Decreased libido is probably one of the most common complaints I get.  The conversation usually goes something like this- I have no desire to have sex- can you please check my hormones.   For women, hormones like estrogen, progesterone, and testosterone usually fluctuate based on the time of the cycle they are checked. Their value at different times in the cycle rarely gives us any insight as to the source of low libido. 

However, what most people forget is that the most common culprit for low libido is side effects from medications used to treat common maladies like hypertension and depression.  About 44% of Americans take at least 1 prescription medication and 17% take 3 or more.  If you look at a list of side effects for commonly prescribed medications, the list is so long that something like low libido can be easily overlooked.  Let’s go over some common medications that can affect your libido.
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1. Antidepressants: SSRI’s like Prozac and Zoloft just to name a few are very well known to decrease sexual desire and diminish or delay orgasm.  58 to 70% of people taking SSRI’s experience these kinds of sexual side effects.  Why does this happen? SSRI’s work to increase the amount of serotonin circulating in the brain.  While serotonin helps you feel less depressed, too much serotonin can decrease a person’s sex drive and make it harder to achieve orgasms.  Talk to your provider if you experience this.  There are other antidepressants that have less of an impact on sex drive, and depending on your medical history, these may be an option. 
2. Birth Control Pills: Oral contraceptive pills, especially those with estrogen, can lower hormones like testosterone, and this can affect libido.  If you experience this, talk to your provider about other options like IUD’s. 
3. Marijuana: While not always used in a medical application, just because it is legal in some states does not mean that there aren’t side effects.  Marijuana can have a significantly negative impact both on libido and even the ability to have intercourse.
4. Opioids: Opioids can lower testosterone and have an adverse effect on sex drive. 
5. Hypertension medication: Blood pressure medications help lower the pressure inside blood vessels, so the heart doesn’t have to work so hard.  This reduced flow can interfere with orgasms in women and erections and ejaculation in men.   Common hypertension medications like beta blockers and diuretics can help lower blood pressure but can also have a negative impact on your libido.
6. Benzodiazepines: Xanax can help reduce anxiety, but it can also dampen your sex drive. The sedative and muscle relaxant properties are thought to lessen interest, excitement and sensation. Essentially, while making you numb to anxiety, it can also make you numb to arousal.
7. Statins: Statins are used to treat patients with high cholesterol.  Cholesterol is one of the building blocks for testosterone.  Interfering with the production of sex hormones like testosterone can adversely affect sexual desire. 
8. Antihistamines:  Benadryl and other allergy medications can dry out your runny nose, but they can also make you dry down there.
9. H2 Blockers (Zantac, Tagamet, Pepcid), which are used to treat gastroesophageal reflux and ulcers, while not as much of an issue for women, can cause impotence as well as breast enlargement in men. 

 
This blog is actually the short version of the list of medications that can interfere with both desire and performance of intercourse.  There are many more medications that can adversely affect your sex drive.  If you are on one of these medications and have noticed an adverse effect on your libido, please talk to your provider before discontinuing the medication.  Weighing the benefits of the medication as it relates to your individual health as well as whether alternative treatment options are available is a conversation that you should have with your provider prior to making any changes in your medical regimen.  Good luck keeping that healthy desire burning!

Dr. Pam

While we may not think about it often, it turns out that our adipose (fat) cells are actually one of the largest endocrine organs in our bodies, and these cells are responsible for secreting a number of hormones that help regulate everything from appetite to the menstrual cycle.  For instance, the average woman in the US weighs just over 170 lbs, so with an average body fat range of 25-30%, approximately 40-50 lbs of her weight will be composed of adipose tissue.  In comparison, the thyroid weighs about 25 grams, the pituitary gland weighs half a gram, the pancreas weighs about 90 grams, and an ovary generally weighs 5-10 grams.  That means the total weight of these other endocrine organs is less than a pound, and while the hormones produced by these organs tends to be more potent, adipose tissue can sometimes have negative effects by the sheer volume of hormone production.

So, what kinds of hormones do adipose cells produce?  While some play expected roles in things like appetite, obesity and insulin resistance, other hormones are responsible for steroid metabolism.  In simple terms, even though we think of the ovaries and adrenal glands as responsible for sex hormone balance, at least 50% of testosterone in premenopausal women and 100% of estrogen in postmenopausal women is regulated by adipose.  Also, depending on each woman’s amount of adipose, a significant portion of estrogen can come from these cells even in premenopausal women.

Why does that matter?  That means extra adipose tissue can cause hormone related issues such as unwanted hair growth on the face/body, increased acne and in some cases, even hair loss from the head.  For women struggling with heavy menstrual cycles, this can be directly related to the increased estrogen because estrogen causes increased thickness of the uterine lining shed each month during the menstrual cycles.  More tissue in the uterus to get rid of means heavier flow and often more cramping each month.  In more severe cases, too much estrogen from adipose can even cause the menstrual cycle to stop.  While this may sound exciting to some women, a lack of normal menstrual cycle can cause everything from infertility issues (no menses=no ovulation=no egg for pregnancy) to increased risk of uterine cancer (gradual buildup of uterine lining over time without shedding can predispose to cancer).

So, too big is bad, but what about too skinny?  We can sometimes see problems at the other end of the spectrum as well.  Super-intense athletes who have extremely low body fat and women with a very low BMI may also have issues with the menstrual cycle.  If the body shifts into starvation mode because there isn’t enough body fat, then one of the functions that may stop is the menstrual cycle and ovulation.

In general, a regular menstrual cycle with normal flow can be a marker of good overall health in premenopausal women.  Granted, there are always exceptions to this rule.  For instance, some women may not have a cycle due to hormonal contraception, which can be normal.  Also, we know that for some women who are very athletic, such as competitive weightlifters, BMI may not be the perfect measure of health.  That being said, generally a healthy BMI ranges from 18.5-24.9, and the average BMI for women in the US is 29.6, which means many women are just below the threshold for obesity.  So, if you’ve been having menstrual cycle issues with either heavy or irregular flow, and your BMI is elevated, especially above 35, then one of the simplest interventions to help improve your cycle may be weight loss.  These normal cycles can also provide health benefits of improved fertility and decreased uterine cancer risk.  By regulating your hormones on your own, then you may be able to avoid having to take synthetic hormones and in turn, also having to deal with unwanted side effects from these medications.  Besides, who wants to deal with daily pills anyway?

Dr. Nick

Let’s face it, in today’s world everyone’s always trying to lose a little weight. We live in a world where UberEATS and groceries can be delivered to your doorstep.  We have dishwashers, washing machines, cars and all sorts of luxuries that we have never had.  If you think how many calories you would have been burning hunting for food and fetching well water, it is not surprising that in our modern-day world it’s so hard to maintain our figure and physical fitness. 

​In our quest to look cute on the beach and be healthy too, there are so many diets out there that claim to help you lose weight.  The question is do they work?  One of the newest ones that has gained a lot of traction is the fasting diet.  There are lots of variations- fast for days, fast for hours and alternate.  Is this the newest fad diet or does it work?
Most of the options for this type of diet recommend severe calorie restrictions the days that you are fasting (500 for women and 600 for men).  Some recommend every other day fasting while some recommend 2 days of fasting per week.  Now, if you are restricting your caloric intake like this even if it is just 2 days a week it’s not surprising that you will experience some weight loss and health benefit. 

Also, most fast diets are rooted in achieving health and fitness goals.  So even while they are saying on your off days you can eat what you please, their recommendations are to eat clean and stick with lean meats and limit processed foods on your non fasting days.  Eating clean and avoiding sugar and highly processed foods is always beneficial to both your health and weight loss goals. 

In addition, there is a physiologic reason as to why fasting if done right can be so successful.  One of the theories out there is that by snacking all day, the body is constantly producing insulin spikes which can put oxidative stress on the body.  This worsens the responsiveness of our cells to insulin creating an environment of resistance to insulin.  Decreasing insulin levels by fasting will cause several things to happen.  First, blood glucose will remain normal and the body will switch to burning fat stores in the absence of food.  This is exactly what we want- we want the body to burn all that extra fat!  Second, regular fasting in addition to lowering insulin levels has been shown to improve insulin sensitivity.  Fasting, in essence, is an efficient way of reducing insulin resistance. 

Let’s review how fasting can help you lose weight.  First calorie restriction and eating healthy non processed foods will help you lose weight.  Second, while fasting your body will start to burn fat stores since it doesn’t have another option.  Third, decreased production of insulin will combat insulin resistance and provide you with another tool to combat insulin resistance and the oxidative stress high insulin levels place on your organs and blood vessels. 

Of course, there is always a catch.  If it was that easy, everyone would be doing it right?  For many fasting even twice a week is just too cumbersome.  Sticking to a 500-calorie diet on your fasting days is hard.  In a society where food is so cheap and easily available, this is a much more difficult task than it appears to be. 

So, will the fast diet help you lose weight?  It likely will if done right.  However, it will not be an easy task, and be sure to discuss any diet plan with your healthcare provider prior to starting.  Hope this helps, and good luck on all your weight loss goals!
 
Dr. Pam

Life has undoubtedly gotten busier for many families, with a higher number of families with both parents who work, and for those families with children, at least 75 activities per child to attend both practice and competitions.  No wonder processed food has made such a rise in popularity.  I mean, who has time to cook with all of the other obligations?  Unfortunately, these grab-and-go options may not be the best choice in the long run.

So, what exactly is processed food?  Essentially, if you can either take it out of the wrapper and nosh on it or warm it up and scarf it, then it’s probably processed.  The same generally holds true if the ingredients are essentially unpronounceable.  If you can pick it from a plant, harvest it from an animal, and it requires more than a defrost setting on a stove or microwave, then it’s much less likely to be highly processed.  Typically, less processed foods have a shorter shelf life as well due to the lack of preservatives.

Well, what’s the problem with easy?  Regrettably, there are a number of issues with processed foods.  Processed foods tend to be higher in salt, which can both increase blood pressure as well as retention of water (which in turn can increase weight and swelling/bloating).  Sugar is often a major ingredient, which may have negative effects on both insulin resistance as well as decreasing satiety (sensation of fullness).  Also, prepackaged foods tend to have larger portions, and this increased portion size can encourage overeating.  Lastly, this doesn’t even begin to touch on ultra-processed drinks.  Studies suggest that sugary drinks provide an increase in calorie intake without providing nearly the level of satiety that similar calorie intake from food can provide.  Most are aware that soda isn’t great for health, but even fruit juice without added sugar can provide a similar carb/calorie profile.  While fruit is great for health, it loses the added fullness benefits of fiber and the bulk of the fruit itself when ingested as a juice.

Are there better options?  Actually, there are a number of good choices available.  Exchanges like water and fruits for sodas and juice and snacks of nuts rather than chips are a simple place to start.  Using fresh ingredients to prepare you meals on the weekend for the week ahead allow you much more control over both your salt and sugar intake, and the effort required to prepare you meals can reduce impulse eating that happens “just because (insert your favorite junk food) was there in the house.”

Ultimately big changes begin with simple steps.  Starting with the steps that are easiest for you and then working toward the more involved processes can allow for maintainable improvements in your health as opposed to very drastic but untenable phases.  While sudden and huge lifestyle modifications can show quick results, these changes often ultimately result in frustration due to the return of previous habits and in turn, previous health status.  Good luck with your fitness goals, and here’s to a healthy summer!

Dr. Nick

Unfortunately, obesity is linked to a lot of stuff: cardiovascular disease, diabetes, kidney disease, liver disease, osteoarthritis, endometrial cancer, colon cancer, postmenopausal breast cancer- the list goes on and on.  Recent studies have unfortunately linked it to a reduction in cognitive function like Alzheimer’s and other dementias as well. 

Currently, an estimated 47 million people are affected with dementia worldwide and one of the risk factors for dementia as we grow older is obesity.  How did these studies measure obesity? They used a waist to hip ratio as their measure of obesity- not BMI.  BMI is body mass index and takes the height and weight of individuals into account to determine body fat.  However, this is not always a reliable measure as body builders and very athletic individuals can be considered obese but have very little body fat. 

What did these studies find? The studies evaluated the cognitive performance by testing memory and visuospatial tasks and found that adults over the age of 60 with higher waist to hip ratios had reduced cognitive performance in such tasks. 

Why is belly fat (increased waist to hip ratio) associated with cognitive decline? Researchers believe that the reason individuals with increased belly fat show more cognitive decline than their counterparts in similar age groups is because fat cells produce inflammatory markers.  In addition to this, just because you are overweight or obese does not mean that you have the appropriate amount of vitamins and minerals.  The body needs a diverse spectrum of antioxidants and phytochemicals to remain healthy and for our cells to function normally.  Unfortunately, while the standard American diet is heavy on sugar, salt, and carbohydrates, it tends to be low on antioxidants which helps decrease the inflammatory response.
So what can I do to decrease the risk of developing dementia?

1. Focus on reducing belly fat.  Belly fat harms the brain because it produces hormones and chemicals that promote inflammation and insulin resistance. 
2. Decrease processed foods as much as you can.  All sorts of additives are added in processed foods to increase the shelf life and make it taste good.  These additives promote inflammation and are usually nutrient poor meaning they have very fewer antioxidants that help in repair and regeneration of cells.
3. Exercise at least 30 minutes a day! Being active and exercising regularly really helps decrease belly fat and improves your overall health. 

 Some amount of cognitive decline, much like physical decline, is somewhat inevitable as we age.  That being said, being proactive about your health can help minimize those changes, and while your 60s may not be quite the same as your 20s, it also doesn't have to be your 90s.  Good choices now can allow you to see the benefits of your healthy decisions both now (fitting into a favorite dress) and later (being sharp enough to own the competition in the weekly card game).  After all, how else are you going to keep up with your grandchildren?  :)

Dr. Pam

We’ve discussed the overall issues of dealing with infertility on our blog, and we’ve also gone into a bit of detail in the female factors for infertility that we manage more frequently, but today we’re going to take a look at infertility from the male perspective.  This is pretty important as male factors can contribute to infertility in at least 45% of cases (roughly 35% male factors alone and another 10% contributing to cases also involving some female factors). 

So, what makes for healthy sperm?  Essentially, the goal is to have an adequate number of sperm that look and move normally.  That number ranges from a minimum of around 15 million per mL of ejaculate to over 200 million per mL.  Typically, there is about 2-5mL of semen per ejaculate, so if you do the math, that’s a lot of swimmers to try to fertilize one egg.

If a man’s count is low, what kind of testing is done, and what may be some of the causes?  Depending on how low the count is and if there are any concerns noted on either exam or history, testing can involve urinalysis (to look for backward ejaculation), ultrasound (to check for testicular or vas deferens lesions), bloodwork (to look for hormonal causes or genetic issues) and in some cases, even testicular biopsy.  That being said, for levels that are only mildly low, skipping to treatment for the low count may be a reasonable option. 

How can a man help improve the health of his sperm?  Turns out, a man’s overall health can play a big role in his ability to conceive.  Maintain fitness by doing exercise of any type (unless you’re over 6 hours per DAY), and particularly resistance training, which has the greatest effect on increasing testosterone.  From a dietary standpoint, limiting processed foods and emphasizing whole foods will certainly be beneficial.  Also, any food high in zinc such as seafood, legumes, and meats can help with improving fertility. 

As always, there are some things to avoid when trying to achieve pregnancy as well.  Alcohol intake and should be limited, and men should avoid tobacco and drug use, both while trying for pregnancy and even when not trying.  Anything that causes significant increase in heating “his boys” should likewise be avoided.  This can include hot tubs, laptops (on the lap), really tight underwear, and saunas.  Any prescription medications should be reviewed with his doctor to see if decreased fertility may be a side effect, but please don’t have him stop any prescription without reviewing your medication change with your prescriber.  Lastly, some lubricants can be toxic to sperm.  Be sure to check the label, and if you are planning to use lubrication, then select one like Pre-Seed that’s approved to not hinder conception.

If my partner has a low sperm count, what can we do about it?  One of the simplest approaches involves IUI (intrauterine insemination).  This involves collecting your partner’s sperm and have a lab concentrate it for placement directly into the uterus by your provider.  Think of this as providing a head start to the sperm to reach the egg by cutting their travel time down to maybe half.  For other causes, hormonal treatment may be the next step, or in cases of a lesion in the scrotum, surgery may be required.  If all else fails IVF (combining the sperm and egg outside of the body with placement into the woman’s uterus after the embryo begins to develop) may be the best bet.

Discussion of infertility often starts at the ob/gyn office, but depending on the cause, collaboration with either a urologist or a reproductive endocrinologist may be required to achieve successful pregnancy.  The journey can sometimes be rather long, but in the end, a healthy pregnancy is definitely worth it.  Regardless of how you get there, we wish you all the best in having your most enjoyable pregnancy and cutest baby 😊

Dr. Nick

Every couple of months I read a new article about something that needs to be placed in your vagina for for one reason or another.   So, do these products serve any purpose in your vagina, or is this just a way to scam you into purchasing something?  You decide…

​First, there was vaginal steaming, which was touted on popular celebrity websites.  So, what is vaginal steaming?  It involves positioning your vagina for up to 45 minutes over a steaming pot of herbs such as rosemary or basil.  I guess you could figure out how to do this yourself or pay $100 a session at a fancy spa offering such services.  The idea is that the steam can relax your muscles and help rejuvenate your vagina. Spas that offer these services even claim that this increases fertility and helps promote weight loss.  If steaming your vagina could cause weight loss, we would likely see a vagina steaming spa on every corner. 

Next came the Jade Eggs.  For a reasonable price, you can purchase a 1-inch egg shaped stone made of jade to put in your vagina.  So why would one want to put stones in her vagina?  Apparently, it allows you to have better sex, improves bladder control, prevents prolapse, intensifies feminine energy and even invigorates life force.  What can’t these eggs do?  Apparently, they’re good for just about anything but weight loss.  Is there any scientific evidence backing the alleged benefits?  Unfortunately, the answer is no.  However, if you want Jade eggs for your vagina, you may have to wait.  In the past, demand has been so high as to cause the eggs to be sold out online!

Another recent trend was wasp nests in your vagina.  On Etsy, you can purchase oak galls, a medicinal paste of bark and wasp excreta (less gross-sounding, scientific way to describe any waste from the body) to put in your vagina.  The product is touted for its ability to tighten and dry the vagina.  What an awesome treatment goal-hooray for the dry vagina? That would just make intercourse more uncomfortable and increase your risk of infection and abrasions. 

Now the latest fad is inserting garlic in the vagina to treat vaginal yeast infections.  Yep, you heard that right- garlic in the vagina.  This fad has become popular because garlic contains “allicin.”  In a laboratory setting, it may be associated with some antifungal properties.  The operative words here are “in the lab.”  This has not been proven effective in animals, much less humans, and last time I checked, the vagina wasn’t a high school chemistry set.  In addition, the idea of crushing garlic (sorry, it wouldn’t work unless you crush it first), and inserting it in your vagina-ewwww!!!  If you just left cloves in there, would you wait until it sprouted to remove it?  Another serious concern is that garlic grows in the soil.  While there are bacteria in the soil and there are bacteria in the vagina, these bacteria are NOT the same.  This sounds like a vaginal bacterial infection waiting to happen.  It would be a lot easier to go to the pharmacy and pick up some Monistat!!

Why do people keep on coming up with all these strange expensive things to put in your vagina?  Probably in order to make some money.  The list keeps on getting longer and crazier.  It’s especially frustrating because most of these items are touted under the guise or organic, natural, and holistic when they should really be described as dangerous and/or expensive, or at least without a proven scientific benefit.  Before placing anything in your vagina, please talk to your provider because, chances are, your vagina is happy just the way it is 😊

Dr. Pam

With over 70% of Americans taking at least one prescription medications and 20% of Americans on 5 medications, it's not surprising that patients are noticing changes in their health other than just what these medications are taken to improve.   Side effects can range from from as mild as an occasional headache to as severe as bleeding from the intestines.  In this blog, we'll take a look at some of the more common complaints from patients.

1.  Weight gain - many women come to my office concerned about their weight, and the go-to medication for blame is often the birth control pill.  Unfortunately for them, while we can see up to a 5% weight gain on Depo Provera injections, typical weight gain, if any, on the pill is between 1 and 4 lbs, and this weight usually goes away after several months of being on the birth control pill.  That being said, there are a number of other common medications that can be associated with weight gain.  Many of the most common antidepressants, especially SSRIs, have been associated with weight gain, in some cases as much as 24 lbs in a year.  Other mood stabilizers can also contribute to weight gain, as can steroids, antihistamines (sorry fellow allergy sufferers!), antiepileptics, and some blood pressure medications.

2.  Loss of libido - as I was reviewing the data for this article, it turns out that there are a LOT of medications that can affect libido, and many of them have negative effects.  We again see SSRIs as a very common culprit for loss of libido.  Birth control is also a common medication blamed for loss of libido, but as opposed to weight gain, in this case, certain types of birth control may decrease libido.  The goal for hormonal contraception is to prevent pregnancy, but some formulations can decrease testosterone, which in turn may reduce libido for some patients.  For others, this change may be a benefit these same decreases in testosterone can improve acne.  Other medications that may decrease libido are pretty similar to those may cause weight gain:  mood stabilizers, antiepileptics, some blood pressure medications and also opioids.

3.  Fatigue - pretty much any of the medications listed above may also cause tiredness or fatigue.  We can include some antibiotics and heartburn medications in this group as well.  If you've recently started any of the medications listed above and have noticed some loss of energy despite adequate sleep, exercise, and nutrition, then it may be worth examining the medicines you're taking.

4.  Insomnia - the counterpoint to fatigue, but if you're not able to sleep, then you're definitely going to be tired.  Some of the more common medications that may negatively affect your sleep include supplemental thyroid medications, ADHD medications, weight loss medicines, steroids, and once again, some of the antidepressants and mood stabilizers.

For some women, their prescriptions can cause nearly as many problematic symptoms as they improve.  While we often look for a simple fix for health issues, the side effects of any medications should also be taken into consideration, and the pros/cons of these medications should be discussed with your provider.  In some cases, there may be non-medicinal options to manage your health concerns, whether diet/exercise for weight/mood, meditation for sleep/focus and other non-prescription treatment options.  That being said, before making any changes with your prescribed medications, be sure to discuss any adjustments with your prescriber as they will be familiar enough with your health history to ensure the desired change is appropriate.  Together, you and your provider can ensure your medical regimen is optimal for your health goals :) 

Dr. Nick​

I get this question a lot from my patients during their postpartum visit.  “So, I just had a baby and would like for my kids to be close in age- when is the best time to have my next baby?”
In the medical literature, this is called “birth spacing” and there have been lots of studies that have looked at ideal timing between pregnancies. 

1. What is optimal time to wait between pregnancies?  If you are <35 and healthy, the ideal time to wait before planning your next pregnancy is 18-24 months and less than five years.  If you are over the age of 35, as fertility decreases at this age, the ideal interval may be closer to 12 months.  Remember these numbers do not apply to a miscarriage.  Most people with a first trimester loss are safe to start trying during the menstrual cycle following their loss.  However, you should consult with your doctor as they would be aware of your medical and pregnancy history and would be able to help you plan accordingly. 
2. What are the risks of spacing a pregnancy closer than the recommended intervals?  Studies have shown that pregnancy within 6 months of a live birth increases the risk of premature birth, placental abruption, low birth weight, anemia, and congenital disorders.  Very closely spaced pregnancies often do not give mom enough time to recover from pregnancy and breastfeeding, as this can deplete your folate and iron stores, and which is why they are at higher risk of being anemic. 
3. What are the risks of waiting too long? Long intervals between pregnancies can affect fertility and can increase the chance of developing preeclampsia.  Moms over the age of 35 have increased risks of preeclampsia, hypertension, diabetes, problems with the placenta and stillbirth.  There is also a higher chance of having a baby with a chromosomal issue.
4. What is different if I had a c-section?  If you have had a c-section, waiting at least 6 months is preferred in order to allow the uterus to heal and decrease the chance of uterine rupture.  Most physicians also require a minimum of 6-12 months between pregnancies if you are considering a vaginal birth after cesarean (VBAC). 

Planning your family can be tough.  Even if you have the perfect plan in mind, there’s no guarantee that your body will cooperate, but by keeping the above guidelines in mind, then you can help make your pregnancy safer and more likely to result in the outcome you (and your provider) are hoping for:  healthy mom and healthy baby 😊

Dr. Pam

For many moms-to-be, the focus is on getting pregnant, but once that happens, there isn’t always great information on what to expect during labor.  As the end of pregnancy looms, some expectant mothers don’t have a clear idea of exactly the next step is going to be.  So, here’s a quick overview looking at the end of pregnancy and delivery.

​When should I expect pregnancy to end?  Full term for pregnancy is beyond 37 weeks, and your due date is at 40 weeks.  We offer induction for patients who haven’t gone into labor spontaneously by their due date because we can begin to see an increase in the risk of stillbirth and need for cesarean section in pregnancies beyond a certain duration.  In fact, the ARRIVE trial suggests that we may even see a reduction in risk for cesarean section with inductions as early as 39 weeks.

How does this labor thing work? 
There are 3 main stages, and the first stage of labor has two parts.  Latent labor, or the beginning of contractions, can last anywhere from hours to weeks.  This process involves the cervical change from closed (0cm) to 4-6cm.  For some women, these contractions may not be noticeable until near the end of latent labor whereas for others, there can be significant discomfort and even frustration if the intensity of contractions increases without cervical change.  Active labor starts between 4-6cm and often progresses around 1cm per hour or sometimes even faster.

The second stage of labor begins following full dilation (10cm).  This stage involves pushing and delivery of the baby.  The second stage of labor can last anywhere from one contraction with pushing (usually a mom who’s done this before) to as many as 3 hours for first-time mothers in certain situations.

After baby gets here, the last stage of labor is delivery of the placenta.  This generally happens shortly after the delivery of the baby, although in some cases the delivering provider has to manually extract the placenta by placing his/her hand into the uterus to remove the placenta.

What conditions would cause the need for intervention for either my baby’s health or my health?  Sometimes, an intervention can be as simple as adding Pitocin to help labor progress.  Since prolonged labor can result in increased risk for intrauterine infection, abnormal heart rate for baby, low oxygen levels for baby and increased need for cesarean delivery, we like to see contractions reach a level of intensity that will continue to cause the cervix to dilate.  Sometimes, the pushing process can cause a lot of stress on the baby, and in this case, operative vaginal delivery (vacuum or forceps) may be indicated.  Also, while we prefer to allow the vaginal tissue to stretch to minimize tearing, an episiotomy (cutting the vaginal tissue) may be required to speed the delivery of a baby in distress.  A cesarean delivery is generally reserved for when all other options have either been tried or are not appropriate.  Some reasons for cesarean delivery can include a baby that is too big to pass through the bones in mom’s pelvis (i.e. mom has been pushing for a long time without having the baby move closer to delivery), a heart rate pattern for baby that suggests waiting for the entire labor and delivery process would increase risk of harm to the baby, or if mom’s cervix stops dilating despite having adequate contraction strength from the uterus.

What can I do to prepare for delivery?  I’d suggest making sure that you and your partner know how to get to the labor and delivery area of the hospital, especially after hours as some doors may be closed during the middle of the night.  If your significant other takes you on the “scenic route” to labor and delivery, you may not appreciate the detour.  I’d also suggest getting a bag together of the things you might want in the hospital for a several day stay.  If you’re not sure what to pack, you can check out a sample packing list here:  https://www.tetonobgyn.com/blog/what-to-pack-for-the-other-labor-day4298355  Lastly, knowing the reasons to go to the hospital are very important.  If you think you might be in labor (generally painful contractions every 5-7 minutes for an hour, although you can always go if you’re not sure), if you think your water has broken (even if you’re not in labor), if you’re concerned that your baby isn’t moving normally, or if you have heavy vaginal bleeding (more than a pad per hour), then you should go to labor and delivery.  You don’t have to call for permission in any of those cases as sometimes we can be busy in a delivery and not able to immediately return a call.  We don’t want you waiting on us to call back while you have your baby in the bathtub.  Just head to the hospital, let the nurses know what’s going on, and they will start an assessment while they get in touch with us.

While a list like the one above can’t take all of the uncertainty out of your labor and delivery course, it can provide a little more information about what can happen and what you might expect.  As every woman is unique, so, too, is her pregnancy.  Please be sure to discuss any concerns you have with your provider, and we hope that you have the perfect labor, delivery and new baby for you 😊

Dr. Nick