Dec 20, 2008: Our Mom started having pains on the night of the 18th. Pains were crampy, coming off and on with no particular rhythm. Since there was not much progress in either the duration or the intensity, we decided to wait and watch, since it could be false pains. By the next morning, the contractions had all but disappeared. However, on the night of December 19th, mom again started with cramps, but this time they were regular – 30 seconds duration about 10-15 minutes apart. As per our birth plan, mom labored at home with dad’s support. By about 4 pm, the contractions were 5 minutes apart, and they headed over to the hospital. An internal exam showed about 3 finger-widths dilation and 70% effacement. Mom continued to walk the hallways, and used many of the exercises and positions that she learnt in the Healthy Mother Lamaze classes (www.healthy-mother.com), to help her labor progress. She had a light meal at around 7 pm, and progressed into more active labor by about 8:30 pm. Still out of bed, she was managing her transition pains in the chair-straddling position, and whenever she started to panic, dad would make himself her point of focus, and breathe with her.

Finally, at just past midnight, on Dec 21st, a healthy baby boy weighing 2.8 kgs was born with mom having to push for just about 3-4 times. Mom and baby were together immediately, and she was able to nurse her baby within half an hour of giving birth. Recovery was remarkably easy, and the family was able to go home 48 hours after their baby’s birth.

Lessons learnt: Labor can be simple, when it is allowed to be. Here mom and dad were well-prepared for what to expect. They labored at home until labor was in a more active stage, and this helped labor to progress comfortably, minus any interventions. Labor in the hospital also happened in the quietness of their room, and the hospital provided support only for intermittent monitoring and for the final delivery. In writing the experiences of these 7 very different labors and deliveries, I hope to have given my expectant moms and dads a better understanding of how labor progresses if it is allowed to, and how moms feel good about their birth experiences if they are well-informed and a part of the decision-making every step of the way.

I invite moms and dads who are reading this to let me know of their birth experiences with their babies. It is my belief that sharing such experiences will benefit countless of women and their families to go through pregnancy in a more informed manner and trust their own bodies to give birth in a more confident manner, all of which helps in facilitating a natural birth outcome.

Dr. Vijaya Krishnan, DPT, PT, MS, LCCE

December 19th, 2008: I had known this mom since her 4th month of pregnancy. She had joined one of our antenatal programs early, since she knew she would be traveling to her hometown of Assam, in northeastern India within the next couple of months and would remain there for her delivery. However, the very next week she was discovered to have placenta previa and was put on complete bed-rest. After a month and a half , she was allowed to be up and about, as her placenta started to pull itself up. Mom and dad finished the rest of their sessions and headed for Assam. After the 7th month, mom started practicing her birth fitness exercises – by this time placenta previa was no longer an issue. She continued to remain in touch with me after every OB check up, and was waiting for labor to start on her due date of Dec 14th.

Dec 14th and went, and there were no signs of labor. On December 18th, mom was admitted to the hospital and was started with gel priming and induction protocol. Since her cervix was not ready to begin with, even after several hours of induced labor, it could finally open up to only 1-2 cm when her baby’s heart rate started to show decelerations. Finally, on December 19th a healthy baby boy weighing 3.5 kg was delivered via C-Section.

Lessons learnt: In this case, mom’s delivery was done by a family member who is an OB. Mom felt that she did not have much say in the process. In my opinion, waiting for labor to start on its own would have been the ideal plan of care, especially considering that mom and baby were both doing fine. Since natural hormones had not yet started to cause the cervix to ripen and be ready for birth, induction failed, leading to a C-Section that could have potentially been avoided.


December, 18th 2008: Just around the time that our mom in Bangalore was starting to be induced, one more of our mothers went into labor here in Hyderabad. Mom and dad had attended our Healthy Mother antenatal sessions to re-prepare themselves for this birth: they already have a 7 year old boy. Since her first delivery was normal, she wanted to ensure that she was able to birth naturally again. Mom was also concerned about starting her pregnancy being slightly overweight, and she wanted to ensure that she did not gain too much weight during the pregnancy. We worked on her nutrition needs, and she diligently followed her exercise programs and walking on a daily basis. She remained very active till the time her labor started.

All through labor, mom remained out of bed, and as active as possible, moving and changing positions, drinking plenty of fluids and practicing her pelvic tilts in various positions. Pains were very manageable with breathing until about 7 pm, and by 10 pm her bag of waters broke. She started to progress into active labor immediately after, and preferred to lie down on her side for a little while. Again, dad was a good source of support and encouragement in managing this intense phase. At one point, she was not very comfortable with trying any other position, so I suggested that we try labor with the head of the bed up in a semi-sitting position. This seemed to help her quite a bit, and she labored through her transition in this position. Finally, at around 4:30 am the next morning, mom felt the urge to push. After pushing in C-position for around 30 minutes, a healthy baby girl weighing 3.5 kgs was born at 5 am on December 19th.

Lessons learnt: Mom and dad were very involved in the whole process of making this pregnancy and childbirth as healthy as possible. Even though they had a previous birth experience, they did not leave anything to chance for this delivery as well, and prepared themselves well for it. Congrats to mom, dad and big brother!


Dec 18th, 2008:: This particular mom had attended my Prenatal Lamaze program in Hyderabad, but went to Bangalore for her delivery – Bangalore being where her mother lives. At the start of the antenatal program, she expressed to me that she was so afraid of labor pains, that she had instructed her sister (who is a doctor) to help her go ahead with an elective C-Section. By the end of the program, this same mom had become a staunch believer in the power of natural birth, but most importantly, in her own ability to handle pains and birth naturally. We worked on a customized birth plan to suit her particular needs, and when she went to Bangalore, she met with her OB and hospital staff several times, to ensure that everybody in the team respected and appreciated her desire to give birth as naturally as possible.

We kept in touch over the next several weeks, and as the due date neared, there was still no sign of labor. Dec 15th was her due date, and it came and went without any signs of labor. However, at the previous OB visit, she was found to be 4 cms dilated, so as per her plan, it was decided that everyone would wait and monitor over the next week for labor to begin on its own. Mom followed her exercise program eagerly, as well as tried some of the pressure points that she had learnt in our classes, to try and help labor to begin. Meanwhile, her husband had to go out of the country on a business trip on the 19th, so mom decided to go in for an induction on Jan 18th, so dad could be present for their baby’s birth. She was induced with oral prostaglandins at about 10 am in the morning, with a repeat dose being given at around 3 pm. Labor started soon afterwards, and by 7 pm, she was in intensely active labor. At some point during this phase, she asked for an epidural, but her husband, sister, OB and her support staff, all reminded of her birth plan, and amply supported her during this phase. Finally, she went onto the pushing phase at around 9 pm, and pushed with her urge and lots of support for around one and one-half hours. Even though her OB knew from her previous visit and scan that the baby’s birth weight would be high, all involved were committed to the cause of natural childbirth, and finally at 10:45 pm, mom gave birth to a healthy 4.2 kgs baby girl without any episiotomy. There were perineal tears that mom sustained during pushing, but in the end mom was able to give birth the way she wanted. Way to go mom!

Lessons learnt: This mother was in charge of her birthing experience, and that is always good. Her OB and labor support were very good and encouraged her every step of the way. Yes, the labor was induced – and yes, it would have been ideal to wait for labor to start on its own; however, given her personal circumstances and the fact that she was already past her due date made her decide to go in for induction. However, her induction probably had better chances of working, since she was already effaced and dilated to 4 cm. If this had not been the case, then the induction might have failed, and potential for a C-Section could have arisen if labor failed to progress adequately. In the end, mom’s knowledge of what to expect, her due diligence in choosing a good OB and hospital, and her preparation for labor through the antenatal sessions, as well as excellent labor support helped her to make her daughter’s birth experience exceptional for her.

Dec 17th, 2008: One more of my moms went into labor! This mom was extremely active, well-informed and conscientious about her exercise program. Her due date was on the 14th of December, but as mom and baby were healthy we decided to wait for labor to start on its own. In the meantime, mom practiced her exercises twice a day, walked and climbed stairs 2-3 times a day, all in an effort to get labor to start on its own! She also tried some pressure points and nipple stimulation in an effort to get labor started.

Finally, on Dec 17th she had her scheduled appointment with the OB. CTG was equivocal, so she was asked to get admitted for observation, since she was already past he due date. Mom and dad called me, and since I was already at the hospital in labor support with another mom, I told them to come in, and that we could talk after they had been in observation for a couple of hours. As luck would have it, by the time mom came in to the hospital, labor had started by itself! I met mom and dad, soon after their admission, and found mom breathing through mild contractions. I told her to continue walking, changing positions frequently, and that I would be back if they needed me for anything. CTG monitoring revealed that all was well with baby, and mom and dad labored through this initial phase of labor on their own in their room. Mom had a light lunch and some rest. When I checked in on her at around 2pm, I found her to be in a chair straddling position, breathing through her contractions. She was still fairly early in labor, with contractions 7-10 minutes apart, and contractions lasting for 30 -45 seconds. By this time, I had been at the hospital for almost 2 days, so I asked mom if she was okay with laboring on her own for a while, until she got into more active labor. She was fine with this, so I headed home for a bit.

At 4:30 pm, the first and only internal exam was done, and it was found that mom was 60% effaced and 2-3 cms dilated. Good News! Labor started to progress into the active phase at around 7:30 pm and mom was managing her contractions well with breathing, and still continued with change of positions frequently, and the pelvic tilts whenever she could. Dad was very supportive with keeping mom well hydrated. At 9 pm mom started going into the transition phase. She wanted to lie down on her back for a few minutes, and we let her do that, but a minute or so later, she was up again, trying to find a position for comfort. Pains were quite intense at this time, and I found that mom was starting to panic. I suggested that she try the birthing ball, and that is how we labored for the next 45 minutes or so. I turned off the lights, and with only a small night light on, mom labored through this most intense phase, rocking on the ball, breathing, occasionally moaning, and resting in between the contractions. When she withdrew into herself, I knew that she would enter the pushing stage soon. Massage seemed to help her a lot, so I continuously massaged her back (rubdown relaxation massage) while she was in transition. At around 10:45 pm, mom said she would like to use the bathroom. She was on the toilet seat for a while, and she looked very comfortable, so I asked her if she wanted to remain seated there for a while, and she said, very calmly “I feel like pushing”. Since we had not done any internal exams after the initial one, I wanted to be sure that she was well dilated before she pushed. Internal exam showed that she was 100% effaced and 10 cms dilated, and baby was at +1 station. She was indeed ready to push! By this time the body’s natural catecholamine surge had ensured that mom was alert and awake and ready to push. Just as I thought we could go back to the restroom to try mom’s comfort position for pushing, her bag of waters started to trickle. Mom said she would like to try pushing, and so we tried the C-position on the bed, and within the first two pushes, the bag of waters burst completely. Mom kept pushing with her contractions, and her natural urges. However, her perineum was extremely tight, and so we had to do an episiotomy with mom’s consent. Breast feeding was started soon after the pediatric check up and mom and baby bonded skin-to-skin for the next hour. Mom was walking within 2 hours. What an empowering birth for mom, and after the previous 2 C-sections, I felt tremendously invigorated as well. This is how birth is meant to be!

Lessons learnt: A informed mother with a strong desire for natural childbirth can and usually does make it happen. Of course, the labor support that she gets and the hospital and her OB are equally important catalysts in helping her achieve the birthing experience she desires and deserves!

Dec 16th, 2008: Our second mom had been very active till the day of her delivery. In fact, on the night before her labor started, she and her husband went for a movie where she climbed 2 flights of stairs. She was also very good about doing her birth fitness exercises she learned in the Healthy Mother classes, and about walking regularly. Her labor started around 3 am at home, after which she continued to labor at home until her contractions were 5 minutes apart. When she came into the hospital, an internal exam showed that her cervix was long and closed. A CTG showed a flat line (which not a great sign and it means that the baby’s heart rate was not showing the reactivity it should usually show to movements and contractions). Mom was put on CTG monitoring every hour. Thankfully, the next CTG was slightly better, so mom decided to labor further. At 1:30 pm, with contractions coming on strongly, it was recommended that mom try Prostaglandin gel to ripen her cervix, since there was no sign of her cervix thinning or opening.

An hour later her contractions started to intensify – now they were 2 minutes apart and 1 to1½ minutes long. Mom was extremely nauseous and did not want to eat. However, she continued to sip water and drink tender coconut water. After a while she started to vomit, at which point she was given I/V hydration. Once this was done, I worked with mom to help her through this very intense and prolonged active phase of labor. She walked, rocked, went on all-fours, kneeled, did side-lunges, climbed stairs and rested. She managed the contractions with some great Rhythms and Patterned Breathing. But all the while she continued to remain nauseous, and we kept her hydrated with ice-chips. We monitored her with CTGs every 1-2 hours and while some of the results were reactive others were not so good. At 10:30 pm an internal exam revealed that her cervix was 50% effaced and one finger dilated. By now, mom had been in intense, active labor for 8 hours. Since she was getting tired, I advised her to rest and labor alternately for some time in between contractions, while her husband and I alternately gave her rubdown relaxation massages.

By now, it was Dec 17th, and we were still hopeful that some progress would have been made. At 4:30 am, the CTG was flat, and mom was feeling less baby movements. So we decided to move her to the labor observation room, and monitor her more continuously. At 6 am, an internal exam showed that her cervix had still not shown any further progress and was at the same 50% effaced state and 1 finger dilated – this was not what we had hoped for. Further, an abdominal examination showed that the baby’s head was still 4/5ths out of the brim. Amniotomy was not a feasible option because her cervix was only 1 finger dilated. Mom had been in active labor for 16 hours, and was tiring fast, but an epidural was not an option for pain relief, again because of the minimal cervical dilation. Mom was offered Entanox to manage her contractions, which helped her to some extent. Fetal heart rate monitoring every half an hour showed that baby was holding up reasonably, with occasional decelerations of heart rate. At 10:30 am, 27 hours after her labor began, mom was given the choice of laboring on further until baby was doing well, with no more internal exams or to have a C-Section.

However, by 1:00 pm, she decided that she did not want to labor any further. Even with all the comfort measures, continuous labor support and encouragement that we provided, at the end, she was physically too exhausted to continue further. A final cervical exam showed no further progress, and she decided to opt for a C-Section. A healthy baby boy, weighing 3.3 kgs was born via C-Section, 35 hours from start of labor! Slight meconium was found during delivery, which probably explains the variations in heart rate that were found during intra-partum electronic fetal monitoring. After birth, the baby was found to have slight tachycardia and was put on oxygen for half an hour, after which his heart rate stabilized. We had mom and baby nursing within an hour and quarter after birth, and the rest of the recovery progressed well

Lesson learnt: Sometimes, even with a good trial of everything, labor’s progress shows variations. There are situations where even though we might have started out with the intention of supporting mom for a natural childbirth outcome, if she is so tired that she is unable to carry on, her wishes have to be respected. Finally, in retrospect, with the findings of meconium at birth and slight tachycardia in baby it was probably the right time to go in for a C-Section, added to the fact that labor was not making any progress. Not that we knew this in advance, but waiting it out further, may have led to further complications for baby at birth.

I return to this blog, invigorated from having taken part in a number of incredible events, each marking a significant moment in the lives of seven members of our Healthy Mother family. Seven “Healthy Babies” joined our Healthy Mother family between the 9th and 21st of Dec. Five of our mothers gave birth in Hyderabad, one in Bangalore and one in the northeastern state of Assam.

I usually do not write about every labor and delivery, but in this group of mothers we had such a complete gamut of birth stories, that I felt, by revisiting these experiences and putting them down on paper, we would be able to learn about the myriad of outcomes and accompany childbirth. These experiences also highlight to me the full range of variability in the progress of labor, and the occasional necessity of Caesarean Sections when it becomes medically necessary for either the safety of mother or her baby.

9th Dec, 2008: Our first mother was attempting a VBAC (Vaginal birth after C- Section). On the day of her delivery, she came in to the hospital with her bag of waters leaking. She had been having small leaks on and off for the past three weeks, and was being monitored periodically for both fluid levels and CTG (cardiotocography – this test measures the baby’s heart rate and indicates how reactive the rate is to both the baby’s own movements and to mother’s uterine contractions). Since baby seemed to be doing well, and since baby’s movements were good, we adopted a wait and watch strategy. However, on the day of admission, mom’s bag of waters burst around 3 pm. After this there was some continuous trickling, and mild cramps, which indicated the start of labor. I told mom to get to the hospital, and told her that I would meet her there. However, mom was reasonably confident that she wanted to monitor the progress of labor at home, and by the time she and her husband reached the hospital, it was around 8 pm. By this time mom’s contractions were about 7-10 minutes apart, lasting for about 30-40 seconds and very manageable with breathing. Mom was in the early stages of labor. However, she was still continuously leaking fluid. On internal examination, it was found that her cervix was posterior, long and completely closed. We felt that it would be prudent to assess her amniotic fluid levels since she had been leaking fluid on and off for several weeks, and it was found that the level was low, with one pocket measuring 5. CTG was still showing reasonable reactivity, and therefore mom decided to labor for a while longer. We tried everything – walking, pelvic tilts, side lunges, wall squats, butterfly, etc. We rested in between and tried again. By about 11 pm, there was no progress in the intensity or duration of contractions, and CTG results were also not definite. Although we normally avoid frequent internal exams, we decided to conduct one in this case to check if there was any progress. Cervix was still long, posterior and completely closed.

We now had to make a choice. Mom had history of a previous still birth and C-Section. In that pregnancy, she had been leaking fluid on and off from her 6th month. It was shown that her baby had IUGR (Intra-uterine growth retardation) and had suddenly stopped moving at around the 36th week. With this history, and the current low levels of fluid, CTG results, and the condition of the cervix, we felt that the risk to the baby would be greater if we continued with laboring. Due to her previous C-section, she was also not a good candidate for any other intervention. We discussed all the possibilities with mom and dad every step of the way, while mom continued to labor until 1 am. By this time it had been about 10 hours since her bag of waters broke, and the CTGs were not showing good responsiveness either – the only reasonable option was to go in for a C- section. Mom and dad also agreed that this was the safest option. Dad, who had been very supportive all through labor, was present during the surgery, to support mom and see the birth of his baby girl, who weighed in at 3.3 kg. He was with his daughter all the time while mom was in surgery. Within the first hour, we had mom and baby in skin-to-skin contact, and nursing commenced without any difficulty. Mom was up and about the next day and both she and baby were doing great when I visited them for a post-natal checkup the next day.

Lessons learnt: Not all births end up being normal, despite the fact that we do everything possible to facilitate normal childbirth. Every mother’s labor is unique and how we deal with mothers’ labor tends to be different in each case. In this instance, mother and dad were diligent about following the advice given to them in their childbirth classes, however, in the interest of her baby’s well being we all made an informed choice of going in for a c-section. While C-section was a required medical intervention, the 10-hour period of labor was good for mom and baby.

In my next blog I will write about yet another birth that I had the opportunity to assist – a completely different experience..

I invite you to share your experience as well

Dr. Vijaya Krishnan, DPT, PT, LCCE