standard American diet (SAD) is indeed sad! You wouldn’t expect a car to run on Kool-Aid or pop. Neither can our bodies. For our bodies to work efficiently, we must put in the right fuels! Not only the right fuels, but in the right ratios, in the right amounts. When we eat junk foods, the cells in our bodies signal us that they need more fuel, because the foods we are eating do not contain sufficient nutrients to keep our bodies functioning. If we keep eating the same non- or minimally nutritive foods, our bodies will keep sending the signal that they need more food. Thus begins the vicious cycle of weight gain!

A wise man said, “[Wo]man shall not live by bread alone.” Luke 4:4. That same book also says, “I gave you the green herb for your health.” Gen. 1:29. We need to grow as much of our own food as we can. When grocery shopping, go around the perimeter of the store, where the real fresh foods are. Skip the aisles filled with processed, canned, boxed, artificial junk.

Even our skin turgor and muscle tone depend on good nutrition. This affects not only the ability to labor well, but even the tendency to tear or not. Our muscles need magnesium and calcium to work well, and without the sunshine vitamin D we cannot metabolize these other elements well. Foods high in vitamin E (d-alpha tocopherol, not dl-alpha; read your labels!) help your skin’s elasticity. This can help prevent both stretch marks and perineal tears. Vitamin K helps clotting. Good-quality lean proteins are essential to maintain a pregnancy to term.

Our bodies are complicated machines. We can eat only wonderful nutritious foods, but still have problems if the diet is unbalanced. We need lots of different nutrients—some still undiscovered by scientists! It is always best to get these vitamins naturally—through food—but when not possible, supplements are better than nothing.

When supplementing, beware of unscrupulous companies that offer bargain-basement pricing. It is better to buy a known, reputable brand. While we are talking nutrition, don’t forget water. Staying well-hydrated is like putting oil in your car: It helps all the parts run smoothly and work together.

Physical health is only a part of what goes into an “easy” labor. The mind, as well as the body, must be prepared. Maybe you’ve heard the old adage, “What you resist persists” (Carl Jung). That is a key to relaxation in labor. Tensing up and resisting contractions makes them harder and more painful. Plenty of books have already been written about this fear-pain-tension cycle; read up, folks. “Forewarned is forearmed” (an old Latin proverb; “Praemonitus, praemunitus”) and “Knowledge is power” (Sir Francis Bacon). With knowledge of pregnancy, labor, and birth, you will not have to blindly follow whatever the good doc says. Medicine is as much an art as a science.

There is no one “right” way to birth, but there is an optimal way for each woman to birth. An individual woman may or may not fit the status quo mold that doctors like to promote. They want things done fast and efficiently (for them), with as little chance of getting sued as possible. It is up to each woman to find her ideal way. The more you read, the more you will know, the more choices you will have.

There are many good ways to help stay relaxed and not fear in labor, but the birthing mom must internalize and believe in a method. While significant physical exertion is involved in labor, much is mind-over-matter, as well. In short, fear makes labor worse! It may be fear of the intensity of the contractions, of the responsibility of parenthood, or even something seemingly as unrelated as whether or not a divorce is final or the laundry is done. (Yes, believe it or not, those are some examples of fears I have encountered that have hindered clients’ labors!)

In general, animals tend to have easier labors than humans, because they act on instinct, not fear. Amish women tend to have easier, faster labors, not only because they are used to hard physical work in their daily lives and do not eat a lot of processed junk food (though they do indulge occasionally), but also because they do not fear birth. Their mothers, aunts, and sisters all had births without hospitals, doctors, or epidurals; it is not the great unknown to them as it is for many “English” (what they call those of us whose primary language is English rather than Pennsylvania Dutch). They are used to and ready for hard work; they do not shirk it; they embrace it. We all can, too!

No matter what the end result, women are generally happier with their births if they feel like they are making decisions and not being scared or coerced.

Let us now be a fly on the wall to look in on some labors:

Angela, 22, was working her way through school by being a model for art students (a lot of sitting, not much time for exercise). Her partner left her as soon as he found out she was pregnant. He also left her with a raging, sexually transmitted infection. This not only demoralized her, but it left her with overwhelming responsibility. Sharon and I were to be her midwives. Labor was long and hard, but she never gave up. After the first day, she wanted more hands-on … counter-pressure on her lower back, hip squeezes, hugs, someone to keep her fed, and remind her to pee. Eventually Sharon had to go feed her family, including a nursling. So we called Gail to take over Sharon’s role. Then eventually, I had to take a nap. By the third day, we were all worn out, in spite of taking turns helping and sleeping. We called in Martha, who eventually called in her husband. By the fourth day, we had also called in Dr. B., as such a long, hard labor lends itself more readily to postpartum hemorrhage. We were all exhausted, physically and mentally—Angela included. She never gave up or asked to transport. She was determined to do this and she did—on the fourth day it was all hard labor! She did it, against overwhelming odds. She never had any more kids and remains single. There was no way she would go through that again!

What could have made it easier? Her lifestyle did not allow for much exercise. She sat in school, as student and model, and then at home studying. She did waitress part-time, as well. That got her moving some, but a lot of standing on her feet on hard floors is not the best kind of exercise. There was little time left for healthy exercise. Without a partner to shoulder part of the load, she had little choice. She ate well; that must have been her saving grace, no junk food. Her attitude toward labor was more like that of the Amish; she was ready to “carpe diem.” She labored without complaint day after day, pulling on our resources to help her through, without any doubts that she could deliver this baby herself, and she did! Possibly, a chiropractic adjustment may have helped. The advantages of chiropractic were unknown to us back then. I believe the main thing that made labor so hard was the lack of a partner—not a lack of partner by choice, but one who pulled the rug out from under her and disappeared while her whole world collapsed. It was not fear of labor, but fear of how she would finish school and raise this child herself. Unfortunately, there was no one there to make that aspect right.

Jessi, 19, newly married, both still in college, found that she was pregnant—regardless of the fact that they had planned to wait until after graduation to conceive. “Best laid plans of mice and men often go astray” (Robert Burns). After the initial shock wore off, they got excited. Jessi had been born at home, in the tub. She wanted to do the same, even with the same midwives, who were still practicing. The couple wisely revised their future plans. They finished off their current year of school. He took a few years off and went into the service so he could support them and eventually get a GI bill to finish school. She would take only one year off from school. Eventually, they discovered that she was having twins. The ultrasound confirmed what I had thought: one head down and the other transverse behind—another shock. They continued with the plan to have a home waterbirth. She was warned to eat more protein with twins. She did well until her husband went to basic training in another state. She ate plenty of salads with green leafies, but became lax about fixing a balanced meal (so skimped on protein) with only herself to feed.

At 35 weeks, she went into labor. We discussed the pros and cons of having a homebirth that early. She decided to go up to her sister’s house—in a big city, five minutes from a good hospital—as opposed to staying home, one hour from a second-rate hospital. As we drove, she did slow, deep breaths, staying relaxed through contractions. She waved her arms in rhythm to her breathing, much like a conductor leading an orchestra. It was so wonderful that she got her own unique style of coping, without being taught. We got to her sister’s around 1:00 am. We kicked her nephew out of his bed and banished him to sleep on the couch. One of the other midwives met us there, and the other stayed back, so she wouldn’t be so far away if anyone else went into labor. Jessi continued to handle contractions well, staying relaxed through the night.

About 7 am, she was 8 cm, still doing well, but decided that she wanted to be in the hospital, in case the babies had trouble starting to breathe. She astounded the hospital staff by the confident way she handled her labor, in spite of the last-minute change of plans. Soon, after only 12 hours of labor, she was ready to push. They made us go into the OR, instead of a labor and delivery room, because they wanted to be ready to do a c-section if the second twin had trouble getting turned around. He didn’t. They kept asking her if she wanted an epidural. She just kept smiling and replying, “No thanks, I’m fine.” She didn’t have to push long. The first baby came head first; the next one turned breech and came feet first, only one minute after his brother.

Looking back, she believes she probably wasn’t eating enough protein after Allen left for training. So, maybe they didn’t get a home waterbirth, but she did get to birth the twins naturally—even the one who stayed transverse until the last minute. She could have done it at home, but it was her choice entirely—a wise one, I might add. She never felt bullied into the hospital or encouraged to stay home. Although it went well, the earlier the baby, the more immature the lungs, so the more likely breathing difficulties. Although twins’ lungs tend to mature sooner than singletons, 35 weeks is considered borderline “iffy” for homebirth. The babies were healthy and didn’t even go to the nursery, let alone NICU. They went home after just two days. No matter what the end result, women are generally happier with their births if they feel like they are making the decisions and not being scared or coerced.

Leah lived on a farm. She had seen lots of babies of all sorts come into this world. She watched from the shadows while horses instinctively did what we call “the birth dance,” prancing back and forth in rhythm with their contractions. They knew instinctively to lick their foals, to get them on their feet, and to nudge them toward their teats. Leah knew cats and dogs usually preferred a dark corner—in a closet, under the porch, in the barn. Cows and goats often go to a far corner of the pasture, if allowed. Privacy is their priority—not running for help, unless they need help. If an animal has trouble birthing, it will get loud so help can be found—but not during a normal birth. Animals seem to instinctively know the rare times when help is needed and will let you know.

Leah had seen these scenarios play out many times in her life. One of her earliest experiences on the farm was when a lamb got stuck. The farmer had the vet on the phone, telling her what to do, but it wasn’t working. She called Leah in to help. Without any formal training, she just followed her instincts. Without fear, she reached up into the sheep and helped the baby turn so it could get out. A few years, and many animal births later, Leah was pregnant with her first baby. It seemed normal to her to birth in the relative privacy of her own home. After only a 10-hour labor, on her due date, she birthed her daughter in her bathtub. She thought labor was not as hard as the pregnancy itself.

Louise had a traumatic first labor in the hospital. She wanted a natural birth, innocently thinking she could get one in the hospital. She even questioned the need for a hospital, but everyone assured her it was too dangerous to birth at home. She naïvely believed them. Like a sheep being led to slaughter, she obediently went to the hospital when her water broke.

In triage, she was asked how far apart her “pains” were. She truthfully admitted she was not having any pain, so an IV with Pitocin was started. Twenty minutes after its start, she was suddenly consumed with intractable pain, one contraction after another, only seconds in between. She tried to stay calm and focused on slow, deep breathing, but the pain overwhelmed her. She got scared. Something must be wrong. It shouldn’t hurt this much to have a baby. What’s wrong? Somebody help! They did; they gave her a shot of Demerol. After that things kept getting worse. The Demerol just made her foggy, she couldn’t concentrate on her breathing, and then she really panicked. After three hours of what she calls “labor from hell,” she was pushing. She was put on her back, with legs up in stirrups, arms tethered by IV on one side and BP cuff on the other. The doc was there, telling her that she was pushing wrong, and she got more confused. Instead of trying to follow her natural instinctive expulsive urges, she was trying to follow the doctor’s direction. Then he did an episiotomy, even after she said she didn’t want one. He picked up forceps; she pushed with all her might; baby’s head popped out; doc put down the forceps and caught the baby. The cord was cut immediately and baby was whisked away to the nursery, sight unseen. Then the doc started pulling on the cord until the placenta came out. As she watched his efforts, he was shaking with the strain of his pull. Louise thought, “Any minute now, he’s going to put his foot up on my bottom for leverage!” Luckily, that didn’t happen. After she was stitched up (she had a 4th-degree tear from the episiotomy, so she needed many sutures), everybody in the delivery room congratulated her on her “natural” birth. She could not understand why they called that natural! She did not get to see or nurse her baby until the next morning. After that experience, she vowed never to birth in a hospital again.

She began to educate herself on pregnancy and birth, so she would not have to succumb to such pain and indignity again. She learned that she actually had been having contractions every five minutes on the drive to the hospital—just not painful ones—so didn’t really need the Pitocin. Contractions that occur naturally are much more manageable than those induced by the pharmaceutical. She learned that the episiotomy had made it more likely that she would tear. She resented being tied in an unnatural, uncomfortable position and being told how and when to push, to boot. She learned that the position of choice is the best position to be in—whatever position intuition tells you to take. She learned that it is best to put baby skin to skin on mom, before the cord is cut, letting baby get all his blood and allowing her and baby to bond well. She learned hemorrhage can be caused by pulling on the placenta. She learned that a bottle should not be introduced before nursing is well-established, let alone before she was even holding the baby.

Before her next pregnancy, Louise had done her homework. She knew what she wanted and why. This time, she knew when her abdomen got tight it was a contraction, which she said was like “being hugged from the inside out”—nothing like pain at all. At 39 weeks her water broke. Right away contractions started coming every few minutes. She tried to make some phone calls—her husband, friends who were going to help her—however she couldn’t do anything but focus on her breathing. She lay down to help stay relaxed. The contractions were all-consuming, intense, but in a good, not a painful, way. She was thrilled to be in labor, in her own house, not worrying about getting to the hospital or who would take care of her boy. She was able to relax, staying on top of each contraction. After just 60 minutes of this, she felt the urge to push. She couldn’t believe it was that close already; it wasn’t even painful yet, so she kept breathing through contractions. Ten minutes later, a girl slipped out between her legs. She described it as intense and a trifle hectic, but not painful. She just had to stay calm and concentrate on her breathing. Looking back, she said that while her first labor was only three hours, she had expected this one to be longer because she didn’t have any Pitocin to speed it up. I think the fact that she had no fears to hold her back helped make it even faster. Having a good diet and lots of outdoor exercise also helped. Having a wide pelvis was a plus, as well.

Thinking of being fat or skinny reminds me of a hard-learned lesson. Shawna was not obese, but pleasantly plump. Prenatally, she said she knew that calcium was important for the bones of her growing baby, but she hated milk (that’s a whole other book!), so she had a big bowl of ice cream every evening to get enough calcium. In labor with her first child, a few days past her due date, she labored well, staying relaxed. She was scared of the thought of a homebirth, but was naïvely hoping for a natural hospital birth. We went to the hospital when she was around 5 cm. The doc declared that she needed a c-section, because by 6 cm the baby’s head was still not engaged. He said it should have been engaged by this stage of labor; the only reason it wasn’t was because baby was too big to fit any farther down in the pelvis. Into surgery she went. The baby was big: 10 lb 3 oz, if I remember right.

The next pregnancy, she planned a VBAC in the same hospital, with the same doctor—which he initially agreed to do. Toward the end of the pregnancy, he changed his tune. He told her she would “rip from stem to stern” if she birthed vaginally. She called me in tears. I reminded her that even if she tore birthing vaginally, the tissue was made to stretch. A tear, at worst, would be a few inches, on average just an inch or less, and at best the perineum would remain intact—as opposed to a 100% chance of a long “stem-to-stern” incision in the abdomen. She felt better until her next appointment. The doctor tried one scare tactic after another. After every visit she would call me in tears. Each time I told her “the rest of the story.”

They called when labor started and I went right away. This time I was to be their monitrice. During my journey, they called, “She’s pushing; meet us at the hospital instead of home. I changed my course and made it 20 minutes after the birth. True to his word, the doc had let her tear “from stem to stern.” If only I’d been there to help her slow the crowning and support the perineum! She still preferred that to the surgical recovery. That baby weighed 2 oz more than the first. And she did it naturally!

By Shawna’s next baby they again tried to talk her into a repeat cesarean, which she calmly refused. This time, I made it in time to help support her perineum and guide her to ignore people shouting, “Take a deep breath, hold it, push, push, push!” She just breathed the baby out slowly, not holding her breath, but pushing on each exhale during the contractions. This worked well. She birthed a big baby without tearing or rupturing.

By the next pregnancy, the hospital had stopped doing VBACs, so she decided a homebirth sounded better than a cesarean. This time I finally got to serve as her midwife. Over the years I had known her, she had slipped over from the pleasantly plump to the slightly obese category. We worked on her diet. I encouraged her to find a less caloric source of calcium than ice cream. During labor I noticed that baby was not yet engaged, remembering how the doc had said if it wasn’t engaged by then it wouldn’t fit, but she had gone on to deliver bigger babies vaginally. As usual, she handled labor well, staying loose and relaxed throughout. Baby and mom were doing great, so I didn’t say anything about the baby still being so high up.

Another midwife (Shari Daniels) had explained that if a skinny mom’s baby was still not engaged by labor, it might really be too big to fit through the lower pelvis, but if the mom was obese, chances are that she had deposits of adipose tissue inside her pelvis as well as outside. Baby could be quite comfy, resting his head on that nice swishy pillow of fat but eventually the force of contractions would get him down. It is so much easier to squeeze through fat than bone!

True to that, baby was still high when second stage began, but all of a sudden, baby came down and out rapidly! If I had realized this the first time, I might have saved her from the cesarean. That baby weighed 10 lb 5 oz. In retrospect, better attention to her diet from the beginning, avoiding so much adipose tissue, might have allowed the babies to descend into her pelvis better, so the doctor wouldn’t have jumped to surgery so fast. Learning how to breathe baby down gently instead of listening to the chorus urging forceful pushing probably would have prevented the tear. Her attitude and relaxation were excellent every time.

While many lessons can be learned here on how to minimize or avoid complications, some are truly unavoidable. We should do our best to enter labor with a willing body and open heart, knowing we have done our best. Fifteen percent of births really do need medical help of some kind. The other 85% will come out just fine if we live a healthy lifestyle, and relax, being confident to let nature take its course, while being vigilant for signs that help of some kind may be indeed needed.

About Author: Marlene Waechter

Marlene Waechter, CPM , is a pioneer Catholic midwife who has served in southern Ohio since the 1970s. She is the mother of seven grown children, including five home-born—one of whom was born in water. She is also grandmother to 16 grandchildren, including four VBACs. Besides being a long-time contributor to Midwifery Today, Marlene co-authored the book The Joyful Mysteries of Childbirth, a practical and spiritual guide for Christian families.

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