THE NINTH MONTH

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You will spend most of your ninth month "in labor." Of course, this extended labor will not be as powerful as the labor you will experience on the day or so leading up to delivery. It's more obstetrically correct to talk of "labor month" rather than "labor day." Throughout the weeks prior to delivery, your mind and body will get ready for one of the most memorable events in your life – the birth of your baby.

Take all the emotions you've felt over the past eight months, intensify them, and you've got an idea of what you can expect emotionally during month nine. You may be tired of being big, tired of being tired, and very ready to get the pregnancy over with. Your preoccupation with the upcoming birth and change in your lifestyle can mean more emotional ups and downs, but the inevitability of what's ahead may make it easier for you to cope. Most women report they feel:

Many women do not want a pregnancy to end. Ambivalence over no longer being pregnant can lead to anxiety about making the transition from pregnancy to parenthood, especially if you are a person who doesn't handle transitions well. Realize that grieving the loss of your pregnancy is a very real need. Give yourself the time and space to do it now – you'll be too busy once baby comes.

Anticipate being more touchy this month, and bothered by well-meaning but insensitive comments. You may feel more irritable toward your spouse, impatient with your children, and provoked by little things that normally wouldn't faze you. It's normal to be irritated and overwhelmed by all this advice and to wish people would just leave you alone and let you have (and rear) your baby your way. You may find yourself becoming very protective of your peace. This is nature's way of protecting you from outside influences that may distract you from the higher-priority event that is soon to come, conserving your energy for what's ahead. If a bit of advice is headed your way, go ahead and temporarily zone out. Even better, stay away from people who make you nervous.

You sometimes lie awake at night going over everything in your head. In your desire to be super-prepared, you make lists so you don't have to worry about forgetting anything, but then you worry about what you may have forgotten to put on the list in the first place. (Keep a pad and pencil next to your bed so you can jot it down and relax back to sleep.) Remember, anything you have forgotten will probably turn out not be so important after all.

Even if you've prepared for this event for the past nine months, it's normal to have second thoughts. Obviously, there is no turning back, and billions of women before you have gone through labor, including your mother. If this is your first baby, fear of the unknown naturally leads to dread. Let your mind work through these thoughts early in the ninth month before your body is asked to do a very strenuous job. The more you trust that your body knows what to do, the more your mind will relax.

Nature often provides you with a nice burst of energy to go along with the urge to prepare your home for the important newcomer. A day of yielding to this energy spurt may provide you with a healthy diversion from the boredom of those endless last weeks. It puts you in control and gives you a sense of accomplishment. But don't overdo it. Even though this nesting instinct may be common among females of the animal kingdom, human mothers don't really need a clean and sanitized nest. Don't let yourself get carried away; you'll end up overtired. Many of these tasks can be done by someone else or gradually after D- day, with baby snuggled in a baby sling sleeping peacefully.

FEELING BIGGERYou may find the muscles in your abdomen hurt from working so hard to support your belly, or that your crotch and thigh bones ache when you walk. In the first week or two of the ninth month, enjoy your bigger silhouette in the mirror because your baby will soon be dropping lower into your pelvis, and the bulge will change. You may wonder how you are going to lug yourself around for another month.

Many mothers find themselves physically exhausted this month. You may be tired of dragging a top-and-front heavy body up and down stairs. Even getting up off the sofa can leave you out of breath. First-time moms will be getting used to a pattern they've never experienced before -- light sleep. Nursing the baby, seeing that older children are covered with blankets, comforting during nightmares, sitting up through illnesses, reassuring a wakeful one – all these things dictate light sleeping for a number of years.

Even though your baby may gain a couple pounds during this month, your weight may increase only slightly, stay the same, or actually drop by a pound or two. Weight loss in the final month is usually due to a decrease in the amount of amniotic fluid, as hormones begin shifting fluid around in your body. You produce less amniotic fluid, and the increased frequency of urination may lead to an overall drop in total body water, and therefore a decrease in your weight.

You may not be able to get comfortable – anywhere. You're not comfortable sitting, standing, or lying in one position for more than a few minutes at a time, and have great difficulty finding the right position for sleep. Short, frequent naps are a necessity this month. So are the relaxation techniques you've been practicing.

Two of the more common annoyances of earlier months, breathlessness and heartburn, often ease during the ninth month. Yet you'll need to urinate more frequently as baby's head begins to press more on your bladder. And while the upper digestive tract may feel better, the crowded lower tract may once again feel constipated and bloated.

As your baby descends into your pelvic cavity, you may find yourself prone to sharp, stabbing pains at the base of your spine or in the middle of your pelvic bone, making it uncomfortable to walk. The increased pelvic aches and pains of the ninth month are most likely due to the relaxation and stretching of your pelvic ligaments in preparation for the job to come. You can ease these discomforts by changing positions. Continue to exercise gently every day. If you cannot walk or exercise without pain, a chiropractor experienced in working on pregnant bodies can give you some gentle pelvic adjustments to get your hips back in balance. It is our personal theory that chiropractic attention in pregnancy not only helps avoid or relieve back pain, but also can affect your labor by helping your back and pelvic structures be better prepared to handle the stresses of labor and birth.

Babies move even less in the ninth month than they did in the eighth, but what these movements lack in frequency they make up in power. You may feel hard kicks in your ribs and punches in your pelvis. Sometimes it may even feel like baby is moving his hands or feet into your vagina – a very odd sensation.

During the ninth month some women feel stiff all over, the way they imagine that arthritic, elderly people feel. Baby's head pressing against the nerves and blood vessels in the pelvis may also cause cramps in the thighs. Like the pelvic aches and pains, these changes are due to the influence of pregnancy hormones on the ligaments of all of your joints. The overall loosening of your ligaments has been known to cause the knees and wrists to feel weak, too, making even light lifting tricky and walking less inviting. However, movement keeps your body tuned up and once you get started on your daily walk the aches and pain will diminish.

1. Be informed. During your childbirth classes you will learn a lot about the anatomy and physiology of labor, especially how the uterus contracts and how your baby turns and bends as he or she navigates the winding road of your pelvic passages. Be sure you understand the importance of relaxation, the labor-stalling effects of fear, and how your hormones work and what you can do to help them work better.

2. Understand medical technology. Inform yourself before labor-day about the wise use of technology and medications during labor. While technology is often life-and laborsaving, it's meant to help your labor progress, not interfere with it. A well-timed epidural, as discussed in month eight, can help an exhausted mother rest and get a second wind, accelerating labor in the long run. On the other hand, the wrong medication or the right one given at the wrong time can interfere with the progress of labor. If you need an intravenous, request a heparin-lock, which will allow you to be mobile, rather than tethered to a bedside I.V. pole. If you need electronic fetal monitoring, ask if it can be done intermittently. If for medical reasons you need continuous electronic fetal monitoring, request telemetry, which keeps you mobile.

3. Be fit. Here's when those hours of pelvic tilts and tailor squats, daily walks, swimming, or stationary cycling really pay off. Pre-toned and pre- stretched muscles are likely to work better for you.

4. Be rested. It's not only hard work that pushes a baby out; it's efficient work. Fortunately, nature provides two breaks for laboring women. The first is during early labor, when contractions are not so difficult to deal with. The second type of break is continual -- those little respites between contractions. Even when labor is at its most intense, there is time between the end of one contraction and the beginning of the next. If you are laboring at home, retreat into a quiet place, take the phone off the hook, and go to sleep, or at least get some rest. During early labor in the hospital, keep your environment restful.

5. Remember to rest between contractions, especially early in labor, when these breaks last five minutes or more. Click into the relaxation techniques you have rehearsed. Even during active labor, when breaks may last only two to three minutes, we have seen veteran mothers use their relaxation techniques so effectively that they are able to momentarily "zone out," as if they are on another planet, and even snore between pushes in the second stage. Don't spend your time between contractions worrying about what the next one will feel like. This will make the pain worse. Fear intensifies pain perception.

6. Think R, R, R. Between contractions think Rest, Relaxation, and Recumbency.

7. Be nourished. A hard-working uterus and the muscles around it need a lot of energy from food and hydration from drinks. Doctors used to discourage eating or drinking during labor in case the mother needed a general anesthesia for a cesarean delivery, relying instead on intravenous fluids to hydrate and provide energy. Since most mothers who end up with a surgical birth now elect to be awake and thus receive an epidural or spinal anesthetic, keeping an empty stomach during labor is not as important as it once was. In the unlikely event that general anesthesia is necessary for emergency delivery, the concern is that you might vomit while you are unconscious and then inhale your stomach contents into your lungs. For this reason, it is preferred that laboring women ingest small amounts of quickly digestible foods. Eating heavily is also likely to make you uncomfortable.

8. Be quiet. You don't have to be like a mother cat and retreat to the closet to have your baby, but you must design a peaceful birthing environment for yourself. Birth attendants (partner, friends, nurses) need to respect your privacy during contractions, so you can concentrate on your work, and between contractions, so you can rest. This is where your mate comes in. Give him the job of peacekeeper, pledged to banish chattering, noisy, and interfering people from your labor room, and to protect the privacy and the dignity of this event.

9. Lighten up. Create your own labor-enhancing environment: dimmed lights, relaxing music, and whatever people and things you need to manage and progress in your labor. Laughter boost endorphins—stay light!

10. Be romantic. The hormones released during lovemaking also enhance labor; endorphins create pleasurable feelings during sex and also relax mother beautifully for birth. Nipple stimulation, by the mother, by her mate, or from water splashing on nipples during a soak in the tub, releases the contraction- intensifying hormone, oxytocin. A well timed kiss, a caressing cuddle, a sensual massage can all get your birthing hormones working for you. These labor- enhancing hormones also counteract anxiety that may cause your labor to slow rather than progress.

11. Be positive. A negative birthing environment is no help to a laboring mother. Banish negative people from the delivery room. You don't want to hear someone else's war stories, comments about how they couldn't progress either, or their labor-strategy comparisons in which you are the clear loser.

12. Be comfortable. Pamper yourself with as many labor-enhancing amenities as you can think of—your favorite music, soft pillows and delicacies to nibble on. Take a shower, soak in the tub, and keep your masseur busy with the touches you need for peace and comfort. If your hospital offers them, take advantage of the new "birthing beds" that can be adjusted to support you in comfort and in your style of labor and delivery.

13. Be progressive. The top labor aid is a professional labor assistant. Several women whose births we attended brought along their own collection of 3x5 cards containing encouraging quips to relax and empower them. If you like this idea, collect memorable lines from birth books, verses from poems or scriptures, or humorous limericks. Hearing a lovely verse read by your lover may be just what you need to help you relax between contractions.

14. Be vocal. Reserve your etiquette for dinner parties; you needn't be embarrassed about the sounds you make in labor. Many women find power and comfort in letting go with a yell, a prolonged moan or gutsy grunt when the going gets tough. These sometimes-involuntary gut sounds vocalize your release of tension and are a powerful way of mustering up inner energy to get through a really tough contraction. The low-pitched, long groan (gut sounds called "sounding") are releasing and energizing. High-pitched, sharp sudden yells are body tensing and frightening. Be sure to prepare your partner for the sounds you are likely to make.

15. Be mobile. In order to take advantage of your body's natural ability to guide you to the best positions for labor and delivery, however, you may have to first go through a bit of cultural deprogramming. In fact, studies show that women who are not culturally locked into the horizontal birthing mindset tend to assume any of eight different positions during the course of their labor, and most of these are upright, semi-upright, or moving.

16. Be upright. Most women, if left to their own devices, labor in an upright or semi-upright position. When you're upright, gravity helps baby descend. When you try to labor on your back, not only does gravity pull the baby toward your back, but your uterus is now forced to push baby uphill. What's worse, the uterus can now compress major blood vessels that run along the spine, reducing blood flow to the uterus and causing the contractions to become less efficient. When you are upright, your pelvic joints, relaxed by the hormones of pregnancy, are better able to shift and accommodate the little passenger with the large head and broad shoulders. Being upright also allows a more natural stretching of the birth-canal tissues making tears less likely.

1. Squatting. You may wonder why you should squat when you could be lying comfortably on your side in bed. Squatting benefits mother and baby. It widens the pelvic openings, relieves back pain, speeds the progress of labor, relaxes perineal muscles so that they are less likely to tear, improves oxygen supply to the baby, and even facilitates delivery of the placenta. If you have practiced squatting a lot during pregnancy, it will be easier during labor. If you try squatting down right now, you can probably feel where your upper leg bones, the femora, are attached to your pelvic bones. When you squat, the leg bones actually act like levers to widen your pelvic outlet by twenty to thirty percent. Squatting gives your baby a straighter route through a wider passage, creating the easiest path for moving baby through your pelvis. (Women who have short second stages will choose not to squat.)

2. Kneeling. Kneeling is helpful to ease overwhelming contractions, relieve back pain, or turn a posterior baby. It is also a position that helps you improvise, and can lead to the kneel-squat, kneeling on all fours, or the knee-chest position.

3. Sitting. The sitting position widens the pelvis, but not as much as squatting does. The most labor-efficient position is sit-squatting on a low stool. Alternatives are to sit astride a toilet seat, chair, or a birth ball you may have practiced on. If you must stay in bed because you've had a pain medication, you can sit astride the birthing bed.

4. Standing and leaning. Since your labor is likely to progress more quickly and efficiently if you walk a lot, you may find yourself upright during an intense contraction. Try stopping and leaning against the wall or your birth partner, or resting your head against pillows on a table.

5. Side-lying. Even though moving and being upright helps your labor progress, it is not humanly possible to be upright during your whole labor. Your hard-working body will need some rest, and if you don't get it, it may stop doing its job so well. Best to be upright, in varying positions, during active labor contractions, but to rest as much as possible during early labor and between contractions. Lie on your left side. Support your body with at least five pillows: one or two under your head, one supporting your top knee, one behind your back, and another under the bulge.

During your ninth month your eagerness to deliver yourself of this bulge and hold in your arms the precious life you have been growing may make you think every twinge from your uterus is "it." It usually isn't "it," and days or weeks will have to pass before you get to touch your baby. Some mothers start their labor with a bang – suddenly, undoubtedly, powerfully – and progress fast. Others ease into labor slowly, sometimes unconvincingly, and progress gradually, yet efficiently. Some tired moms will have a labor that starts, stops, goes in spurts and pauses, and drags on for days. It's easy to be confused by all the terms: "false labor," "real labor," "prelabor"; the list goes on. While every mother's labor and delivery are as individual as her pregnancy, these are the usual stages most women go through when delivery time is approaching.

1. Dropping. Some time during the final few weeks you may notice that your baby has moved down lower in your abdomen. Most first-timers notice their babies dropping within two weeks of delivery, though some mothers "drop" as many as four weeks before D-day. Second-time mothers often find their babies do not drop lower until labor begins, because mom's pelvic muscles have already been stretched, and no warm-up is needed. Baby's head settling into the pelvis is also called "lightening" (because the lower-riding load seems smaller and lighter) or "engagement" (since baby's head engages the pelvic opening). Whether baby "drops," "lightens," or "engages," you will feel and look different. Your breasts probably no longer touch the top of your abdomen. You might be able to sense baby's head resting just beneath the middle of your pelvic bone.

2. Frequent urination. Now that baby's head lies closer to your bladder you may be going to the bathroom more often.

3. Low backache. As baby gets heavier and drops lower, count on some aches or pains in your lower back and pelvis as your uterine and pelvic ligaments are stretched even more.

4. Stronger Braxton-Hicks contractions. You may notice that your warm- up contractions go from feeling uncomfortable to being rather painful like menstrual cramps. Even though these prelabor contractions are not as strong as labor contractions, they are strong enough to be starting the work of thinning out, or effacing, your cervix from a thick-walled cone to a thin-walled cup. While these contractions will get even stronger just prior to labor, they can continue this way, on and off, for a week or two before labor starts. They become less intense when you change position or start walking.

5. Diarrhea. Birth hormones acting on your intestines may cause abdominal cramps and loose, frequent bowel movements -- nature's enema, emptying your intestines to make more room for baby's passage. Those same hormones can also make you feel nauseated.

6. Increased vaginal discharge. You may notice more egg white or pink- tinged vaginal discharge. This differs from the "bloody show."

7. Bloody show. The combination of baby's head descending into the pelvic cavity and the prelabor contractions thinning the cervix can "uncork" the mucus plug that previously sealed the cervix. The consistency of this mucus varies from stringy to thick and gooey. Some women notice the one-time passing of an obvious mucus plug; others simply notice increased blood-tinged vaginal discharge. Some of the tiny blood vessels in your cervix break as your cervix thins, so you may see anything from a pink to a brownish-red-tinged teaspoonful of bloody mucous. If your discharge shows more blood than mucus – like a menstrual period or a lot of bright-red blood -- report this to your practitioner immediately. Once you notice a bloody show, you are likely to begin labor within three days, but some mothers hang on for another week or two.

8. Bag of waters breaking. Only 1 in 10 mothers experience their bag of waters breaking prior to labor. For most mothers this doesn't happen until they are well into labor. If your water breaks before labor has started, plan on your labor starting intensely within the next few minutes or hours, or at least within the next day.

You're officially in active labor when your cervix is four centimeters dilated. Some women can stay just shy of this stage of dilatation for days or a week or two before they experience consistently regular, hard contractions. So we will arbitrarily say your labor has begun when your contractions become regular and increasingly intense, and you are likely to see your baby within a day.

We do not find the terms "true" and "false" labor helpful, nor accurate, since there is no such thing as a "false" labor contraction. As discussed, all those prelabor Braxton-Hicks contractions you've had for weeks and months have been toning the uterus, adjusting baby's position, and effacing your cervix, all preparing for the day you're going to labor a baby out. Instead, we find it helpful to divide contractions into preparing-the-passage-for-baby contractions (prelabor contractions) and delivering-baby contractions (labor contractions). Many women, especially first-timers, can't pinpoint the exact moment labor contractions begin. Labor contractions can seem like prelabor ones at first. After the fact, of course, mothers can look back and say, "Oh yes, that was when they started." Once active labor is well underway, you'll no longer doubt that this will end except with the delivery of your baby. Here's how to tell the difference.

1. Be a "gopher." Encourage your wife to rest in whatever nest she has prepared while you serve her food and drink.

2. Offer massages and back rubs and whatever physical and emotional support she requests.

3. Be brave. This is a stressful time, but you will be so thrilled when you hold your very own son or daughter. This little person and his mom will be very dependent on your steady, calm, supportive presence in the weeks and months to come.

Helping to push the baby out. Your contractions may now be less painful and are further apart, around 3-5 minutes from the beginning of one to the beginning of the next. Once transition ends, your cervix is fully dilated, and baby's head begins to descend into the birth canal. You may feel an uncontrollable urge to bear down. As you push your baby through the birth canal you may feel an alarming sensation of tearing momentarily as your vaginal tissues stretch to accommodate baby's head. The average length of the pushing stage is from one to one and a half hours in first-time moms. Your cervix, fully dilated after transition, allows baby's head to enter the birth canal. As baby's head stretches the vaginal and pelvic floor muscles, microscopic receptors in these tissues trigger the urge to bear down. They also signal your system to release more oxytocin, the hormone that stimulates uterine contractions. These two natural stimulants work together to push baby out.

Crowning – baby's head appears. After you push for a while your labia will begin to bulge – visible results of your work. Soon your birth attendant can see a puckered little scalp appearing as you bear down, then retreating when the contraction stops, to reappear with the next one. When your birth attendant announces, "Baby's starting to crown" your perineum gradually begins stretching until eventually your vaginal opening fits like a crown around baby's head. Once baby's head rounds the corner and ducks under your pelvic bone, it won't be able to slip back anymore. As your labia and perineum become more stretched, you will feel a stinging, burning sensation like a "ring of fire." This stinging feeling is your body's signal to stop pushing for a moment. In a matter of minutes the pressure of baby's head naturally numbs the nerves in the skin and the burning sensation will stop.

Once baby crowns, your birth attendant may advise you not to push, but rather to ease baby's head out slowly to avoid tearing your internal tissues or your perineum. As baby's head begins to stretch the skin of your perineum, some practitioners will decide to do an episiotomy. Be sure you have made your episiotomy wishes known ahead of time. A few more contractions and the baby slithers out into the hands of your birth attendant or onto the bed.

Your healthcare provider will suction mucous out of baby's nose and mouth if necessary, rub baby's back to stimulate a breath (you'll then hear baby's first cry!), and then drape baby over your belly tummy-to-tummy where a quick check-up for Apgar score is done. The cord will be cut (some dads want to do the honors) and your baby is ready to meet you. Sometimes baby may need some special care such as suctioning meconium, stimulating respirations, or administering oxygen, in order to make a healthy transition into life outside the womb.

Delivery of the placenta. You will feel some cramping and even a weak pushing sensation as somewhat milder contractions help deliver the placenta. If you had an episiotomy or tore, your birth attendant may have a bit of stitching to do. Your uterus continues contracting, both to expel the placenta and to clamp down on the blood vessels to stop the bleeding. If there's a problem, you may receive an injection of pitocin and ergot to help contract the uterus and stop the bleeding more quickly. A birth attendant may massage your uterus to help it contract and make sure it stays firm. Delivery of the placenta may take from five to thirty minutes.

1. Push when your body tells you. As soon as you have the overwhelming urge to push, bear down. This urge may come at the beginning of a contraction, or well into a contraction.

2. Push properly. Research validates what many mothers do instinctively: short, frequent pushes conserve your energy, preserve blood vessels in your face, deliver more blood to your uterus, enhance contractions, and deliver more oxygen to baby. After five or six seconds of bearing down to your maximum intensity, blow the air completely out of your lungs. Then inhale quickly, filling your lungs with enough new air for the next push.

3. Assume the best position for pushing. Lying on your back is the worst position for pushing; upright squatting is the best. Squatting widens your pelvis and takes advantage of gravity so baby can move down and out faster.

4. Take your time. New studies suggest that it is the intense and prolonged bearing down during the pushing stage that can deprive baby of oxygen, not the length of the second stage itself. Don't be alarmed if you hear the bleeps on the electronic fetal monitor slow down during your contractions, as long as they bounce back to normal after the contraction is over; baby's heart rate normally slows down during contractions and recovers between them.

5. Rest between pushes. When your contraction is over, ease into a position that lets you rest. Suck on some ice chips, listen to soft music, keep your room and attendants quiet, and use whatever relaxation techniques you need to drift into your own calm world.

6. Protect your perineum. The first few urges to push may take you by surprise, prompting you to tense instead of relax your pelvic floor muscles. Here's where your Kegel and relaxation exercises really pay off.

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