Ep 212: What Happens During Labor – A Sneak Peak Inside The Birth Preparation Course!

Dr.Nicole (00:00): Today is a special episode where you are getting a sneak peek of what's inside my online childbirth education class, the birth preparation course. Welcome to the All About Pregnancy and birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy in birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/ disclaimer. Now, let's get to it.

(00:53): Hello there. Welcome to another episode of the podcast. This is episode number 212, and whether you are a new listener or a returning listener, I am so glad that you are spending some of your time with me today. In today's episode, you are going to get a sneak peek inside. Look at the birth preparation course. What I'm going to do is go through one of the lessons in the course, and this is a lesson on exactly what happens in labor when you get to the hospital. Now, if you don't know, the birth preparation course is my signature online childbirth education class that gets you calm, confident, and empowered to have the most beautiful birth with a focus on birth in the hospital. Everything is completely online. You can do it on your own time and at your own pace. It also comes with the bonus of a wonderful community, a private Facebook group where you can connect with other mamas, where you can ask me questions.

(01:55): Of course, you get lifetime access to the course, so you get access to all of the updates that are done, anything that changes along the way, so you have it for all of your pregnancies. You can check out all of the details of the birth preparation course at drnicolerankins.com/enroll. But in the meantime, today, you're going to learn about what happens in labor in the hospital. So I'm going to go through what happens from the moment you arrive. We'll talk through or you will learn what vaginal exams are. We'll talk about the importance of position changes to during labor, and then exactly how long labor will last. Now, this episode is great as audio, but it's even better with video because you can see some of the things that I demonstrate. So again, if you're interested in, you're like, oh, well, I just want to hop into the course, then head to dr nicole rankins.com/enroll, but otherwise, let us hop on into the episode about what happens during labor.

(02:55): Okay, so first off, let's start off with what happens when you get to the hospital, when you arrive, when you hit the door, and I'm describing the scenario of if you come from home, so you're at home, your water breaks or you have contractions and then you go to the hospital, it's a little bit different. If you're induced but you come from home, then this is what it's most likely going to be like. And I should give the caveat that of course, I can't describe every situation in every single hospital, but this is a very good generalization of what things are. I've worked in several hospitals and know from my experience that this is what things are like. So when you get to the hospital, you're going to generally stop in a place called triage, or it may be called Obed, the OB emergency department, which is specifically for pregnant folks, and this is where you will get evaluated to see if you're going to stay.

(03:48): You're going to first be seen by a nurse, and these rooms tend to be smaller. They're like little tiny rooms. They have a bed. The monitor may be a place for one person to sit, and the nurse is going to see you and she's going to ask you like 50, 11,000 questions. Okay? Because there tend to be prompts in the electronic medical record that nurses have to go through asking all of these questions to get all the things boxes checked off that they are supposed to do. So that's going to be like your health history. That's going to be like your plans for feeding your baby. That's going to be like, what pharmacy do you use? Now, good and dare I say good, but I can't think of a better word, but good hospitals will kind of bypass some of those things if it's obvious that you're in roaring labor and will ask those questions later.

(04:43): But in general, you're going to get asked a few questions about your health history, your pregnancy and things as you're getting situated before you see a doctor. Okay? This is where it can be really helpful for your partner to know your medical history because they can certainly answer some of those questions for you. Who's your doctor? Where's your office? Have you had any surgeries with your due date? All of those kinds of things, okay? So that if you're in labor, you can concentrate or be able to manage that and not have to answer all of those thousand questions. And I'm not lying. It's like a thousand questions, okay? Now, when you're in triage or obed, you may or may not see a doctor. More and more hospitals are going towards making sure you see a doctor and what's considered the OB emergency space or the triage space, but it really depends on your hospital.

(05:33): If they're hospitalists like what I do, then you will almost certainly see a doctor. You will definitely see a doctor, but not all hospitals have hospitalists, and in the middle of the night especially, there's a good chance that you may not see a doctor. You may just be seen by the nurse. The nurse may be the one to check your cervix. She may be the one to see if your water is broken. She will report back to the doctor over the phone and then come up with a plan from there. Okay? So again, you get there, you get in the smaller room, you may or may not see a doctor, and it may just be the nurse who does everything, and these are questions that you can ask ahead of time to kind of know what the flow is and what to expect, okay? Now, depending on where things are, you may not be admitted to the hospital right away.

(06:21): If your water is broken, then yes, you will be admitted to the hospital typically, but if you're less than four centimeters, then you may be watched for a couple of hours and triage or obed and then rechecked in a couple of hours to see if your labor's actually progressing. Labor can be a slow build. It's not always fast, and sometimes the right thing to do is to send you home so you can do that early part of labor at home and to come back when things are actually more active. It's actually super, super, super common for folks to come to the hospital, especially with first baby, and think they are in labor and they're not. So if you go and you get sent home, please don't feel bad. That's really, really, really, really common. Okay? Now, if you are staying in labor, if your water's broken, if there's a reason for you to stay, then you're going to get moved to the nicer labor room.

(07:15): Now, inside of the birth preparation course, I have a couple of images of what a typical labor room looks like. They're going to be more friendly, they're going to be more appealing, they're going to be a lot larger. Typically, most hospitals have gone to making them more like family friendly kind of spaces. You may or may not get a new nurse depending on how the hospital works. Some hospitals, you'll keep the same nurse who saw you in that triage area as your labor nurse. Some hospitals, not some hospitals only have nurses who focus on triage, and you'll get a new nurse when you get moved to your labor room. So once you get settled into the room or get in the room, you're going to get settled. You'll get oriented to the room, you'll get, where's the call bell, where's the bathroom? If you haven't changed already, they'll ask you to change into a hospital gown, or if you bought your own clothes, changed into your own clothes, which you can definitely bring, you will get an IV or a sailing lock placed if that wasn't done in the triage area, and you're be of course hooked up again to the monitor to monitor the baby.

(08:15): All right? So that's what's going to happen when you first get in the room, get all of the things situated oriented, come up with the plan, all of that good, great stuff, okay? Now, I want you to remember that that labor room is yours while you are there, okay? You and your insurance company are paying to use that space, so make yourself comfortable. Do not be afraid to ask for blankets for you or for your partner. Ask for towels, washcloths. Adjust the thermostat in the room so the temperature is comfortable for you. Okay? Dim the lights in the room. Ask the people, Hey, I like to keep the room dim. Please don't turn on so many lights. This is your room, your space, okay? Get your music set up if you want to do music, as long as you are not disrupting your neighbors, you can certainly do that.

(09:11): Do not be afraid to make that space yours. This is a really important part of creating the energy surrounding your birth where you feel like you're in a nice comfortable environment that is really supporting you being in a great, happy, positive mental space. Now, during the course of your labor, your nurse is going to come into your room about every 15 to 30 minutes, all right? She may stay at the bedside longer if you are attempting an unmedicated birth, and she may be able to, or she should help you more with things like position changes and managing your pain. But typically, they come in every 15 to 30 minutes check on you, and then they're going to leave. This is one of the reasons why a doula can be so important because a doula is going to be with you during the course of your labor.

(09:59): They're going to stay at your bedside. They're not going to leave and go with other people. So the nurse comes in and out every 15 to 30 minutes, she will be your nurse for the duration of her shift, so she is going to be your nurse for as long as her shift has left, and shifts are typically eight or 12 hours, and it depends on what time they change. Some hospitals do seven to seven, some do 3:00 PM to 11:00 PM. It's different shifts, but you can expect that you will have one or two nurses depending on how long your labor is. Okay? That is not unusual to have one or two nurses during the course of your labor. Now, I mentioned, or I have not mentioned yet much about seeing a doctor. Again, if you are in the Obed area and you're in a hospital or triage and you're in a hospital that has hospitalist, then yes, you will probably see a doctor there.

(10:52): If not, if it's during the day and your doctor's in the office seeing patients, your doctor will come first thing in the morning before the office gets started. They may check in around lunchtime and then they may check out, check in after office hours are over, and if you, of course I can are going to deliver before then they will come of course for the birth. But otherwise, those are in general the times that you can expect to see your doctor before the morning office starts around lunchtime or after the office is over. Remember when your doctor's in the office seeing patients, they're with you, seeing patients, and that's what they're still doing. Even though you're in the hospital, people are often really surprised at how little that they see their doctor during labor. It really, honestly, truly is the nurse who is with you the most.

(11:43): For sure, for sure, for sure. If it's during the middle of the night, you may not see your doctor until it's close to delivery, so until you're like eight or nine centimeters, if your water breaks during the night and you're not in active labor, if your doctor's not in the hospital, which they won't be unless they have other people in labor or unless there's a hospitalist like me, you're not going to see your doctor until tomorrow morning. So don't be surprised at how little you see your doctor during labor. It really is, and this is the same really for midwives, for the most part, especially hospital-based midwives. It really is your nurse who is with you the most. And also, again, that's why having a doula to provide that continuous labor support and be that continuous thing for you is really important.

(12:31): Now, during labor, there really is not a whole lot that happens. There's two big things that happen that are important, and those are vaginal exams, and then position changes to help get the baby in a good position. So let's start off with vaginal exams. So vaginal exams, check how dilated or open your cervix is, how thin or effaced your cervix is, and the position of your baby in your pelvis, okay? So it's three numbers, and I'm going to tell you what those three numbers are and kind of what we mean when we talk through those three numbers. Vaginal exams can be done by your labor nurse, they can be done by your doctor, they can be done by your midwife, all right? And the reason that vaginal exams are done is that they help determine how your labor is progressing. It's really the most reliable way to assess progress.

(13:24): Your three centimeters, your six centimeters, your eight centimeters, whatever it is, and here's the truth, doctors are trained and rely pretty exclusively on changes in your cervix in order to assess the progress of labor. That's how we were trained, all right? Some midwives may be more in tune with those subtle physical cues. Those are more present when you don't have an epidural, for example, you can tell for someone who doesn't have an epidural when they're transitioning or when they're ready to push, they're often, I feel like I got to push, okay? You can often tell how someone looks if they're really an active strong labor, but for the most part, we rely on those vaginal exams and by we, I mean physicians rely on those vaginal exams to tell how you're progressing in labor. So I'm explaining this to you because at some point you are going to be asked about getting a vaginal exam.

(14:24): Almost certainly if you are giving birth in a hospital, somebody going to ask you about a vaginal exam. So let's go through it in a little bit more detail. Now, you'll hear us say three numbers When we do those exams, like I talked about, the first one is dilation, how open your cervix is. The second one is ment, how thin it is, and the third one is the fetal station. All right, so dilation is how open your cervix is. That ranges from zero centimeters where your cervix is closed to 10 centimeters where your cervix is completely or fully dilated. We do dilation in centimeters and not inches, centimeters make a lot more sense in general and just because of the base 10 system and they're easier to convert. That's a side note. The US has this sort of backwards system of inches that's based in feet, which is based on nothing that's easily relatable.

(15:18): The centimeter system just makes a lot more sense. But anyway, when you look inside the birth preparation course, I have some images of what a dilated cervix looks like, and I'll talk through some things that reference in just a minute. Now, a ment is how thin or short your cervix is. That's usually described as a percentage of the normal length of the cervix. So 0% effacement means your cervix feels like a normal length. It's not faced at all. All right? So it's about three to four centimeters long, okay? 50% of ment means that your cervix has shortened to about half of its normal length. All right? It's thinned out to about half of its normal length, and a hundred percent effacement means your cervix is completely thin like paper. There's no length to it at all. It's very thin, and again, I have images of that inside of the course.

(16:10): Now, the last number in vaginal exams is station that refers to the position of your baby's head in your pelvis in relation to your ischial spines. The ischial spines are part of the bones in your pelvis, and when the top of your baby's head is at the level of your is issue spines, the station is zero. When the top of your baby's head is above the is issue spines, the station is a negative number, and as your baby goes past the issue spines, it becomes a positive number, either plus three or plus five as the baby comes down into the state, into your vagina, depending on which system folks use. Okay? The general thing that you need to know is that the more positive number, the more positive the number, the closer your baby is to come it out. All right? And then other things that we may comment on during your vaginal exam are the consistency and position of your cervix.

(17:04): So as for consistency, we will often say whether it's soft, whether it's firm, your cervix is going to get softer as you go further into labor during the course of your pregnancy. It stays nice and firm and hard in order to protect the baby inside of your uterus, but as you go into labor, it starts to get softer. Also, we talk about the position of your cervix. Is it anterior meaning rotated forward in your vagina, or is it posterior meaning rotator further back in your vagina? During the course of pregnancy, your cervix stays towards the back or posterior part of your vagina. It helps to protect it and keep it from being exposed to anything negative like any detrimental bacteria or anything. But as you go into labor, your cervix is going to rotate more and more interior and more and more forward. So putting all of those things together, an example of a cervical vaginal exam, your Dr. May check you and then they're going to call out, okay?

(18:04): Your five 80 minus one, okay, so that means your five centimeters dilated, you're 80% and your baby's head is at minus one station. We also may say your cervix is soft in interior, but we may or may not say that, but we will keep that information in our head. I may not always tell a patient your cervix is anterior posterior. It really just depends, but you'll hear those numbers. It'll be five 80 minus 1, 3 50 minus two. Those are what we're talking about is the dilation of ment and the station. Now, just some examples, one centimeter is about as open as the size of a blueberry. You can get one finger in the cervix roughly at one centimeters when your cervix is five centimeters is it is about as open as the width of a typical lemon, and when your cervix is cervix is 10 centimeters, it's about as open as the width of a bagel, and that's when it's open wide enough to push and when the baby's head can fit through.

(19:07): Okay? Now a word about inches in centimeters. In general language, we don't use centimeters much. The US measurement system again is the backward system of inches in feet, which is based on somebody's foot measurement, a king back in the day or something ridiculous like that. So I want to give you sort of a reference. An inch is about 2.54 centimeters, not about it is it's 2.54, 2.54 centimeters, and I know that because I actually know that, but from memory, because I majored in math and engineering and college side note nerd alert, but an inches 2.54 centimeters. And so if you want to look at a ruler, like an old school ruler, look at the top and bottom. They often have inches on one side, centimeters on the other. Then you can just see the difference to sort of maybe that helps you get a better visual.

(19:59): You can see that 10 centimeters is roughly about four inches, and so when you're completely dilated, your cervix is open about four inches. Okay? Now, how often are vaginal exams perform? They typically are done anywhere from every two, no sooner than every two, typically to even six hours. In the active part of labor, it may be a little bit more frequent than that if there's a concern about your baby or if you feel something different. So if you feel more pressure or you're like, Hey, something is coming, then we're going to check sooner than two hours. But other than that, it's really two to six hours really. I typically do every four to six hours. They just don't really need to be done that frequently, especially in the early part of labor before five. It may be even longer than that, longer than six hours.

(20:51): So I typically will do maybe two to three vaginal exams during labor. It really doesn't have to be a lot, okay? It really doesn't have to be a lot. Now, one thing I want you to know and hear me say is that vaginal exams are an estimate. They are an estimate. No one is actually putting a ruler up inside your vagina to get an exact measurement of how open your cervix is. So for this reason, vaginal exams will vary between providers. One provider will check you and say your three centimeters dilated, and then another one will check you and say your two centimeters dilated. Same thing can happen with a basement in station. Somebody says you're 70% of face, somebody says you're 50% of face. This can be crazy confusing and frustrating, especially if you feel like the number is going backwards. But please note that these small differences are not a cause for concern.

(21:46): We each develop our own reference for exams. So for me, one centimeter is I can get one finger in the cervix. Three centimeter is if I can get two fingers in the cervix, if I can spread them a little bit, then that's four centimeters, and I have an idea of how far I spread for five or six centimeters. So they really are an estimate, and don't be discouraged if there are just slight differences in between exams between different people. Now, that's why we like to have the same person do exams to have that consistency and know, okay, I checked before and here's what I see now. All right? We'd like to try to have that consistency, but don't be surprised if different providers have slightly different numbers even in pregnancy, office visits week to week if the numbers are slightly different. Okay? All right. Now, the truth is that vaginal exams can be very uncomfortable for some folks.

(22:43): They can be quite uncomfortable even if you don't normally have discomfort with vaginal exams or pelvic exams. The vagina is more sensitive during pregnancy and you just may have more discomfort. They can also be more uncomfortable in the early part of labor. When the cervix is more posterior or further back in the vagina, we have to reach further back in order to feel it. The good news is that as labor progresses, the exams are less and less painful. As the cervix rotates forward and the head comes down, the exams are less and less painful. So even if they start off uncomfortable in the beginning, they typically get better as labor progresses. Now, there are some things that can be done to help make exams less painful. One is to try and relax. I know that that is easier said than done. However, it actually really does make a difference when we are anticipating something that's going to be uncomfortable, we have a tendency to tense our bodies up, and when you tense the muscles of your pelvis, that's actually going to make the more painful.

(23:47): So you want to try and let all your muscles go really loose, soften yourself, melt your body into the bed, and let things be loose like spaghetti noodles as best you can. The other thing to do is to breathe. Yes, breathe. And I mean really slow down and breathe. It is actually quite hard to tense your body. If you're concentrating on breathing slowly, okay, try it. It's actually hard to tense yourself. If you're really concentrating on taking slow deep breaths, these need to be deep breaths where you really feel your lungs count to three on the inhale count to three on the exhale. It definitely definitely helps. The other thing you may do, or your Dr. May ask you to do is to ball your hands up and put them underneath your back, on the back of underneath your pelvis. I'm sitting here showing you what I mean, knowing that you can't see it.

(24:54): You can't see it inside the course, but you ball your fist up and put them underneath at the top of your butt and lay on your fist. And what that does is that helps to tilt your pelvis forward, and that can make the exam easier because it's going to tilt your cervix forward. Now, if none of these things are working and it is just too painful, then tell the doctor, stop. Stop. This is hurting. Stop. Okay? They should absolutely respect your wishes and do so, okay? As a matter of fact, there are an important non-negotiables about vaginal exams. They should always ask your permission before perform performing, performing a vaginal exam. I'm ashamed to say that we actually don't always do this. This isn't even something that I always did. We're just not taught this. We had this habit of saying like, I'm going to check you now and putting on the gloves and just kind of going for it.

(25:53): That's what happened in one of the birth stories that happened recently. The doctor just kept doing that, but we're so ignorant that we don't know. Is it okay to check you? Now? Is what should be happening is what I have changed to in my practice. Is it okay to check your cervix and really getting your expressed consent? Okay, so we should always, always be asking permission. And then if you don't want a vaginal exam, if someone is coming to do a vaginal exam, you need a minute or you don't want to do it at that moment, then you always have the right to refuse. You always have the right to say, Hey, hold on. Can we talk about this? You always have the right to put the breaks on the process, okay? But I will add this caveat that especially in the setting of hospital birth, where again, remember I said doctors know the progress of labor.

(26:48): The only way we typically know is by vaginal exams. So if we don't have that information, then we're going to be like, oh, well, how do we know what's going on with labor? Da, da da. Okay? So be ready to discuss your reasons why you don't want a vaginal exam at that moment, and then come up with a plan of care, okay, based on your concerns when they d Again, when we don't have that information, then sometimes we get all up in arms cause we don't know any other way. We haven't been taught any other way to tell if your labor is progression progressing. Some doctors, again, going to be honest, might actually get upset. They might actually get frustrated if you decline an exam. Okay? So it's best to say, let's revisit in two hours or when I'm feeling different. So have a plan for when you want to circle back to it to help diffuse any tension and keep the working relationship positive.

(27:50): All right? Okay, so let's finish up by talking about some of the position changes. Oh, actually position changes, and then how long labor last. Okay, so let's talk about the position changes that happen during labor. Position changes are really important to help facilitate your baby getting in the optimal position for birth. Really tiny little millimeters of space can make a difference, okay? Now, the most optimal positions are head down. That is called cephalic presentation with the vertex presenting the vertex is the top of the head. You can actually have the head be down, but the face can be presenting or the forehead can be presenting. You really want the vertex, which is the top of the head presenting, and then the most optimal positions are oput anterior or oput posterior, and I'm going to tell you what those mean in just a second. So oput anterior is the most favorable position for birth, whether it's direct oa, meaning that the back of the head is facing towards the mother's front, so towards the anterior.

(28:59): So the baby is like if you're laying flat, then that means the baby's looking down at the floor, all right? Now, sometimes it can be l o a or r o a. So left oput in interior or right oput anterior where the baby's head is tilted to the left or right. Either one of those are okay, but in general, it means if you're laying flat, the baby is looking down at the floor. That makes it easiest for them to kind of move their head underneath the pelvic bone. All right, so that's oput in the interior. The other position that vaginal birth can happiness os put posterior, oh, and I forgot to say oput is the back of the head, so the oput is the back of the head. So ASSA put posterior meaning the back of the head is facing towards mom's back as put back of the head posterior towards mom's back.

(29:46): That's a sunny side up baby, meaning the baby is looking at the ceiling. That can cause back labor where you feel more of your labor in your back. Don't know why it's that way, but it just is. If you're having a lot of back labor, your baby may be op or oput, PA posterior. Most of the time. Babies will rotate as they descend into the pelvis to oput anterior, but sometimes they don't, and if they do stay in op position, it can be take a bit longer to push a op baby out because their movements aren't quite as smooth as an OA baby. It can be a little bit harder, take a bit, a little bit longer, but it can definitely, definitely happen. Now, there are a couple positions where you cannot have vaginal birth at all. One is transverse. That's when the baby's going across your belly.

(30:33): If the baby's going across, the head is on the side on one of the sides and the baby's going across, it's not not coming out of your vagina like that. That's just not, you can see physically like that's not going to happen. Also, if the baby's a bit oblique or tilted, then they can't come out like that either. They have to be kind of straight down in the pelvis. Now, most often, oblique babies will correct themselves to OA or OP as they descend into the pelvis, but if they stay oblique, they will not come out vaginally. They're just not going to fit. The vagina is built for a vaginal birth for the baby to come straight down, not sideways or anything like that. Okay? Now, how do you facilitate your baby getting into a good position? Well, one of the things is movement, walking, swaying lunges, squats, leaning.

(31:23): These are all the things I teach inside of the chorus. I have a separate lesson on medication-free pain management techniques, and they don't just help with pain. They help get your baby into an optimal position for birth. Now, if you have an epidural, then we have to try to mimic some of those things, so we're going to do things like put a peanut ball between your legs, move you around in different ways. All right? Peanut ball literally looks like a peanut shaped ball, all right? Or we use a birth ball where you can sit on a birth ball. Also, we do something called spinning babies at our hospital in many hospitals, spinning babies is a program where there are different movements and position changes. They were developed by a midwife and they help get babies in the most optimal position for birth. More and more nurses are being trained in spinning babies, and again, I have some visuals of these type of different movements, the peanut ball, the birthing ball inside of the birth preparation course.

(32:24): I also have a whole pain management technique guide inside the birth preparation course that you can download with lots of different pictures and tips on medication, free pain management techniques. Okay? Now the final thing I'm going to tell you is like, well, how long am I going to be in the hospital in labor? How long is labor going to last? Well, the answer which may not be very satisfying is that it varies for first time moms. On average, it's six to 12 hours once an active labor, and active doesn't start until five centimeters. All right? So once in active labor, active isn't until five centimeters. The point from zero to five can take hours, can take days even for some people, but once an active labor, on average six to 12 hours, all right? So expect that if you come to the hospital, you're in active labor, it will typically be 12 hours, six to 12 hours until birth.

(33:27): It could be longer, it could be less. All right? Just be prepared that it could be some several hours before things happen, and that can stretch out to be even longer if sometimes labor slows down or stalls, and we have to do things to try and encourage it, but just be prepared that from the moment you hit the door, it could be 12 hours before you have your baby. All right? Again, it could be less, could be more. Okay, so just to recap, when you get to the hospital, you're going to be assessed in triage or obed. You're going to be seen by a nurse. You're going to get asked a bunch of questions. It may be some time before you see your doctor. If you stay, then you're going to move to a labor room. That's where you get settled in. That's going to be your space.

(34:14): Your space, until you have your baby, make it your space. Dim the lights. Music, if you want to do like non-electric candles that, I mean non flm, flammable candles, you want to do electric candles, all right? Do all of those things to make the space yours. During the course of your labor, your nurse is going to be in every 15 to 30 minutes. Your doctor will probably be in two or three times at the most. During the course of your labor, you'll get those vaginal exams, or there should be a discussion, or there will be a discussion about vaginal exams. Anywhere from every two to six hours, I would say on average is probably four to six old school hospitals that adhere to outdated standards. They're probably going to do two hours more. Progressive hospitals are going to do every four to six hours. You can always decline a vaginal exam, but have a plan.

(35:02): If you do have a plan for when you want to do it or what you want to do going forward and be ready to discuss that, and during the course of labor position changes are important. You want to move. You don't want to be sitting in the same position, whether that is with or without an epidural, okay? You want to move around those little tiny bits, millimeters make a difference in order to get your baby to fit through the pelvis and labor can take on the short end, six hours on average, longer, 12 hours could be even longer. Okay? All right? And remember, you can get all of that and more, including the visuals and the downloads and the guides and all that great stuff inside the birth preparation course. Since dr nicole rankins.com/enroll, you get lifetime access. It is very reasonably priced and affordable.

(35:55): You get access to the private community and Facebook group, all the good, great stuff. I would love to serve you inside of the course. All right, so there you have it. Do me a solid share this podcast with a friend sharing as caring, and I am on a mission to reach and serve as many people as possible. I would love your help with doing that. So share this with three friends. Also, subscribe to the podcast wherever you're listening to me right now. Leave me an honest review or shoot me a message on Instagram. Shoot me a dm. I'm on Instagram at Dr. Nicole Rankins. Let me know what you think about the show. Let me know. Any suggestions for future episodes, my dms are open. All right, so that's it for this episode. I hope you enjoyed that sneak peek of the birth preparation course. Check it out at drnicolerankins.com/enroll. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.