Although our babies' births were naturally painless, they were at times strenuous or prolonged for one preventable reason or another.  Here are the main lessons I've learned... the hard way:

1.  No one birth book or childbirth course has all the answers.  Always keep on learning, even if you are a birth veteran.

2.  Each one of us moms has the birthing instinct deep inside her, but some of us are able to access that instinct more readily than others.  That is because, to a greater or lesser degree, all of us have been exposed to, even "brainwashed" by, cultural notions such as "drug-free birth always hurts", "birth is the hardest work you will ever do" (not always true - women have been known to have totally effortless births), "birth is supposed to take place in bed" and so on.  It may take not only extensive pre-birth study, but also one or more births, for many of us "civilized" women to fully attain our birthing potential.  My fervent hope is that the information and links shared on these pages will help moms along the path toward full, instinct-led empowerment in birth.

3.  Castor oil doesn't always work to start labor.  And whether or not labor is successfully "induced", the castor oil will often cause unpleasant side effects such as vomiting or diarrhea, either of which is an unwelcome distraction during early labor.  That's my opinion based on experience, and I've known other moms who feel that way, too.  Still, many midwives feel that castor oil is a safe and therefore desirable way to try to induce labor.

4.  I used to believe that it was best to not ever lie down during labor, that it was preferable to be active and keep upright throughout.  But after giving birth to our fourth baby, I've learned that it's best to simply follow your instinct and comfort level when it comes to proper positioning.  Each labor is different, and what works with one labor and birth may not work for another one.  Sometimes lying down (on your left side to optimize blood flow to uterus and baby) really is the right thing to do.  It depends on how the labor is progressing, and on what is happening inside you during labor.

An example is what I experienced while in labor with our fourth baby.  I felt instinct-led to lie on my side during prodromal labor, when the contractions were strong but still irregular and very far apart.  This simply felt right to me;  I was much more comfortable that way, and baby was fine, kicking, moving and resting as usual.  Once active labor began, with ever stronger and closer-together contractions, I preferred to be upright.  But at the end of first stage, when I began to get the pushing reflex and tried to push along with my uterus, something deep within me warned, "NOT RIGHT!"  I was still upright because I had already made up my mind, prior to labor, that I would be giving birth upright, in a kneeling squat, half-squat, or one of the other squat variations.  But I ended up giving birth while lying on my left side (to find out why, see our son Jonathan's birth story).  My body/instinct warned me, and my midwife confirmed that warning, so that it was a good thing I did change positions before proceeding with pushing. 

So our fourth baby's birth taught me that it is best not to make up your mind ahead of time as to what position(s) to assume during labor and birth.  It is better to follow your instinct and go with the flow as your birth unfolds. 

5.  Even if you're not sure you're in labor yet, be sure to keep hydrated and maintain your energy level with plenty of clear fluids and light, nourishing foods.  As labor gets more intense, you may find it best to suck on ice chips made from plain water or from a sports drink (electrolyte replacer), and in that way take your fluids in small, manageable "doses".

6.  Again, listen to your body, don't fall prey to thoughts or suggestions that your body is "dysfunctional" if, for example, labor slows down or gets really uncomfortable.  Your body is probably telling you to change positions, to get up, to try something different.  Or, for example, when my water broke with baby #2 and labor wouldn't start on its own even after 24 hours, it wasn't that my uterus was "lazy", it was that baby was still a bit early!  Another example is the oft-declared "diagnosis" of "your pelvis is just too small for you to deliver vaginally - we'll have to do a cesearean".  In reality, true cephalo-pelvic disproportion is rare, and many apparent cases of this would simply disappear if mothers were permitted to get up out of bed and push out their babies in a standing or squatting position, or even on all fours or while side-lying.  Realizing such truths helps you to see that your body really is quite capable, and that certain medical "helps" and "routines" such as keeping you in bed the whole time are counterproductive to easier, more comfortable, natural labor.

7.  If your uterus takes a break, take advantage of it and rest.  You might even need to go to sleep for awhile.  Provided you and baby are well and showing good vital signs, this "labor plateau" can be perfectly acceptable, a variation of normal, and a useful resting phase until labor resumes.  The Bradley Method® childbirth course explains this labor variation in more detail.

8.  Deep, total-body relaxation can be very helpful during active labor and transition.   You can learn more about this in the book Natural Childbirth the Bradley Way.  Laboring in a birthing pool or in the shower can help a lot, too (I haven't done either, but I've read that water is a wonderful aid in labor).

9.  If you have back labor, you don't have to take it lying down, as I did during our first two babies' births.  You can get relief from all that lower back pressure by following the technique discussed in the book Back Labor No More!!  This is a safe and proven self-help technique, but you should not perform it without letting your OB or midwife know first -- because it can really speed things up!  Take it from me, you can go from hard back labor to pushing within just a few contractions.  I don't think I would call this technique "instinctive" or altogether "natural", but especially if you've gone through back labor before and are determined not to go through it again, this book is well worth seeking out.

According to Back Labor No More!!, there are four main causes of back labor, including prior back injury, short rise (mom is short-waisted) or sway-back;  or baby in posterior position (the back of baby's head is resting against mom's spine instead of against mom's tummy).  It's certainly possible to give birth vaginally to a posterior baby, but it's generally not the easiest way to do it.  Posterior presentation can make birth unnecessarily painful and prolonged, and in the worst-case scenario, can require caesarean section.  So in most cases, it's preferable to try to get baby to turn before s/he descends through mom's pelvis.  Better yet is to turn baby before labor even starts.  The page Optimum Foetal Positioning has many useful tips and links for doing just that, as well as for turning baby once labor has begun.

10.  Stay off your back and bottom during pushing.  This gives baby his full natural allotment of room to pass through your pelvic opening, which was not designed to be constricted during baby's descent!  Yet that is exactly what happens when a mother is made to labor and birth on her back and/or while reclining:  the pelvic outlet is up to 30% smaller than it would be if mother were free to assume a more comfortable, instinctual pushing position such as squatting or standing (see Balaskas).  The reclining mother's weight is on her tailbone, which is then forced into the pelvic space through which baby needs to pass.  Further, gravity is not enlisted to help baby descend, as it would be if mother were upright and off her bottom.  Besides the squat variations, all fours is another good position for descent and pushing, as it too takes advantage of gravity and gives baby more room.  Even side-lying permits mom's tailbone to pivot out of the way as baby travels through mom's pelvis.  The typical supine labor and birth position, on the other hand, in addition to making vaginal birth impossible in some cases (see (6) above), can also lead to excessive skull compression and even "facial slant" in the newborn;  see the articles "Just Fetal Headaches" and "Birthing Choices".

11.  Push only per the guidance of instinct and your body's signals.  Strenuous pushing is hard on mom and on baby too.  Physiologic positioning, such as an upright squat or one of its variations, will most likely make strenuous pushing unnecessary anyway, because then gravity is helping you.

12.  Avoid using a birth stool.  Birth stools can be hard on mom's perineum, stretching it before it needs to, causing swelling and leading to tearing or episiotomy.  The use of birth stools can also lead to awful hemorrhoids during and after birth.

13.  Be considerate of your perineum during pushing, to help protect it from "needing" an episiotomy.  I've had three episiotomies, which I now know were caused by improper positioning as well as lack of perineal preparation.  The fourth time, I finally got it right, and we had a lovely, episiotomy-free birth. 

Based on what I have learned, read, and experienced first-hand, poor positioning during pushing is THE main reason that women "need" episiotomies.  It is very important to use pushing position(s) that protect the perineum, such as the squat or its variations, or all fours or side-lying.  These positions allow the perineum to stretch gradually with baby's emerging head.  With them, there is no additional strain on the area as occurs with mother in lithotomy position or on a birth stool.

Now there are exceptions to every "rule", and I am aware that some women can and do deliver babies over an intact perineum while reclining, in the lithotomy position or on a birth stool.  These women may have naturally very resilient tissues, and/or may have prepared for birth with perineal massage or other measures.  But it cannot be denied that in many cases, assuming one of these unnatural positions practically guarantees that episiotomy will be "necessary" in order to get baby out.  These positions pre-stretch the perineum before baby's head arrives so that the peri generally hasn't got enough "stretch" left to finish the job.  In that scenario, unless mother changes her pushing position to side-lying, all fours or squat, she is likely to either tear or be cut.

I mentioned perineal preparation.  In my particular case I have no doubt that preparing the perineum was the main thing that helped me to stretch enough to birth our fourth baby episiotomy-free.  That is because we'd tried all the right pushing positions with baby #3, and still my peri refused to stretch more than halfway.  For baby #4, my preparation included, during late pregnancy, perineal massage and daily supplementation with zinc and vitamins C and E in addition to my prenatal vitamins (check with your birth attendant to ascertain safe amounts). 

Another helpful measure, which we used during pushing, was hot, moist compresses (clean hot washcloths) on the perineum.  Laboring in water and perineal support with hands during crowning can also be very helpful.

Here I would like to editorialize a bit (as if I haven't been already!) ;-)   I am one of those few women who have naturally very UN-stretchy bottoms.  But I didn't know this with my first three babies, and I believed what some midwives and women have written, which is that to do prenatal perineal massage or any of these other measures is to behave as if the mother's bottom can't stretch without unnatural "help".  It is, in other words, to show a lack of faith and trust in the perineum's ability to perform perfectly when it needs to.  Granted, in many a case, all a mother has to do is assume a physiologic pushing position to give birth without tearing or needing an episiotomy.  But some of us women really do benefit from prenatal perineal massage and support measures during pushing.  If I had heeded the advice of the midwife who attended our third baby's birth (she assisted baby #4's birth too), we would have done the prenatal perineal massage, and I might well have not needed that third episiotomy.  (To read more about possible causes of the stretch-resistant perineum, see my Kegels page.)

How do you know if you have a peri that might need the extra help of prenatal perineal massage and/or some of the other helpful measures?  If sex is usually painful for you (pain and tightness at penetration and during intercourse), that's a clue.  Another one is if your doctor or midwife discovers that you are unusually firm and toned "down there" during an exam.  Yet another clue is if you have a lot of hard, tough scar tissue from previous episiotomy(ies).  If any of these applies, I encourage you to look into this issue further as well as check with your birth attendant, to learn if prenatal perineal massage might be indicated in your case.

~~~

Note that I am warning against episiotomy, not tearing.  Most natural tears are not nearly so drastic a thing as an episiotomy can be, and with proper care, a tear generally heals better and faster than an episiotomy does.  I urge you to do all you can to avoid episiotomy;  far from being a "harmless little cut", this surgical procedure can and often does lead to painful scarring, sexual dysfunction, and other long-term problems.  And recovering from episiotomy can add an uncomfortable and unpleasant, even painful, note to the otherwise lovely newborn time.
 

References

Books:

Active Birth, Balaskas
Birth as an American Rite of Passage, Davis-Floyd
Ina May's Guide to Childbirth, Gaskin
Back Labor No More!!, McCoy King
Natural Childbirth the Bradley Way, McCutcheon (I have the older edition; this link is to the revised edition)
The Birth Book, Sears and Sears

FYI:

Castor Oil Induction
Medical Risks of Epidural Anesthesia During Childbirth, Mehl-Madrona, Lewis, M.D., Ph.D.
"Just Fetal Headaches"
Perineal Protection
The Bradley Method® Home Page
Optimal Foetal Positioning
The Benefits of Perineal Massage
Taking Care of the Perineum
Episiotomy: Ritual Genital Mutilation in Western Obstetrics

Articles from Mothering magazine:

Ashford, Janet Isaacs.  "Sitting, Standing, and Squatting in Childbirth" (Winter 1996).
Kitzinger, Sheila.  "Empowering Through Birth" (Winter 1996).
Tatje-Broussard, Nancy.  "Second Stage Labor: You Don't Have to Push" (Fall 1990).

Articles from Midwifery Today:

Dobson, Justine.  "Birthing Choices" (Spring 1995).
Frye, Anne.  "Nourishing the mother" (Autumn 1994).
Odent, Michel.  "Laboring Women are not Marathon Runners" (Autumn 1994).

Articles by Laura Kaplan Shanley:

Pleasurable Childbirth
Don't Push the River, It Flows by Itself
Childbirth Books that Empower Women