OBJECTIVES At completion of Part 5 the learner will:
■ outline male and female reproductive cycles with appropriate hormonal changes.
■ list the stages of embryo development.
■ list common changes in sexual activity experienced during the childbearing year.
■ recognize pregnancy as a life-changing event that prompts adults to make healthy lifestyle changes.
■ compare and contrast the physical, emotional, and mental symptoms of stress.
■ suggest nutritious foods to serve in a childbirth class.
■ list nutrients that influence a healthy pregnancy and the foods where they are found.
■ list appropriate weight gains in pregnancy and how the weight is distributed.
■ share resources for four groups of clients with special dietary needs.
■ share information about and suggestions to cope with four discomforts of pregnancy.
■ list steps a woman can take to promote breastfeeding success.
■ recognize ACOG Guidelines for exercise during pregnancy.
■ demonstrate positive exercises that enhance pregnancy, labor, and postpartum comfort.
■ list potential threats to pregnancy that clients may choose to avoid.
YouTube Foramen Ovale and Ductus Arteriosus –
https://www.youtube.com/watch?v=cgccQV cFLi4&list=FLgH3azySd4MiajnyjVst6cQ&in dex=2 (wrong link)
https://www.youtube.com/watch?v=cgccQVcFLi4 (14:12) Khan Academy Medicine
Fetal Heart – looks like adult heart but some differences:
Superior Vena Cava – dragging blood back from arms and head region. Blue blood
Inferior Vena Cava – blood coming from body and umbilical vein (oxygen rich blood from placenta). Pink blood. Major source of oxygen fetus is getting is from inferior vena cava.
4 Chambers of Heart: Right Atrium, Left Atrium, Right Ventricle, Left Ventricle. Full of purple blood (mix of blue and pink).
Parts of heart: Aorta (main artery in human body, originating from left ventricle of heart), Pulmonary Artery (carries deoxygenated blood from heart to lungs), Pulmonary Veins (large blood vessels that receive oxygenated blood from lungs and drain into left atrium of heart).
Right Lung – blood coming into arterioles & capillaries from pulmonary artery. In fetus, nothing but fluid inside of alveoli sacs. If full of flow of amniotic fluid, not much oxygen in there. Main source of oxygen from umbilical vein. Since such low oxygen in sacs, causes arterioles to constrict. When have smaller radius on blood vessel, amount of resistance goes up. If happens in millions of arterioles, pulmonary arteries face really high resistance. Increase resistance when oxygen low – hypoxic pulmonary vasoconstriction. If heart wants to pump blood through lungs, pressure needs to be high. Pressure starts going up everywhere. Heart faces choices – can try to find shortcut to bypass lungs.
2 shortcuts to get blood from right side to left side (aorta) bypassing lungs.
Shortcut #1: 2 walls stuck together in middle of lungs – septum primum & septum secundum. Septum Secundum has tiny hole called foramen ovale. Septum primum also has a little hole. If pressure from right atrium pushes into foramen ovale, then septum primum becomes like a flap/valve and falls away. Right atrium blood will flow into left atrium.
Not all blood goes through foramen ovale. Some passes normal way. Into right ventricle (want muscles to get stronger). Pumps into left and right pulmonary arteries.
Shortcut #2: Fetal heart has a little vessel goes from pulmonary artery into aorta – Ductus Arteriosus.
10% of blood goes to lungs. But 90% goes through ductus and foramen ovale.
Expecting Multiples: Twins, Triplets or More
A woman discovers she’s pregnant with multiples via ultrasound. Caregiver may suspect if they hear 2+ heartbeats or uterus seems to be growing faster than normal. Twins – 3% of all births. 1/5 of 1% – triplets or more; incidence increased in recent years.
Women pregnant with multiples have increased risk of preterm birth; prematurity causes most problems for multiples but improved medical care has helped decrease risk of preterm birth of extremely small and immature babies.
Requires more energy; need to consume more calories and rest more often because of discomfort, fatigue and increased risk of preterm labor.
Birth is more complicated; chance of cesarean birth rises with number of babies you’re expecting.
Woman increases likelihood of multiples if: large and tall; older than 35; Caucasian/African American (less common in Asian/Hispanic); had at least 1 other pregnancy; used fertility drugs or in vitro (more than 1 egg implanted). Most of these only affect rate of fraternal twins because identical is unpredictable and random event.
Sex During Pregnancy – 1st trimester: hormonal changed and increased blood flow to pelvic organs and no worries about getting pregnant increase desire; some have nausea, vomiting, fatigue and breast tenderness and it decreases libido.
2nd trimester: stronger libido and more pleasure than other trimesters.
3rd trimester: decreased desire for sexual intercourse – bigger bellies and increasing fatigue.
Air embolus – air bubbles in blood if blow in vagina; potentially fatal condition
Avoid sex during pregnancy if high-risk: at risk for preterm labor (or expecting multiples), partner has STI, you have placenta previa (low-lying placenta), incompetent cervix (opens early), vaginal bleeding during pregnancy (spotting first month after intercourse may be fine), painful cramps after intercourse, membranes have ruptured.
If not at risk, have sex as often as desire. Uterine contractions are a normal part of having an orgasm. Try positions that don’t put partner’s weight on belly (side-lying, hands and knees, woman on top).
Treatment to Prevent Preterm Birth
If have any symptoms, contact caregiver immediately. Prompt treatment may stop labor. May try to stop contractions.
When preterm birth unavoidable – give birth at hospital with NICU. Survival rate with very premature/very low birth weight is greater when in hospitals that provide intensive care.
Pregnancy: A time for Change and Preparation ~ time to assess diet, fitness level, lifestyle, finances and relationships
Birth as a Long-Term Memory – women vividly recall birth experiences for many years; decisions during pregnancy will affect memory of your birth experience
Making Decisions for a Satisfying Pregnancy and Birth – where you have baby, caregivers, how educated you become, who provides companionship and support in labor, how you want to manage labor pain and to what extent you what caregivers to manage your care
More than birth of a baby – self journey
Informed Decision Making: www.childbirthconnectionorg; www.motherfriendly.org; www.birthcenters.org/fine-a-birth-center; www.acog.org/member-lookup; http://familydoctor.org; http://cfmidwifery.org; http://acnm.org/find.cfm; www.mana.org; http://cfmidwifery.org/find; www.icea.org; www.lamaze.org; www.bradleybirth.com; www.birthingfromwithin.com; www.dona.org; www.doulamatch.net
If disagree with caregiver: in U.S and Canada, a pregnant woman has legal right (in most circumstances) to change caregivers, and caregiver has right to discontinue care if there are other options for pregnant woman
BRAN – Benefits– problem were trying to identify/prevent/fix; how is it done; how likely is it to work, Risks – possible risks/side effects for baby/me. Other tradeoffs/disadvantages such as additional procedures or precautions; cost, Alternatives-other options available; other procedures that may work; delay treatment or choose not to; risks and benefits of alternatives and effectiveness (low risk options sometimes less effective), Next Steps– if it solves problem, what can we do after; if it doesn’t, what after?
Health Care Coverage – licensed midwife may charge as little as $2,500 for uncomplicated home birth. Midwife for prenatal/birth center – $4000-$4500. OB uncomplicated birth $7,500. Cesarean complicated can cost more than $20,000.
Contact insurance company representative to understand coverage. See work sheet on PCNguide.com
Some insurance plans cover but don’t pay directly for midwifery care, childbirth prep, birth or postpartum doulas, home birth and breastfeeding assistance, but you pay and they reimburse you. Can also use a FSA (flexible spending account).
~25% of people in U.S. can’t afford health insurance or don’t work for employers who offer it as a benefit. Medicaid coverage can help cover costs although only a limited number of caregivers and birth places.
www.thebirthsurvey.com – new mothers to share info about their birth experiences.
Choosing a Birthplace
Models of Care – Midwifery vs Medical
A caregiver’s philosophy of care typically follows one or the other.
Midwifery Model of Care – designed to maintain and enhance a woman’s physiological and psychological resources for giving birth
Medical Model of Care – designed to replace or alter the body’s own resources with medical and technological interventions
Interviewing a Potential Caregiver – when scheduling, make it clear it’s only to learn more about the caregiver and his or her practice
Questions to Ask a Potential Caregiver
Changing Caregivers if dissatisfied – it’s essential you feel comfortable
Choosing Childbirth Prep Classes – hospitals, colleges and universities, nonprofit community organizations, groups of caregivers, and independent childbirth educators offer
Hospitals usually have provider oriented about hospital which avoid discussion of reasonable alternatives or controversial topics.
Birth Doulas – Cochrane Library issued a report about dehumanization of women’s birth experiences. Review found that support was most effective when provided by women who weren’t hospital staff.
Most studies show that continuous support benefits laboring women, especially when the support begins in early labor and is given by someone whose only role is to provide it. Benefits include:
A few hospitals provide doula services at low cost or no cost to the patient, and some charitable agencies or public health departments cover doula’s fees for women who can’t afford; health insurance plans rarely cover.
www.dona.org/mothers/how_to_hire_a_doula.php for lists of questions to ask
Baby’s Health Care – make decisions about baby’s health care before birth. Ex: circumcision and vaccinations
Choose a caregiver before birth –
Health Care Coverage for baby – cost depends on plan. Children’s health clinics usually cost less than private practices, but they may have longer waiting times. If clinic is associated with a medical school, its staff may change frequently. Community health clinics or well-child clinics associated with a public health department offer free or low-cost checkups and vaccinations, but they usually don’t provide care for sick children.
Questions to Ask Potential Caregiver – do you support breastfeeding, formula feeding, work with lactation consultants, thoughts on circumcision, vaccinations, comfortable with home remedies, use of antibiotics, available for phone consultation, do you have hospital privileges, examine baby after birth. PCNguide.com; http://www.pcnguide.com/wp-content/uploads/2016/03/4-Questions-to-Ask-Potential-Caregivers.pdf
Schedule an interview w 1 or more caregivers before birth – check with insurance to see if it covers such appointments; if it doesn’t, see if caregiver will charge a fee.
Finding Help After Baby’s Birth – family members and friends help by cooking meals, running errands, doing laundry, housecleaning and watching baby so parents can sleep/relax. Babys nurses or nannies can take care of baby while you do other activities and mother’s helpers cook and clean but don’t help with baby care or give advice.
Postpartum doula – someone (typically a woman) who’s trained and experienced with helping a woman and her family adjust to postpartum life by teaching them about newborns’ needs and abilities, and about infant feeding, sleep and cues, while providing assistant with household tasks; potential costs may seem daunting but help and care are well worth the price. Health insurance plans rarely cover. Put aside money during pregnancy.
Questions to Ask Potential Postpartum Doula (try to hire before birth)– www.dona.org/mothers/how_to_hire_a_doula.php
Training/education/experience; criminal background check; TB test, DTap vacc, CPR cert, philosophy, meet before birth, additional services, call with questions before birth; when do services begin after birth; experience with breastfeeding, fee, refund policy
Returning to Work – see if possible for family to delay returning to work (you or partner), if one can work part-time/job share, work from home, costs of returning to work – child care, more visits to baby’s caregiver (daycare), income exceed total costs making it worthwhile, how will person who works feel about other staying at home? See PCNguide
Finding Child Care for Baby – arrange well before birth; try to wait 3-4 months after birth before returning to work. Allow at least a month to find child care that best suits your needs. Ask coworkers/other working parents about child care. Consider sharing nanny/babysitter. Ask family members/friends. Stagger you and partners work schedule or work part time. Some works have day cares. If outside your home – see saferchild.org/caregiver.htm and www.childcareaware.org for advice on evaluating. Give appropriate holiday gifts to caregivers.
10 Steps to Improve Your Chances of Having a Safe and Satisfying Birth
Common Changes and Concerns in Pregnancy
Your Body’s Preparation for Pregnancy – reproduction anatomy includes internal and external structures. Labia, urethra, clitoris and vaginal opening are external genitals. These plus panus are perineum. Pelvic floor muscles. Internal – uterus (womb, shape of a pear), and vagina -stretchy tube-shaped canal. Lower part of uterus, which protrudes into vagina is cervix. Fallopian tubes provide paths for egg (ovum) to travel from ovaries (sex glands) to uterus. Ovaries produce female sex hormones estrogen and progesterone. During a cycle, egg matures in 1 ovary and causes increased secretion of estrogen, which along with progesterone stimulates growth of uterine lining (endometrium). Usually only 1 egg ripens each cycle and is released into one of your fallopian tubes. Ovulation occurs halfway through cycle. As fine hairs in fallopian tube propel egg slowly toward uterus, ovary produces more progesterone, which stimulates uterine lining to become a rich, nourishing home for a fertilized egg. If fertilization doesn’t occur, estrogen and progesterone levels diminish and your uterus sheds its unneeded lining (menstruation).
Conceiving Your Baby – he ejaculates ~1 tsp of semen, which contains 150-400 million sperm; they can live inside you for up to 3 days, while egg is viable for 12-24 hours after ovulation. Occasionally, woman ovulates more than 1 egg, resulting in fraternal twins, triplets etc or a single fertilized egg divides into 2 and produces identical twins.
Now That You’re Pregnant – breast changes – fullness/tenderness, tingling, darkened areola; fullness, bloating, ache in lower abdomen; fatigue and drowsiness; feeling lightheaded or faint; nausea, vomiting, frequent urination, increased vaginal secretions
Confirming Pregnancy – hCg – human chorionic gonadotropin, hormone only produced during pregnant. Take 1 test after missed period and another a few days later. Confirm via blood test.
Calculating Due Date – Pregnancy/Gestation lasts average 280 days or 40 weeks after first day of last menstrual period. Difficult to know exactly when ovulation occurred. Simple formula – subtract 3 months from date of last period and add 7 days. Optional ultrasound in early pregnancy to help estimate due date. Babies born healthy and normal any time from 3 weeks before to 2 weeks after; most babies born within 10 days; 5% born on due dates. Due date important to determine best time to do genetic testing, whether results of lab tests within normal range, to diagnose preterm or post-date pregnancy, or see if baby is growing more slowly or rapidly than normal.
Hormonal Changes During Pregnancy – placenta is the major source of hormones
First Trimester Changes for You and Your Baby – “Formation period” because by end of it baby’s organ systems are formed and functioning.
First 4 Weeks
2nd Trimester Changes for You and Baby – “Development” period – baby’s organs and structures begin to enlarge and mature.
3rd trimester changes for you and baby – “Growth period” – changes for an easy transition to life outside womb improve closer to due date.
39th/40th Weeks of Pregnancy
41st Week of Pregnancy and Beyond – Post-Dates
Common Concerns and Considerations in Pregnancy
Note to Expectant Fathers – may never felt so important yet so ignored, so committed yet so abandoned and so deeply in love and sexual yet afraid of sex. Share with other expectant fathers casually or in group.
Special Challenges in Pregnancy – past traumatic experiences can present additional challenges
Key Points: 1st trimester – formation period; 2nd trimester – development period; 3rd trimester is growth period
III. Stress management
Reducing Stress during Pregnancy – when anxious/feel stressed, body produces adrenaline and cortisol, which signal a “fight or flight” response, causing tight muscles, constricted blood vessels and elevated heart and breathing rates. In long term, chronic stress can constrict blood vessels to placenta and within it, reducing amount of blood and nutrients to growing baby. may increase chances of preterm labor or decrease bay’s birth weight even if not preterm. High anxiety can also affect baby later in life by increasing her chances of developing behavioral and neurodevelopmental problems, such as ADD/hyperactivity, anxiety disorders and language delays.
What causes chronic stress? Any situation or event that upsets you can cause chronic stress if left unmanaged. Examples include demanding job, financial worries, unstable home life, problems with partner, loved one’s illness or violence or danger in life. May have an extreme reaction to everyday pressures because of unresolved or untreated anxiety from a pervious traumatic event (including emotional, physical or sexual abuse), a chemical imbalance that causes your brain to interpret minor stresses as major ones, or hormonal changes.
Coping with Chronic Stress –
Finding Your Own Way to Cope with Labor Pain: The Three R’s: Your response will depend on nature of your labor, your coping style, your goals/expectations and how prepared you feel for labor. Those who cope well have 3 behaviors in common: 3 R’s: Relaxation, Rhythm and Ritual.
Relaxation: May move about between contractions and let their muscles relax during contractions. May become active during contractions (swaying, rocking, stroking bellies) and relax only between contractions. Or may remain quiet and unresponsive to their surroundings during and between contractions.
Rhythm: Rhythmic activity calms the mind and lets a woman work well with her body. May rhythmically breathe, moan or chant during contractions. May rhythmically tap or stroke something or someone. May rock, way or dance in rhythm. May curl her toes in rhythm. Partner or doula’s role is to enhance the rhythm and reinforce it through contractions. Can breathe/sway in rhythm/dance/direct.
Ritual: Repetition of meaningful rhythmic activity during contractions. Relaxation, breathing (223) and attention-focusing (208) common rituals that childbirth educators teach. Help women in early labor establish effective coping style. Most spontaneously adapt their planned rituals or find a new one to increase ability to cope as labor progresses. Partner’s behavior and actions can influence the effectiveness of a ritual. He must not do anything to change your ritual. Having someone act in same way during each contraction will be reassuring to you. May be: maintaining eye contact with you, repeating the same words or phrases, counting your breaths through each contraction. If focus is inward, partner may be close by and protect you from interruption. Can switch ritual at anytime – look to doula, partner or caregiver for suggestions. Hospital policies, options or interventions may limit your options so make sure to practice one you can do during disturbances, such as self-talk (silent or vocal), tapping or stroking. Ex: rock in rocking chair, partner stroking leg, partner points out when halfway through contraction; swaying through contractions
Comfort Techniques for Labor: Remembering labor pain is part of process helps keep pain manageable. Think about what helps your relax: listening to music, massage, soothing voices, warm bath, meditation, praying, chanting, humming, recalling pleasant places, visualization, empowering images. Think about what makes you feel safe. PCNguide.com download comfort techniques.
Tune in to pain or tune out the pain.
Attention Focusing: Visualization: picture uterine muscle contracting and pulling our cervix open. Visualize baby pressing cervix open. Imagine calm, pleasant places. Recall happy, peaceful events. Visualize each contraction as a steep hill to climb, wave to ride…
Cognitive Attention focusing: thinking/saying words of song/poem/verse/prayer – direct attention away from pain: counting with rocking/swaying/walking/ dancing /tapping/stroking.
Visual Focus: partner’s face, picture, reminder of baby, flower, view, focus on a line.
Sound: favorite music, partner’s soothing voice, repeated rhythms, recording of rhythmic environmental sounds by moaning, sighing, counting breaths, singing, reciting poems/prayers, chanting. Low-pitched sounds better.
Baths/Showers: can help body relax – try to stay in for at least 20 min. Bath pillows/lean against folded towels. Can kneel over side of tub. Temp close to body temperature so don’t overheat. Studies show no infection after membranes ruptured. Can also lower blood pressure. Can slow labor in early labor so take shower instead. Active labor, bath speeds up labor while delaying intensity of pain.
Foods and Fluids: high carb (fruit, pasta, toast, rice and waffles). Easy to digest food/beverages (soup, broth, herbal tea). May become less interested, but hunger (or low blood sugar levels) may decrease tolerance for pain. If not hungry, to keep hydrated: can sip clear broths, popsicles, water, tea, juice, sports drink. Empty bladder often as it may slow labor/increase pain. Recent studies women eating/drinking during labor no disadvantage for low risk. IV if vomiting, prolonged labor to prevent dehydration. Rolling IV moves around. If dry mouth – ice chips, popsicle or sour lollipop. Brush teeth/rinse mouth with cold
Heat and cold: Electric heating pad/hot water bottle on lower abdomen, back, groin or perineum relieves labor pain. Cloth bag/sock filled with rice and heated in microwave. Soak washcloths in hot water; wrapping in plastic retains heat longer.
Cold pack on lower back can relieve back pain. Ice packs for perineum after birth. Cool wet cloth, bag of ice cubes or frozen peas, frozen wet washcloths, cold cans of soda, frozen gel packs w straps. Wear warm robe or use blanket.
Have partner hold in hand for few seconds without pain and have cloth in between source and skin. If have pain medication, avoid using on numb areas.
Comfort Items: Rolling pin/rolling massage devices, gardener’s foam knee pad, shawl/rebozo, warm blanket and socks, fan, iPod, transcutaneous electric nerve stimulation (TENS), birth ball
Birth Ball – Since forces you to have proper posture when you sit, decrease muscle strain. To help relax trunk and perineum, sit on ball and sway hips side to side. Relieve back pain and adjust baby’s position, ball on bed and kneel on bed or stand next to it and lean over ball. Sway hips from side to side or front to back. Practice before labor. See below.
Massage and Touch– two of most effective ways to direct attention away from labor pain. Firmly stroke, rub or knead your neck, shoulders, back, feet or hands. Lightly stroke back or thighs. Press firm on tense areas such as hips, thighs, shoulders, hands, lower back. Tightly embrace partner. Shower head. Lightly rhythmically stroke belly, following lower curve of uterus – imagine stroking baby’s head. Dust hands with baby powder. Match movements with breath.
Crisscross Massage– ease back pain and relax lower back muscles. Kneel forward on hands and knees or over birth ball or lean forward onto counter, chair or birth ball. Flex hips so thighs are about 90 degrees from spine. Partner stands or kneels next to you, facing your side. Places hand on each side of your body at narrowest part of waist. Presses into sides, moves each hand up and over back following waistline
Acupressure for Comfort and Progress in Labor: Hoku (back of hand where thumb and index bones come together) and Spleen 6 (inner side of leg, 4 fingers above anklebone). 10-60 seconds, rest for same amount before repeating 3-6x. Reduce pain/speed up labor. Don’t press before due date – preterm labor.
Partners: practice beginning contraction to end; practice with ice cube with and without comfort measure; remind mama to move around; be aware of facial expressions and tone of voice
Relaxation and Tension Release: Remaining relaxed especially important in early labor. Practice releasing muscle tension then so you get used to it. If you tense up in early labor, you’ll have trouble relaxing later.
Recognizing Muscle Tension: in order to release muscle tension, must be able to recognize. Make right tight fist, feel muscles in forearm with left hand. Relax, feel muscles. Shrug shoulders towards ear. Lower and feel.
Passive Relaxation – lie on side or sit in semi-reclined position with floor or bed supporting head/limbs. Can put pillows under/between knees, beneath head or under belly. Begin breathing slowly, easily and fully – this is how you breathe as you fall asleep. Your body and mind release tension and thought, your breathing slows and you pause slightly at the end of each inhalation and exhalation (observe someone as they fall asleep). Have partner read script in a calm, slow, relaxed voice. Take a couple breaths after you release each area.
Relaxation Countdown: After mastering passive relaxation, use following to release tension quickly. Helpful when you want to fall back to sleep, stressed, or when trying to relax after a contraction
Inhale through nose and exhale out mouth, releasing muscle tension in the following order: Head, neck, shoulders; arms, hands, fingers; chest and abdomen, back, buttocks and perineum; legs, feet and toes. Use 5 slow breaths at first (1 for each of the 5 areas). Then try slowly exhaling one deep breath for all 5 areas (rapid relaxation countdown). During labor, first or last breath of each contraction can be rapid relaxation countdown.
Progressive Relaxation Script: Yawn/Exhale completely; Focus on toes, feet – how warm they are. Think how floppy and loose ankles are – they’re relaxed. Focus on lower legs. Knees – wiggle them to see how relaxed they are. Thighs – large strong muscles are soft and relaxed. Buttocks and perineum- needs to be especially relaxed during labor so let it become soft and yielding. Tissues of perineum will spread to let baby make her way out. You’ll let perineum relax and open for your baby. Lower back – someone with strong, warm hands is giving you a back rub. It feels so good. Your muscles are relaxing, and your lower back is comfortable. Notice the tension leaving your back. Let belly muscles relax. Let belly rise and fall with in breath in and out. Focus on baby within your uterus. She’s floating or wiggling and squirming in warm water of your womb – a safe baby where you’re meeting all your baby’s needs for nourishment, oxygen, warmth, movement, and stimulation. Your baby can hear your heartbeat, your voice, my voice, and other interesting sounds. What excellent care you are giving your baby. Now, chest. As you inhale, your chest swells easily, making room for air. As you exhale, your chest relaxes to help air flow out. Breathe easily and slowly, almost as if you’re asleep. Inhale through nose and out mouth- slowly and easily, letting air flow in and out. At top of inhalation, notice just a little tension in your chest, which you can release with an exhalation. Listen as you exhale. Your breath sounds relaxed and calm, almost as if you were asleep. Every exhalation is relaxing. Use your exhalations to breathe away any tension. Good.
Touch Relaxation– during labor, use partner’s touching as a cue to relax. Lie on side or sit in comfortable position. Contract muscle and have partner use a firm yet relaxed hand to touch tense area. Release tension and relax into partner’s hand. Imagine the tension leaving that part of the body. Try different touches: still touch (partner places relaxed hand on tensed area while you release tension until you’re relaxed); firm pressure (partner firmly presses tense area, then gradually relaxes the pressure as you release the tension); stroking (lightly strokes in direction of fingers or toes for arms and legs and in circles on belly); massage (firmly rubs or kneads tense muscles; give feedback on pressure). Partner: keep one hand in contact with body; when mom closes eyes, hard to relax if partner’s touch disappears. Practice on: eyes/brow; jaw; neck; shoulders; arms and hands; abdomen; buttocks; legs and feet.
Movements and Positions for Labor: may speed up labor by changing shape of pelvis and by using gravity, both of which help baby rotate and descend into birth canal. Being upright might give greater sense of control and active involvement than lying down. During 1st and 2nd stages of labor, can sway, rock, etc. Change positions every 30 minutes
Breathing Techniques as Comfort Measures: When you swim, run, practice yoga, sing, or play a musical instrument, you need to regulate your breathing to perform effectively and efficiently. Breath awareness has the following benefits: enhances relaxation, helps reduce pain by supplying your muscles with oxygen, provides a focus to calm you and distract you from pain. Breathing won’t make labor pain completely disappear, but it’ll help make pain more manageable.
Avoiding Hyperventilation: When you breath too deeply or too quickly (or both), you exhale too much carbon dioxide, which alters the balance of oxygen and carbon dioxide in your blood and may cause over breathing. While rarely serious, it makes you feel lightheaded or dizzy, or can make your fingers, feet, or the area around your mouth tingle. If you master rhythmic breathing before labor, you’ll unlikely hyperventilate during contractions. If it occurs: breathe into cupped hands, a paper bag or a surgical mask; hold breath after a contraction until you feel need to inhale – this will allow carbon dioxide levels in your blood to normalize; relax and reduce tension/anxiety – take a shower, bath, have a massage, use touch relaxation or listen to music; breathe with a slower rhythm or breath more shallowly. Partner can help with a visual cue (like orchestra), talking to you, or rhythmic stroking or by breathing with you.
Slow Breathing: can calm you in labor. Keys are keeping an even rhythm and trying to release tension during exhalations. Begin using when contractions become so intense that you can’t walk or talk through them or can’t be distracted from them. Use it for as long as it comforts you – probably until you’re well into the first stage of labor and possible all throughout labor. Shift to light breathing or a variation if you strain to keep your breathing slow at the peaks of contractions.
Rehearsing Slow Breathing for Labor: rehearse until your confident in using for 60-90 seconds a time (typical length of contraction). Practice with different positions. With each exhalation, focus on relaxing different part of your body (See pg 219 for Roving body check) so you can relax every muscle that’s not required to maintain your position. If uncomfortable to inhale through nose and out mouth, can breathe through only which is comfortable. May want to let belly expand first, then chest as you inhale deeply (belly breathing). Or may let chest expand as you inhale (deep chest breathing). Make sure its rhythmic, calming and relaxing.
Light Breathing: helps manage labor pain when you can no longer relax during contractions, when contractions are too painful with slow breathing, or when you instinctively begin speeding up your breathing. Many women switch when contractions are close together and intense. When in active labor, let responses to contractions help you decide when to use. If partner notices you losing rhythm, tensing, grimacing, clenching your fists, or crying at peak of a contraction, he may suggest switching to light breathing.
Rehearsing Light Breathing for Labor – you may not feel this is right for you when you practice – may make you tense or that you’re not getting enough air. With practice, it will become 2nd nature and you’ll be able to work with body easier during labor. Will come more naturally as labor becomes more intense. Just as running makes you breathe faster to meet oxygen needs. Take 1 breath every second or 2, for 10 seconds. If you take between 5 and 10 breaths in that time, you are doing it correctly. Continue for 30 sec – 2 minutes. When you can do effortlessly for 2 minutes, try adaptation is following seconds.
If you become lightheaded/dizzy, try to focus on exhalations, perhaps by making small sounds while exhaling such as “hee hee hee” or “puh puh puh” – by doing so, body will naturally inhale as much air as it needs. Breathing lightly through open mouth may cause dryness. Try touching tip of tongue to roof of mouth just behind teeth or hold moist washcloth near your mouth. During labor, may also sip water or other fluids between contractions or suck on ice or popsicle. Brushing teeth, rinsing mouth can also relieve dry mouth.
Partners: Interject encouraging works. Ex: 1, okay, 2 good, 3 let go, 4, just like that, 5 great. During labor, the # of breaths per contraction won’t vary significantly from one to the next, so you’ll be able to figure out peak and half over. Point out when she’s passed half way.
Adaptations to Breathing Techniques: ways to adapt rhythmic breathing by combining slow and light breathing patterns. During labor, try switching to one of these techniques to cope if you become overwhelmed or exhausted, can’t relax or begin to despair. May even discover a spontaneous rhythmic pattern of your own in labor.
Vocal Breathing: combines slow or light breathing with vocalization. As you exhale with each rhythmic breath, you moan, sigh, count, sing, recite poems, recite affirmations, chant or make or say other sounds or words. Low-pitched moans. Loud high pitches sounds, especially if lost rhythm, may indicate suffering or fear – partner can ask “Are the sounds you’re making helping you?” if they aren’t, partner can help lower pitch by moaning with you and maintaining your rhythm with the Take Charge Routine (pg 256). If it helps you cope, no one should change. Support team should keep doors closed so you can make sounds as you please.
Contraction – Tailored Breathing: use intensity of contraction to guide rate and depth of breathing. If contractions peaking slowly, breathe slowly when each contraction begins. As contraction intensifies, quicken and lighten breathing past the peak. As contraction subsides, gradually slow and deepen breathing. Think of each exhalation as a way to relax completely. If contractions are peaking quickly, slow breathing won’t help you cope. Instead, use light breathing throughout each contraction.
Slide Breathing – some women, especially with respiratory condition such as asthma, find that quicker pace of light breathing makes them uncomfortable and tense, regardless of how often they practice. If you can’t master light breathing after several attempts, slide breathing is a good alternative.
Inhale deeply and slowly, then exhale with 3 or 4 light puffs of air. Pause, then repeat process. To help guide breathing, say “in” to yourself as you inhale, drawing out the word to match the length of your inhalation, then say “out” with each puff of air you exhale. Although deep inhalations make slide breathing similar to slow breathing, the change in rhythm provides a different focus.
Variable Breathing: combines light, shallow breathing with a longer or more pronounced exhalation, sometimes called “pant pant BLOW” or “hee-hee-HOO” breathing. Just with slide breathing, this is an option for women who feel uncomfortable or short of breath when using light breathing. Also helpful for women who need breathing patterns to have structure.
Use light breathing for 2-4 breaths, then take another light inhalation followed by a long, slow, emphasized exhalation (the “blow”). The last exhalation helps you steady your rhythm and release tension. Some women emphasize it by making a drawn out “hoo” or “puh” sounds. Find a comfortable pattern and repeat throughout contraction. Partner can count breaths to keep rhythm. “1, 2, 3, Blow!” or can count breaths to yourself to focus attention.
Rehearsing Breathing Adaptations for Labor: include favorite adaptations and practice in various positions. Relax for only 30 sec or so between practice contractions to prepare for brief rest you’ll experience during late 1st state of labor. In this stage, contractions may last 2 minutes or they may occur in pairs with little break between the 1st and 2nd contractions (Coupling). Be prepared to use light breathing or its adaptations for up to 3 minutes without losing breath.
Using Breathing Techniques to Avoid Pushing – may have early urge to push at peak of a contraction – this urge is considered premature if it occurs before cervix is completely dilated. If you have urge and don’t know if completely dilated, alert nurse or caregiver – they can confirm dilation by vaginal exam. If dilation not complete, you’ll be asked to resist urge to push.
To avoid pushing, lift chin and either breathe deeply, pant, or blow lightly until the urge subsides. Can say/sing “puh, puh, puh” or “hoo, hoo, hoo” with each exhalation. When urge to push passes, resume rhythmic breathing for the rest of the contraction. Changing positions can also help reduce the premature urge to push (try hands and knees, side-lying and open knee-chest positions). These won’t take away body’s urge to push, but will keep you from holding breath and bearing down with urge.
Rehearsing Breathing Techniques to Avoid Pushing: occasionally practice a premature urge to push. Hold your breath or grunt as you breathe to signal to your partner that you have an urge to push. They can remind you how to resist urge until it passes. Rehearsing this can be silly and fun, but its good practice.
Comfort Techniques for Back Pain, Slow Labor or an Extra Challenging Labor – contractions may begin to couple or become irregular. Labor may become prolonged. Baby’s position may give you back pain (pg 285 for positions).
Positions and Movement – to reduce pressure of baby’s head on back or to speed up slow labor, use positions to help baby rotate into a better position or movements that decrease back pain
Asymmetrical Movement and Positions: Lunge, Side-lying and Semi-Prone- one side of body is doing something different than other side. Try on both sides. Use the side that’s more comfortable or alternate sides.
A Note to Fathers and Partners About Relieving Back Pain – the following can help reduce back pain and make her move more comfortable. If one doesn’t work, try another.
Other Comfort Measures to Reduce Back Pain – heat and cold, baths, showers and:
4 stimulating pads are placed on back, then connected to small hand held battery operated generated. Between contractions, set intensity to level that feels comfortable and set stimulation to burst mode. When contraction begins. Change stimulation to continuous mode. As back pain increases, increase intensity. Specially designed maternity TENS available – Bodyclock.net. Check with caregiver.
Comfort Techniques for 2nd Stage of Labor (Pushing)
Many of comfort techniques during first stage also helpful during 2nd stage.
Working with urge to push in labor – around time cervix becomes completely dilated, your breathing rhythm will change and you’ll feel pressure on your pelvic floor as your baby moves deep into your pelvis. These developments will cause you to have an irresistible urge to push. At first, you may mistake this urge for the need to have a bowel movement. (if have epidural, will feel urge to push much less clearly or might not feel it at all)
Spontaneous Bearing Down – your responses to contractions during the 2nd stage will depend on the sensations you feel. Will probably feel several strong surges (irresistible urges to push) during each contraction. Each surge will last a few seconds. During a surge, you’ll use expulsion breathing. Breathe using whatever technique suits you until you have an urge to push and body begins bearing down. Bear down for as long as you feel the urge. Then breathe lightly until you feel another urge or contraction ends. Expect to bear down 3-5x per contraction, with each effort lasting ~5-7 seconds. Between contractions, rest and relax.
How hard you bear down in response to an urge is similar to how hard you sneeze in response to an irritant in your nose. Both sneezing and spontaneous bearing down are involuntary reflexes. Sometime you need 1 tiny sneeze to clear an irritant; other times, you need several explosive sneezes. Sometimes you need to gently bear down; other times you feel compelled to push with all your strength.
Spontaneous bearing down is recommended if labor is progressing normally and you haven’t had anesthesia. If you have, you’ll use delayed or directed pushing since it diminishes the pushing sensations and the effectiveness of your ability to bear down.
Using spontaneous bearing down in labor –
Rehearsing Spontaneous Bearing Down for Labor– when practicing comfort techniques for 2nd stage of labor, bear down just enough to feel your pelvic floor bulge. Don’t bear down forcefully. To practice more effectively, use different positions and imagine what will be happening when you’re pushing in labor. Visualize your baby descending and rotating into your birth canal. Remind yourself that contractions are proof that your baby is working to be born and it’s important to relax and bulge your pelvic floor.
Directed Pushing – unlike with spontaneous bearing down, when you push in response to an urge, directed pushing is bearing down when someone tells you to do so. You’ll use this if:
Directed pushing is typically more forceful than spontaneous bearing down, which means it may be more stressful for both you and your baby. For this reason, many caregivers reserve this type of pushing for births that may require forceps delivery or vacuum extraction. Before the birth, check whether directed pushing is routine for your caregiver or birthplace. If it is, find out when and under what circumstances it’s used.
Using Directed Pushing in Labor – caregiver, nurse or partner will tell you when, how long and how hard to push. Can use various positions
Directed pushing will continue for each contraction until your baby’s head is almost out. At that point, your caregiver may tell you to stop pushing to allow your baby’s head to pass slowly through your vaginal opening. Relax and exhale completely to decrease your risk of developing a vaginal tear.
Rehearsing Directed Pushing for Labor – since told when and how hard to push, practice only enough to coordinate holding breath with bearing down and bulging pelvis, as partner coaches you through the contractions as described above. May find it helpful to occasionally hold breath and bulge your perineum during perineal massage.
Prolonged Directed Pushing – requires you to hold your breath and push hard for 10 seconds. Caregivers generally don’t recommend, but some circumstances require it. Because you’d only use under guidance, no need to practice it.
Positions for 2nd stage of labor – just as moving around/changing positions helps in first stage, can help during 2nd stage. Until in labor and ready to push baby out, you won’t know which positions will feel right. Try to practice spontaneous bearing down in all positions so you’re prepared to effectively bear down while in any of them.
If baby descends rapidly, you might not have the time or desire to change positions, however, if 2nd stage progresses slowly, you’ll have a chance to try many positions.
Other factors may influence the positions you can try, such as caregiver’s preferences or your willingness and freedom to change positions. Some procedures/equipment may impair your mobility, including electronic fetal monitors, catheters, anesthetics, IV equipment and narrow beds. With help and encouragement, you can work around these.
Discuss birthing positions when preparing birth plan. Although some are comfortable with any, most are confident only with supine or semi-sitting position for delivery. Ask whether you can use other positions that allow the pelvic outlet to open fully during beginning of pushing until baby is close to being born.
Prenatal Perineal Massage – stretches inner tissue of lower vagina. Teaches you to respond to pressure in vagina by relaxing pelvic floor muscles; a rehearsal for responding to sensations of vaginal stretching during birth.
Enhances hormonal changes that soften connective tissue during late pregnancy, which can reduce chances of needing an episiotomy or developing a serious tear during birth. Massage your perineum 5-7x a week during the last 5-6 weeks.
Some caregivers aren’t familiar or don’t recommend. Some women find it distasteful. Others feel it is worthwhile. Some may even find it enjoyable after they’ve learned to relax while it’s done.
If you have vaginitis, genital herpes sore or other vaginal problem, perineal massage may worsen condition. Wait until problem is completely gone before beginning.
How to Do Perineal Massage – you or partner can do with clean hands and short fingernails. If either has rough skin, use disposable vinyl or latex gloves. If doing yourself, may want to use mirror to help guide.
Practice time as a Rehearsal for Labor – learn how to work with partner to use techniques effectively. Practice enough so you’re comfortable with them and review periodically. Visit. PCNGuide.com for a practice guide. Practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.
Lack of Exercise – prevention of cardiovascular disease and in management of chronic conditions such as hypertension, arthritis, diabetes, respiratory disorders and osteoporosis. Exercise also contributes to stress reduction, a mood enhancer and weight maintenance. Aerobic exercise produces cardiovascular involvement because and increased amount of oxygen is delivered to working muscles. Anaerobic exercise such as weight training improves individual muscle mass without stress on the cardiovascular system. Weight bearing aerobic exercises such as walking, running, racquet sports, and dancing are preferred. Excessive/strenuous exercise can lead to hormone imbalances, resulting in amenorrhea and its consequences.
Stress – many women thrive in busy surroundings. However, excessive or high levels on ongoing stress trigger physical reactions such as rapid heart rate, elevated blood pressure, slowed digestion, release of additional neurotransmitters and hormones, muscles tenseness, and a weakened immune system. Flare ups of arthritis or asthma, frequent colds or infections, gastrointestinal upsets, cardiovascular problems and infertility. Psychological symptoms such as anxiety, irritability, eating disorders, depression, insomnia and substance abuse have also been associated with stress.
Depression, Anxiety and Other Mental Health Conditions – depression sometimes described as a co-traveler because it exists comorbidly with other physical conditions. At extreme, creates a risk for suicide, greater risk for developing cardiac disease if have anxiety and depression. Can experience other mental disorders such as bipolar.
The “fight-or-flight” and “Tend-and-befriend” responses to distress and fear in labor
“Fight or flight” response is a physiologic process that promotes survival of endangered or frightened animal/human and is triggered by outpouring of catecholamines or stress hormones. Triggered by physical danger, fear, anxiety or other forms of distress, it has potential of slowing labor progress. During most of 1st stage, excessively high levels of circulating catecholamines cause maternal blood to be shunted away from uterus, placenta and other organs not essential for immediate survival to the heart, lungs, brain and skeletal muscle, the organs essential to fight or flight. Decreased blood supply to uterus/placenta slows uterine contractions and decreases availability of oxygen to fetus.
Fear/anxiety also causes woman to interpret caregivers’ words or labor events in a pessimistic or negative way. High levels of catecholamines prevent woman from entering instinctual mental state, sometimes called “the zone”
As woman nears 2nd stage of labor, which requires alertness and great physical effort, outpouring of catecholamines normally occurs and has beneficial effect of speeding birth by causing fetal ejection reflex. Many women briefly exhibit fear, anger or even euphoria, typical catecholamine responses, just before birth.
Although physiology of fight or flight response is similar in men and women, behavioral differences exist between the two sexes. Males’ responses follow fight or flight pattern (fight to protect self, family, village or country against dangerous attackers, or flee from danger if odds are too great), females’ behavioral responses characterized by pattern of “tend and befriend” which refers to protecting their young from harm and reaching out for help or affiliating with others to reduce risks to themselves and their offspring. Women want and need supportive people around them during labor. In face, absence of this kind is one of the most frequently mentioned reasons for later dissatisfaction with childbirth and is associated with PTSD after childbirth. A woman’s protectiveness toward her child is evident when told by a respected caregiver that her baby is in danger. She will quickly agree to whatever treatment is suggested; however, if she does not trust caregiver, she may try to protect child by resisting suggested treatment.
Maternal Effects of Anxiety (Tend and Befriend Response) in Labor
Excessive maternal catecholamine levels in 1st stage of labor:
Excessive catecholamine levels in 2nd stage labor:
What’s Going on During Pregnancy?
Chart on pg 4 in handbook helps to keep expectant parents focused on development of baby, along with physical and emotional changes they themselves are experiencing. Discussions of pregnancy discomforts, exercise and nutrition can easily tie into the changes noted in the 3 trimesters of pregnancy.
Update: Birth Hormones. Childbirth Connection is to publish online Hormonal Physiology of Childbearing by Dr. Sarah Buckley, author of Gentle Birth, Gentle Mothering. Evidence based info on orchestration of labor, birth, breastfeeding and attachment by “Birth hormones” – oxytocin, endorphins, catecholamines, and prolactin. Receptors for oxytocin, endorphins, and prolactin increase throughout pregnancy in preparation for labor, birth and the postpartum period. Believed that prolactin during pregnancy helps pregnant women deal with stress.
Small group activity/learning task – if male/female couples, divide by sex into small groups. Give each flip chart and markers. Ask to discuss and record answer on chart – how have you changed during this pregnancy? How has your partner changed during this pregnancy? Make own notes to ensure important parts you wish to make are covered. (Pg 4 in workbook)
Guided discussion with visual aids – Emotions During Pregnancy graph pg IV-5. Video teaching fetal growth and development, especially helpful for early pregnant class to relate own physical/emotional experiences to growth/development of baby. Milner Fenwick’s “A Nine Month’s Journey” – short, comprehensive and visually appealing.
Books – A Child is Born, Understanding your moods when you’re expecting; In the Womb
DVDs: A nine-month journey; in the womb
Video Clip: the VisualMD “From conception to birth” www.thevisualmd.com/websearch/?q=pregnancy&at=video
Websites – Stress and pregnancy www.marchofdimes.com/pregnancy/lifechanges_indepth.html
Fetal Development – www.nlm.nih.gov/medlineplus/ency/article/002398.htm
Emotions During Pregnancy Chart – Good for PowerPoint slide pg IV-5
Teaching Relaxation: first learn to relax yourself, then it will be much easier to teach others. Begin with a recorded session that you play for your class as you join them in relaxing. Model a relaxing position as you introduce session with a soft, relaxing voice. Dim lights, play soft music and shut out distracting noises. Scripts in Prepared Childbirth – The Family Way (pgs 104-106). Begin and end sessions with time to slowly lead in and out of relaxed state – do not rush! Offer a variety of techniques for releasing tension as not everyone responds to the same method. Give time for couples to give feed back to each other. If they can’t communicate their needs now, they won’t be able to in a time of tension. Open discussion after.
Various relaxation techniques:
Biodots: small temperature sensitive pads which may be placed on each student’s hand before a relaxation session. Extremities warm as relaxation occurs, causing the Biodot on the hand to change color. Remind students to check the color of their dot, both before and after the relaxation exercise. A color key is usually included. ICEA bookstore sells. Can wear the next day to see how it changes according to activity/stress levels.
Spiraling relaxation into each class:
Class 1) progressive relaxation and tension awareness; hand massage
Class 2) Selective relaxation; release to touch; autogenic phrases
Class 3) Massage, stroking in various positions
Class 4) Visual imagery; positive affirmations
Class 5) Partners find mom’s “hidden tension” and help her to release it
Class 6) Review all relaxation skills in a labor rehearsal
References: The relaxation and stress reduction workbook; Mother massage – a handbook for relieving the discomforts of pregnancy; Massage during pregnancy by B. Waters
DVD: Penny Simkin’s Comfort measures for childbirth
Relaxation: Awareness Exercise: (sitting in chairs or on floor). Teach tuning into bodies and awareness of bodies early in pregnancy. Script summary “awareness of tension is mastered by consciously focusing on each area of your body – how it moves and how it feels and how it relates to the space around it. 1st, focus on surroundings, then move inward. Feel eye muscles as you look around – what do you see (colors of light, walls, ceiling). Be aware of what you see. What you hear (fan, outside noises). Smell (air, aromas, fragrances, like/dislike, think of smell comforting to you and remember it), feel your presence in this room – you are with others, in a building on this ground on this earth, which you are apart of. Can have eyes focus on point in room or inward. Take a cleansing breath and signal body to let go. Acknowledge thoughts and let them pass. Concentrate on head – tension may cause headaches or may be present with a busy mind. Many muscles and nerves in face and scalp. Think of a pleasant sensation for your head – good hair brush, shampoo/scalp massage, warm hair dryer, cool wind blowing through hair. Try to IMAGINE those you find pleasant (pause for several breaths). Lift fingers and run them through your hair in a way that feels good to you (pressing, massaging, scratching, stroking). EXPERIENCE that sensation now. Try to wiggle scalp. Find the muscles in your scalp – move them – then concentrate on the tension leaving as you allow them to release. Breathe air in through nose – feel it go to lungs and expand your chest/rib cage. Feel release of tension as you sign air out through mouth. Tune into how you breath. Movement of chest/belly. Feel cool air as you breathe in and warm air go to lungs. Can picture a color of the air. May breathe in relaxing color and release a different color. Try for several breaths. Consider jaw – is it tight with clenched teeth? Stretch it open wide, drag it down, yawn, let it go. Let it remain loose with teeth not touching. Move focus to shoulders. Rub them. Feel for tight muscles. Pull shoulders down toward feet to stretch tension away. Release. Drop chin to chest. Feel stretch in back of neck. Feel it with hands. Hold for several seconds. Lift head and look forward. Put right hand on left side of head and pull. Hold. Change hands. Put hands in lap. Think about hands and fingers. Stretch and release stretch. Think of all the wonderful things hands do for you. Cleansing breath and feel release in head, neck, shoulders, arms and down your back. Readjust sitting position. Rock pelvis to be sure you are sitting on “sit bones”. Let tension go from pelvis and let legs flow to your toes. Scan body from head to toe, paying attention to how each of you feels when tension has been released – head, scalp, face, eyes, jaw, tongue, shoulders, neck, arm hands, fingers, back, hips, legs, feet, toes. When you feel tension in any of these during the day, send a relaxing breath to that part. Breathe softy, consciously, with awareness. Return to a state of alertness, slowly increasing pace of breaths. Look around. Move hands and arms, feet, legs. Discuss experience with partner.
At home review of following on page 104 in handbook
Progressive Relaxation Script: If lying on floor: “Get as comfortable as you can. If pregnant, lie on side. Place pillow under head, between knees and under upper arm so you can release into pillows, feeling well supported. Partners – can place pillow on back and under knees. Legs uncrossed. Lying on floor and seated “Purpose of exercise is to learn how a muscle group feels when tense and when it is released. Let go of any worries in your mind. Allow a deep, soothing relaxation to come over your body. Take a deep breath in and let it out. Take breath in and let tension release with a sigh. Think about forehead – is it released or tense? Raise eyebrows in a look of surprise. Release. Frown and feel deep furrows in brow. Hold and release. Imagine someone smoothing your brow, with a warm hand or cool cloth. Move eyes slowly and hold briefly in each direction – look up, down, right, left. Feel tension in your eyes as you move them, then close softly, peering into darkness. Press lips in a tight pucker. Release. Part lips after moistening with tongue. Stretch an exaggerated smile and then release to a soft, relaxed smile. Press tongue to top of mouth – feel what a strong muscle it is – even it can carry tension. Release it to fall loosely in mouth. Bite teeth together gently. Feel tension in jaw as you hold even a gentle bite. Allow jaw to fall open so teeth do not touch. Stretch your jaw by dragging it down, wide open. Yawn if you wish. Allow jaw to close but keep it loose and slack. Pull head into shoulders like a turtle. Release. Let chin drop to chest. Hold. Arc chin to right shoulder. To left. Back to center. Clench fists – hold tight. Release. Be aware of the sensation. Stretch fingers long. Relax. Round shoulders forward. Feel stretch across back as you hold. Release. Pull shoulders back and down. Release. Pull arms tightly against your body. Hold. Now let rest loosely by side. Breathe deeply- filling lungs with air. Blow air out of mouth in a deep sigh. Feel belly rise and pull belly inward as you slowly exhale. Moms body will hug baby with the breath out. Release hug as you inhale and allow baby to float peacefully. Pinch buttocks together. Feel tightness. Release. Push feet and legs together. Release. Push hips and knees outward. Hold. Release. Flex right foot and stretch your leg. Drop foot and leg. Repeat with opposite. Curl toes gently without pointing foot. Hold feel. Release. Wiggle toes. Scan body, thinking of each muscle we just worked. Release them all. Concentrate on this feeling of relaxation. As your practice, the time required to reach this state will shorten.” With more energy “Now it’s time to leave this relaxed state. Do not move quickly. Take time to readjust. Think about the room you are in and the people around you. Be read for the lights to brighten. Slowly move arms and legs. When you are ready, return to a state of alertness. You will feel quite refreshed.”
Illustrations of following on pg 22-24 handbook
Release to Touch – practice in a variety of positions. Refer to illustrations on pg 22-24 in Prepared Childbirth – The Family Way.
Can be done in slow dance, walking and supported standing, but ideal positions are side lying, which provides partner with easy access to mom’s arms, legs, hips and back while she is fully supported and supported sitting, which allows partner to reach limbs, belly, face and neck, while maintaining eye contact.
Script: “Moms, take shoes off and find a comfortable position so you will feel fully supported as you learn to release to touch. Partners, take your place facing her if she is on her side or in front of her or to the side of her if she is sitting so you can reach her shoulders and arms, then hips and legs. Try to keep space on both sides of her as you will have to move around during this sequence. Partners- rubs hands briskly together to warm, then place both hands- warm and relaxed – on mom’s shoulder nearest you. Hold them there, allowing her time to release her tension toward the warmth of your hands. Both of you take a cleansing breath together as a signal to let go of your tension. Partner’s hands should be loose. Gently stroke down her arm with both your hands – all the way to the fingertips, “pulling” the tension from her body. Do not allow her hand to fall. Gently place it back where it was as your hands leave hers. Ask her if she wants more or less pressure. Repeat that motion on the same arm, adjusting pressure to suit her. Hands pause on her shoulder, stroke down the arm, off the hand. Her arm should now feel very loose and relaxed. Notice the difference in the feeling of relaxation in her two arms. Now, place your hands on the crest of her hip. Mom, release to the touch of warm hands as your partner strokes down the top and sides of the leg with both hands…slowly, gently, firmly…all the way to the foot. Pull all her tension out her toes. Ask her about pressure. Adjust it, then repeat stroking the leg from the hip, to the knee, ankle and off the foot. Move to opposite side and repeat the entire sequence. Hands pause on shoulder, stroke down the arm, off the hand. Move to hip, stroke down leg, all the way to her foot and out her toes. Now move to a position behind mom, so you can comfortably reach her shoulders and head. Place both hands together at base of her neck, with your fingers spreading to the tops of her shoulders. Gently press down with the heel of your hands. Mom, release your tension to the pressure of warm hands. Partners, move your touch to a new point on top of her shoulders and press down gently, firmly. Before we move on, ask mom if she likes having her head touched. If she does not, you can massage her shoulders again. Place hands on her head with your fingers touching and the heels of your hands above her ears. Moms, imagine that your partner’s hands are magnets that attract tension and pull it away. Partners, press in very gently with your hands, then just hold slight pressure on her head. Partner’s hand very slowly begin to release pressure, then barely touch your hair. Pull away slowly into the space around the head. Your tension has gone with your partner’s hands. Partners, shake your hands out, then repeat, adjusting again for pressure as she desires. If you are comfortable on side, back is open for touch. If sitting, lean forward so partner may touch and stroke down your back. When doing long strokes on the back, be sure that one of your hands maintains contact with her body at all times. Begin with the heel of your hand near her left shoulder. Stroke firmly with your open palm all the way down her back and hip. Before you release that hand from her hip, place your other hand near her shoulder, just to the right of your last stroke. When that hand begins to move, release the first hand from her hip. Slowly work across her back, hand over hand, stroke after stroke- until you reach her left shoulder. Keep your strokes firm and slow. Discuss your reaction with your partner. Did it help you release tension? Was any touch more irritating than relaxing? Then, reverse roles. Mom, stroke, press or massage partner in a manner to show him how you like to be touched. Demonstrate the pressure and speed you like, then listen to your partner’s feedback. You will probably find you like different types of touch. In the future, you will know how to touch your partner according to their desire, not yours.
Hand Massage: position partner’s hand so it is supported for relaxation, and for you to work comfortably with it. If you choose to use a massage oil or lotion, pour it on your hands, then rub it together to warm it before touching your partner’s hand.
Squeeze and hold gentle pressure with both hands, moving to various positions around the hand. Turning the palm up, use both thumbs to apply pressure in the middle of the palm, just under the knuckles, using counter-pressure on the back of the hand with your fingers. Hold for about 10 seconds. Slowly walk the thumbs randomly throughout the palm of the hand with slow, firm presses or circling motions. One finger at a time, rub on all sides of each finger from the palm to the fingertip. Turn the hand over. Grasp the hand with your thumbs together on the back of the hand. Pull your thumbs firmly to each side as if “breaking a popsicle”. Repeat several time. Supporting your partner’s hand with one of your hands, use your free hand to stroke from the wrist down to the tip of each finger and thumb. Massage and gently pull each finger. With your fingers toward the wrist, place one of your hands on top and one on the bottom of the hand begin massaged. Squeeze firmly and hold to a count of 5, then lighten the pressure and slowly pull your hands down the wrist and of the fingers. Repeat 3x.
Foot Massage: Position the foot so that it is supported in a relaxed position, and it is comfortable for you to work with it. Socks may be left on the feet or, if barefooted, you may choose to use a massage oil or lotion. Pour the oil or lotion on your hands and rub them together to warm it before touching the foot. Use firm strokes and both hands to massage the foot.
Squeeze and hold gently pressure with both hands, moving to various positions around the foot. Press just under the ball of the foot with your thumbs and hold for about 10 seconds. Walk the thumbs around the bottom of the foot with slow presses or circling motions. Use your knuckles to massage the instep and the outer edges of the heel. Use your fingertips to make small circles around the top of the foot. Stroke from the top of the ankle down between each toe. Massage and gently pull or wiggle each toe. Squeeze and release the top of the foot with both hands several times. Squeeze and release the bottom of the foot with both hands several times. With fingers pointing towards the ankle, place one hand on top and one on the bottom of the foot. Squeeze firmly and hold to a count of 5, then lighten the pressure and pull hands down the foot and off the toes slowly. Repeat 3x.
Visual Imagery: House of Colors – Discuss how colors affected them after this exercise. Did they learn anything about how colors make them feel? Were any colors more stimulating, stressful or relaxing than others? Can be a cue for colors to use in labor, nursery, or in home.
Script: Spend a few moments making yourself as comfortable as possible. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be your time…to experience colors.
As you participate in this imagery session, you may discover how different colors affect you. Some colors you may find relaxing, others more alerting; some may make you feel the sensation of warmth and others may cool you; some colors are pleasant and comfortable and others are not. First, notice this room. Think of the colors you see, and the textures and temperature you feel around you. Then you may wish to close your eyes and take a brief journey in your mind to the remarkable House of Colors.
Imagine if you will, walking up the sidewalk to a fascinating old Victorian style house. Now imagine walking up to the front door. You turn the door handle and enter the first room of the house. This room has been completely decorated in the color red. The ceiling is red, the walls are red, the floor is red, everything in the room is red. What objects do you see in your red room? Pause. Notice how you feel in the red room. Notice how you feel being completely surrounded by the color red. Even the air you breathe is red. Pause. Now prepare to leave the red room behind and open the door to the next room – the orange room.
Repeat with rooms of other colors – Yellow, Green, Blue, Purple, White. The room has been completely decorated in the color ____. The ceiling is _____, the walls are _______, the floor is _______, everything in the room is ______. What objects do you see in your _____ room? Pause. Notice how you feel in the _____ room. Notice how you feel being completely surrounded by the color ______. Even the air you breath is ____.
Now it is time to leave the House of Colors. Imagine yourself leaving the white room, going out the back door, and walking around the front walk, to the sidewalk. Pause. Now it is time to return to this classroom. Remember the colors and lights in this room. Feel the floor under you. Move your arms and legs a little. When you are ready, let your eyes open.
Visual Imagery: Your Special Place
Script: Spend a few moments making yourself as comfortable as possible in any position you choose. You may take off your shoes, glasses, and put them safely aside. Settle into your pillows, and let the next few minutes be your special time. Visual imagery is really just directed daydreaming. I will ask you to imagine a place where you can become very relaxed. This can be a place that really exists, or simply a place in your imagination. Perhaps you will remember a special vacation – sunning on a warm, sandy beach; enjoying a fireplace in a cabin in the woods; or lounging in a hammock by a cool mountain lake. Or, this can be a place where you have never been, but perhaps have dreamed about. It doesn’t even have to be a real place. In your own imagination you can even be floating on a cloud. It doesn’t matter. The important thing is that this place can become very special to you – it is a place where you can totally relax and enjoy yourself now, and can return to at any time.
Now, if you have settled in, allow a deep, soothing relaxation to come over you as you participate in this imagery exercise. Take a deep breath in…and gently let it out. Take another deep breath in…and gently let it out. As you take a third deep breath in, feel yourself release comfortably into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions. Picture yourself now, leaving this room…and the are where you live. Your imagination takes you to a road. Walk along this road until you come to a spot where you can see forever. Look out from this spot and find an inviting and comforting place…a place in your mind that will become your special place… Pause
Now imagine that you are there in your special place. Pause. Are you by yourself? Or is there someone with you? Pause. What are you doing? Pause. When you look around, what do you see? Pause. Are you indoors? Or outdoors? Pause. What does the air feel like around you? Pause. Are there any special smells in this place? If so, take a moment to enjoy them. Pause. When you listen, what sounds do you hear? Pause. Are there any special sensations that you feel? Take a few moments to enjoy all the sensations that you are feeling in your special place. Enjoy the feeling of relaxation. Pause.
Remember, that anytime you want to, you can return to your special place in your mind, and you can feel the peaceful relaxation that you are enjoying now. Pause.
Look around you before you say goodbye. Now it is time to leave your special place and return to the spot where you could see forever. Walk along the road in your mind, until you return to this room. Feel the floor beneath you. Remember the colors and the lights in this room. Begin to stretch your arms and legs a little. And when you are ready, let your eyes open and come to a sitting position.
Visual Imagery: Birth (for all relaxation and imagery exercises, speak slowly and clearly)
Script: Spend a few moments making yourself as comfortable as possible. You may wish to take off your shoes, and if you wear glasses, you may take them off and put them safely aside. Choose the position that is most comfortable for you. Your arms and legs should be bent at every joint and separate with pillows so that you can be totally release. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be *your* time. Do nothing at all except allow a deep, soothing relaxation to come over you as you participate in this imagery session.
Although this exercise is directed to the pregnant women, I would like the partners to imagine what is happening to her and how you will be able to best support her when it comes time for the baby to be born.
Take a deep breath in, and gently let it out. Take another deep breath in, and gently let it out. As you take a third deep breath in, feel yourself release comfortable into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions.
For this exercise, I would like you to imagine your baby’s birth. It may occur a few days before, or after your due date, or even exactly on the day that you have been expecting your baby. In this exercise, you will think about the sensations that I will be describing, but you will not actually experience these sensations until it is time for your baby to be born.
Think for a moment about the positive aspects of your pregnancy…the amazing way that your belly has grown to make room for your growing baby…the way your breast have gotten bigger to prepare for nursing your infant…the way that your baby communicates with you by kicking and moving around. Many scientists think that when the time is right, your baby will release tiny amounts of a hormone that will instruct your uterus to being contracting. Pregnancy is an amazing, natural process. You are feeling strong, healthy, and confident about giving birth.
Toward the end of your pregnancy, your hormones will instruct your body to prepare for birth. Your cervix may move from a position tilting towards your back to facing forward, right into the birth canal. Your cervix will soften, “ripen”. Periodically you may feel the uterus tighten, as it begins to prepare for labor. These contractions will come and go intermittently, whether or not you feel them. Your baby will settle down into your pelvis. On the day of your baby’s birth, these contractions will gradually become stronger, longer, and closer together…and they will continue to occur…instead of stopping as they have done on previous days. The cervix will stretch and open: 3 cm, 5 cm, 7 cm…this process takes time. Each contraction sends a signal to your brain to release oxytocin. The oxytocin will cause contraction to increase in strength,. And, as the strength increases, labor will progress, and you will be that much closer to holding your baby.
You will find that the pain of labor has a purpose. It will help you discover ways to help your labor progress. You will move and change positions in response to pain. You may walk…slow dance to the music you bring with you…stand under warm water in the shower…or do pelvic tilts on all fours r on your bed. Moving in response to the pain of contractions will actually help you…and will encourage your baby to move into position and down the birth canal. Narcotic-like endorphins are released by your brain in response to pain…to decrease your perception of pain. High levels of endorphins also allow you to “go into yourself,” and tune into your natural instincts, which will help you to manage your labor. Your internal focus on your labor will become more important to you that the surrounding environment. But you will want to have people with you who will encourage you quietly and patiently, so that you will not be afraid. You will feel totally supported, and comforted, as you flow with your labor. Even if labor is long, you will have the energy you need to persevere. You will rest between contractions, paying no attention to the time. Even 30 seconds of rest is a gift. Surround yourself with people who trust the birthing process and who will know that you have the strength and the confidence to give birth. Labor is hard work, but you can do it.
Finally, your cervix will open to 10 cm. your body will rest for a few minutes, then you will begin to feel an urge to push. You tune into the strong sensations that you are feeling, and bear down with your contractions. Your baby will move and rotate, find a way through the birth canal.
After your final push, you will reach out to hold your baby. You will feel joy, excitement, relief, and pride. You and your baby will gaze at one another…in awe of one another. Slowly your baby will nuzzle at your breast, then begin to suck. Sucking will cause oxytocin to be released, and the uterus to tighten. You will then push out the placenta with very little effort. It is a perfect design. The miracle of birth will overwhelm you. A new star in your family constellation will change you forever.
As we end this birth visualization, I would like you to return your mind to the classroom. While you are still relaxed, take a moment to think about what you need to make your birth experience what you want it to be. Pause.
Over the next week, talk to your partner, and to those who will be with you during labor and birth…about those things that will help you to give birth as you wish. Will you have the support and encouragement you need? …the freedom to move around and choose the comfort strategies that best help you? … The patience to let the miracle of birth take place as rapidly or as slowly as it is meant to happen for you? Pause
When you feel ready, slowly begin to increase your breathing rate, move or stretch your arms and legs, then come to a sitting position.
Health Screening Guidelines and Immunization Recommendations for Women Ages 18+ – pneumococcal (1 or 2 doses between 19-64; 1 after 65); herpes zoster/shingles (1 dose at 65); HPV (primary series of 3 injections for girls ages 9 to women 26; those not previously exposed)
Nutrition – half plate filled with fruits/veggies, 1 quarter with grains, 1 quarter protein.
Folic acids helps reduce high levels of homocysteine, an amino acid that damages the heart and blood vessels and increases the risk of heart disease, stroke and dementia; present in citrus fruits, broccoli, spinach, asparagus, peas, lettuce, beans, whole grains and OJ.
Antioxidants prevent oxidative damage in body such as cancer, heart disease, stroke.
Most women do not recognize importance of calcium to health.
Exercise – 150 min per week of moderate or 75 min per week of vigorous. Moderate 30 min a day, 5x a week. Divide 30 min per day into 2-3 segments of 10-15 min. Physical inactivity increase with age, especially during adolescence and early adulthood. It reduces risk of colon and breast cancer. Brisk walking, hiking, stair climbing, aerobic exercise, jogging, running, bicycling, rowing, swimming, soccer and basketball. Home maintenance, yard work, and gardening good for older adults.
Kegel Exercises – control/reduce incontinent urine loss. Hold for 10 seconds, rest for 10 seconds. Can start with 2 seconds and build up. Should feel pulling over the 3 muscles layers so contraction reaches highest level of pelvis.
Stress Management – women 2x as likely as men to suffer from depression, anxiety or panic attacks. Women experiencing major life changes such as separation and divorce, bereavement, serious illness, and unemployment need special attention. Role playing, relaxation techniques, biofeedback, meditation, desensitization, imagery, assertiveness, training, yoga, diet, exercise and weight control are all techniques to help.
Substance Use Cessation – most people stop several times before they accomplish their goal. Many are never able to do so. Use of drugs at an early age tends to be a predictor of greater involvement later.
Sexual Practices that reduce risk – vaccinated with HPV – series of 3 vaccinations to prevent cervical cancer
Health Screening Schedule – early diagnosis of problems; portions now being carried out at events such as community health fairs
Health Risk Prevention – injuries continue to have a major effect on the health status of all age groups. Wear seat belts at all times. Wear safety helmets. Follow driving rules. Place smoke alarms throughout home and workplace. Avoid secondhand smoke. Lock doors and windows.
Lecture/Discussion: Pain Management Theories
The Fear-Tension-Pain cycle is an old standard that still gives good rationale for what we teach. Draw the circle on a board or poster or display the PowerPoint slide. Show how the cycle can be changed:
(Consider ICEA certification program Dr. Sears L.E.A.N. for additional training in this topic http://www.icea.org/content/become- dr-sears-lean-certified-health-coach)
Eating Well – before & during pregnancy has huge impact on health baby’s well being
Good Nutrition during Pregnancy – include plenty of fresh fruits and veggies, whole grains, dairy, protein and 2 quarts of liquids. Eat small, frequent meals to keep blood sugar level stable, reduce morning sickness in 1st trimester and reduce heartburn in 3rd trimester. Beginning in 2nd trimester, consume 200 more calories a day (assuming you exercise for 30-60 min). in 3rd trimester, consume 400 more calories, ideally from high-protein, high-calcium and iron0rich foods.
MyPlate: Recommended Food Groups – has customized information for specific audiences, including pregnant/breastfeeding www.myplate.gov
To analyze daily diet, visit www.mypyramidtracker.gov – how much of each nutrient you’ve consumed
Grains – wheat, rice, oats, cornmeal, barley or rye. Contains iron, b vitamins, minerals and fiber and some are fortified with folic acid. Try to make half of grains whole. Try to limit refined grains. Whole grains – brown rice, oatmeal, popcorn, barley millet, quinoa, spelt, buckwheat, bulgur and wile rice. Or if ingredients list whole-wheat flour, whole oats.
Veggies – try to vary. Dark green (Broccoli, kale, lettuce, spinach), orange (Carrots, sweet potato), dried beans and peas (legumes – black beans, chickpeas, pinto beans, lentils), starchy veggies (corn, potatoes), other veggies (Artichokes, asparagus, brussel sprouts, cauliflower, cucumber, eggplant, onions, peppers, tomatoes, zucchini)
Fruits – eat a variety. Rich in fiber, potassium, Vit C and folate
Milk and Milk Products – calcium for you and baby for strong bones. Protein, potassium, vit A, B, D.
Meats and Beans – contain protein, which builds muscles, skin, enzymes, hormones, and antibodies. Also contain B vitamins, Vit E, iron, zinc and magnesium. Choose lean cuts of meat, drain grease after cooking, choose meats that don’t include excess salt/fat. Eat fish 2x a week – choose seafood low in mercury and high in omega3
Choose organic fruits and veggies when possible. Some have more pesticide residue – apples, peppers, potatoes, spinach, strawberries. Choose fresh local produce in season. More recently picked, more nutrients. Raw fruits and veggies have higher nutrition than cooked. Best to worst for preserving nutrients: steam microwave, stir fry, roast, bake, boil.
Get nutrition from food vs supplements – books: In Defense of Food; Food Rules Michael Pollan
Weight Gain during Pregnancy – depends on prepregnancy weight and height, quality of diet before and during pregnancy, ethnic background and number of previous pregnancies.
Figure out prepregnancy BMI to gauge total body fat. BMI equals weight multiplied by 703 and divided by height in inches squared. Many women gain more or less and their babies are fine. Women who gain too little increase risk of having premature baby or one with low birth weight. Women who gain too much increase risk of developing preterm labor, gestational diabetes, high blood pressure or macrosomia (large baby hard to deliver vaginally).
In early pregnancy, gain weight slowly, 1-5 lbs by end of 1st trimester. In 2nd semester, up to 1 pound per week. A sudden, excessive change in weight can be a sign of illness or preeclampsia, especially if accompanied by other symptoms (such as sudden swelling).
Extra Weight: Baby 7.5-8 lbs; Placenta 1-1.5 lbs; Uterus 2 lbs; Amniotic fluid 2 lbs; Breasts 1 lb; Blood volume 2.5 lbs; Fat 5-8 lbs; Tissue fluid 6 lbs. Total 27-31.5 lbs
Prepregnancy BMI/Total Weight Gain
Less than 18.5/28-40 lds
18.5-24.9/ 25-35 lds
25-29.9/ 15-25 lbs
More than 30/ 11-20 lbs
Weight Loss After Baby – lose some within a few weeks and remaining over following months. Breastfeeding promotes weight loss because milk production burns calories but until baby weans, body may naturally hang on to a few pounds of fat as a way to ensure baby is well nourished should you experience a food crisis.
Procedure: Papanicolau Test (Pap Test) – Don’t have sex 24-28 hours in advance. Reschedule if menstruating. Mid-cycle is best time for visit. Cytologic specimen is obtained before any digital examination of vagina is made or endocervical bacteriologic specimens are taken. A cotton swab may be used to remove excess cervical discharge before specimen is collected. If woman has had a hysterectomy, the vaginal cuff is sampled. Slide is sprayed with preservative within 5 seconds. If cytology is abnormal, liquid-based methods allow follow up testing for HPV DNA with same sample. Women vaccinated should follow same screening guidelines as unvaccinated. 21-65 every 3 years and after every 5 years (if had Pap and HPV test negative). No screening for under 21 unless sexual activity – get tested within 3 years of sexual activity or 21 whatever comes first. Women with high risk factors such as exposing do diethylstilbestrol (DES) in utero, those treated for cervical intraepithelial neoplasia (CIN) 2 or 3, cervical cancer of HIM may need more frequent screening. Young women who have been treated with excisional procedures for dysplasia have an increase in premature birth; a large majority of cervical dysplasias in adolescents caused by HPV resolve on their own without treatment. Women older than 65 who have not had serious cervical pre-cancer or cancer in past 20 years may discontinue testing.
Fluids / Carbs and Sugars also Bottled Water – may lack healthful minerals which were filtered out before water was bottles. Some concern over whether plastic bottles leach harmful chemicals into water
When Milk Supply Dwindles – can reduce milk supply: birth control pills containing estrogen, prescribed estrogen cream to treat vaginal dryness; returned to work or other time-consuming activity and nurse less frequently; offering baby more supplemental bottles and not breastfeeding as often; pregnant
Problem with Let-Down: extreme stress, inadequate nipple stimulation, excessive amounts of alcohol, caffeine and tobacco may delay/inhibit
Nutrition While Breastfeeding – during pregnancy, body prepares for lactation by storing 5-7 lbs of extra fat to provide some of extra calories necessary for milk production in early months. May maintain some or all of this for entire time you breastfeed. Make sure diet consists of variety of healthy food and additional protein (helps produce milk) and calcium. Many women’s diets don’t include enough calcium, as well as vit B, thiamine, folic acid, vit D, zinc and magnesium –diet deficient in these reduces mother’s nutritional stores and poses health risks for mom and baby.
Prenatal Visit Schedule – first visit within 12 weeks; monthly visits weeks 16-28, every 2 weeks from weeks 29036; weekly visits weeks 36-birth
Group prenatal care – Centering Pregnancy facilitates learning, encourages discussion and develops mutual support.
In recent years concept of preconception care recognized – specifically good nutrition, entering pregnancy with as healthy a weight as possible, adequate intake of folic acid, avoidance of alcohol and tobacco, and prevention of STIs.
1. Normal weight, underweight, overweight, and obese clients
Exercise Tips for Pregnant Woman- Decrease weight bearing such as jogging and running and increase non-weight bearing such as swimming, cycling, or stretching . if you are a runner, starting in 7th month, can walk instead. Exercise regularly every day. Exercising sporadically can place undue strain on muscles. Take pulse every 10-15 min. if more than 140 BPM, slow down until it returns to 90 BPM. Avoid becoming overheated for extended periods. As body temp rises, heat is transmitted to fetus. Prolonged or repeated elevation of fetal temp can result in birth defects, especially during first 3 months of pregnancy. After 4th month, not exercises flat on your back. Rest for 10 min after exercising, lying on side, which removes pressure and promotes return circulation from extremities and muscles to your heart, thereby increasing blood flow to placenta and fetus. Choose high protein foods such as fish, milk, cheese, eggs and meat.
Nutrition during Pregnancy Use food diary, 24-hour recall of food frequency approach. Discuss eating patterns and reasons that lead to decreased food intake (morning sickness, pica, fear of becoming fat, stress, boredom)/ set target weight gains for remaining weeks of pregnancy. Assess state of hydration. Review nausea history (frequency of episodes, likelihood of progressing to vomiting, factors precipitating or associated with nausea, and any relief measures that woman has tried). Review measures for prevention or relief of nausea and vomiting
F. Discomforts of pregnancy
1. Nausea and vomiting
4. Food cravings and pica
5. Changes in sexuality
6. Diastasis recti abdominis
High Body Temp- over 100.4F for 3-4 days may harm baby, especially in early pregnancy. Don’t take fever-reducing medication unless caregiver instructs. To lower temp, drink plenty of liquids and take lukewarm bath or shower. If temp higher than 102, call caregiver immediately. Hot tubs/taking saunas may raise body temp to dangerous level
Severe Nausea and Vomiting (Hyperemesis Gravidarum) – persistent, severe. Affects less than 1% of pregnancies, can result in weight loss, dehydration, changes in blood chemistry. If continue to vomit foods and fluids for a day or longer, call caregiver. Early management may help prevent its progression. If dietary/lifestyle isn’t effective, caregiver may prescribe medications to relieve vomiting (antiemetics) and if necessary to treat infection. If vomiting can’t be controlled, you may need hospitalization to receive IV fluids. Sometimes psychological problems can worsen.
Uterine Fibroids – up to 75% of women develop fibroids at some time during their lives (aka leiomyomas or myomas), but they usually don’t cause problems. During childbearing years, less than 25% of women with fibroids experience symptoms such as excessive menstrual bleeding, pelvic pain or infertility; only some have surgery to shrink/remove them.
Discomforts Related to Pregnancy:
Medications and Herbal Preps – possible teratogenicity still unknown, especially for new medications and combinations. Greatest danger of drug-caused developmental defects in fetus extends from time of fertilization through first trimester.
Immunizations – live or attenuated live viruses contraindicated in pregnancy. Live virus include measles (ruebola and rubella), varicella (chickenpox( and mumps as well as Sabin oral poliomyelitis vaccine (no longer used in US). Vaccines that can be administered include Tdap, recombinant Hep B and influenza (inactivated). Tdap should be administered between 27 and 36 weeks during each pregnancy regardless of prior vaccinations. All women pregnant during flue season should be offered. Intranasal contraindicated because contains live virus.
Alcohol, Cigarette Smoke, Caffeine, and Drugs – maternal alcoholism associated with high rates of miscarriage and fetal alcohol spectrum disorders (FASDs); the risk of miscarriage in first trimester is dose related (3+ drinks per day). Cigarette smoking or continued exposure to secondhand smoke associated with IUGR and increase in perinatal and infant morbidity and mortality. Smoking associated with increased frequency of preterm labor, PROM, abruptio placentae, placenta previa and fetal death. Coffee – 200 mg max daily intake
Calcium – no increase in DRI of calcium during pregnancy and lactation. 1000 mg for women 19+ and 1300mg for those under. Milk and yogurt especially rick sources, 300 mg per cup. Lactose intolerance – common in African-Americans, Asians, Native Americans and Intuits (Alaska Natives). Alternative – calcium fortified almond milk ; natural almond milk doesn’t contain calcium. Some cultures it’s uncommon for adults to drink milk. Calcium supplements may be recommended when woman experiences leg cramps caused by imbalance in in calcium to phosphorus ratio.
Same amount of calcium as 1 cup of milk: 2.5 cups refried beans, 1.5 cups kale, 4 slices French toast, 2 waffles, 3 pieces cornbread, 1 1/8 cup OJ, 3 oz creamy pesto, 5 oz cheese sauce, 1 c tofu
Other Minerals and Electrolytes
Fat Soluble Vitamins – include vitamins A, D, E and K. High potential for toxicity, so take supplements only as prescribed.
Water-Soluble Vitamins – body storage much smaller and readily excreted in urine unlike fat soluble. Toxicity less likely. Must be consumed frequently
Other Nutritional Issues During Pregnancy
Assessment – nutritional assessment performed before conception ideally.
Obstetric and Gynecologic Effects on Nutrition – nutrition reserves can be depleted in multiparous woman or one who has had frequent pregnancies (esp 3 in 2 years). History of preterm birth or birth of LBW or small ofr gestational age (SGA) can indicate inadequate dietary intake. Maternal diabetes mellitus can be associated with birth of large for gestational age (LGA) infant. Contraceptive methods can also affect; increased menstrual blood loss during first 3-6 months after placement of intrauterine contraceptive; user can have low iron stores or even iron deficiency anemia. Oral contraceptives associated with decreased menstrual loss and increased iron stores.
Health History – chronic maternal illnesses such as diabetes mellitus, renal disease, liver disease, cystic fibrosis or other malabsorptive disorders, seizures and use of anticonvulsant agents, hypertension and PKU can affect nutritional status.
Usual Maternal diet – determine usual diet, allergies and intolerances, medications and supplements, cultural practices, adequacy of income. Nutrition related discomforts such as nausea and vomiting, constipation, and pyrosis (heartburn). Eating disorders or frequent/rigorous dieting before or during pregnancy. Lactose intolerance of concern in pregnant and lactating women because not other food group equals milk and milk products in term of calcium content. Quality of diet improves with socioeconomic and educational level. Poor women may not have access to adequate refrigeration and cooking.
Physical Examination – anthropometric (Body) measurements provide short and long term info on nutritional status. At a minimum, height and weight taken and weigh measured at each subsequent visit. Lower extremity edema often occurs when calorie and protein deficiencies are present but it can also be a normal finding in 3rd trimester. Lab testing when indicated.
Lab Testing – only nutrition related needed by most is hematocrit or hemoglobin measurement to screen for anemia. Lower limit is 11g/dl in 1st and 3rd trimester, and 10.5 g/dl in 2nd trimester (compared w 12 g/dl in nonpregnant state). Lower limit for hematocrit is 33% during 1st and 3rd trimesters and 32% in 2nd (compared with 36% in nonpregnant state). Diagnostic values for anemia are higher in women who smoke or live at high altitudes because the decreased oxygen carrying capacity of their RBCs causes them to produce more RBCs than other women produce. Tests for complete blood cell count with differential to identify megaloblastic or macrocytic anemia and measurement of levels of specific vitamins/minerals believed to be lacking.
Physical Assessment of Nutrition -cardiovascular function – rapid heart rate, enlarged heard, abnormal rhythm, elevated BP; skin – dry, scaly, pale, easily bruised, petechiae; face and neck – lips swollen; oral cavity – bleed easily, teeth with unfilled caries, absent teeth; extremities – nails spoon shaped, brittle; skeleton – bowlegs, knock knees chest deformity at diaphragm
Nutritional Care & Teaching – programs in US: Supplemental Nutrition Assistance Program (SNAP or food stamps) and Special Supplemental Nutrition Program for Women, Infants and Children (WIC). WIC foods include items such as eggs, milk (or cheese, soy milk or tofu), juice, fortified cereals, legumes and peanut butter
Daily Food Guide and Menu Planning – My Plate (www.choosemyplate.gov). individualized daily food plan. Consuming adequate amounts from milk, yogurt and cheese groups should be emphasized, especially for adolescents and women younger than 25 who are still actively adding calcium to their skeletons.
Diagnosis of Pregnancy – Presumptive indicators of pregnancy include subjective symptoms (amenorrhea, nausea and vomiting (morning sickness), breast tenderness, urinary frequency and fatigue. Quickening – mother’s first fetal movement between weeks 16 and 20 and objective signs (elevated BBT, breast and abdominal enlargement and changes in uterus and vagina. Others striae gravidarum, deeper pigmentation of areola, melasma (mask of pregnancy), and linea nigra). Probably indicators – physical changes in uterus. Objective signs – uterine enlargement, Braxton Hicks contractions, placental soufflé (sound of blood passing through placenta), ballottement (examiner feels fetus float during vaginal examination), and positive pregnancy test. Positive indicators of pregnancy include presence of fetal heartbeat distinct from mother, fetal movement felt by someone other than mother and ultrasound.
EDB (Estimated date of birth) – Naegele’s rule – accurate recall of last menstrual period. Assumes 28 days cycle and fertilization on 14th day. Subtract 3 months and add a week. Only 5% give birth; most women 7 days before to 7 days after.
Adaptation to Pregnancy – Much of research on family dynamics in U.S has been done with Caucasian middle class nuclear family.
Maternal Adaptation – Early in pregnancy, woman may spend much time sleeping to increased fatigue. Many women are upset initially when they discover they are pregnant, especially if unintended. Non-acceptance of pregnancy does not equate with rejection of child, because a woman can dislike being pregnant but feel love for the child to be born. Sexual desire usually decreases, especially if experiencing breast tenderness, nausea or fatigue. Most important person to pregnant woman is usually father of her child; Women have 2 needs: to feel loved/valued and having child accepted by partner. “I Am Pregnant” – child as viewed as part of self
With perception of fetal movement in 2nd trimester, woman turns attention inward to her pregnancy and relationship with mother and other women who are pregnant. Increased pelvic congestion increases desire for sexual release. “I am going to have a baby” – fetus as distinct from herself, usually accomplished by 5th month. Ultrasound and quickening confirm reality of fetus. Women becomes more introspective. If other children in family, they can become more demanding in efforts to redirect mother’s attention to themselves.
Historical Perspectives on Childbirth and Breastfeeding – birth occurred in families/communities throughout history. Before 18th century, concept of prenatal care didn’t exist. Breastfeeding was normal and expected sequel to pregnancy. If baby could not be breastfed by mother or another nursing mother, the child died. As technology and interventions increased, breastfeeding decreased.
Normal and expected location for giving birth shifted from homes to institutions around the world at different rates and in different ways. In Africa, more than half babies still born at home. Home birth in industrialized countries ranges from .05% in Australia and 1% in U.S to 30% in Netherlands. Place of birth affects birth practices available to mom, which in turn affect mother-baby dyad’s ability to initiate and continue breastfeeding. One cannot assume all births at home are followed by uncomplicated breastfeeding; neither can one assume institutional births lead to complications for breastfeeding.
Location for Birth Matters: Home Birth and Institutional Delivery – until early in 20th century, most women in world labored and birthed babies at home. Labor w support of relatives, a familiar empirically trained birth attendant and only rarely w a medical professional. Breastfeeding began and continued for several years. If serious complications lack of immediate access meant some mothers, babies or both would die during or soon after birth. Breastfeed was an unusual concept – babies were simply fed.
Be end of WW2, giving birth in hospital became norm in U.S. Exception was in rural, racially segregated South where “lay” midwives continued to practice until outlawed in 1970s (perceived as a threat). “Grand” midwives, trained mostly by own moms/grandmoms provided pregnancy, home birth and postpartum care to African American and poor white communities.
1940s-1060s, most women had physician at birth and following was typical scenario: pubic hair removed and enema after admitted to maternity hospital. Labor alone, no food/drink. Pain relief – meperidine injections (Demerol or Pethidine) or another combination of morphine (narcotic) and scopolamine (amnesiac) known as twilight sleep. For delivery, breathe nitrous oxide or ether or given spinal block, numbing from waist down. As research began to link these to labor dysfunction, maternal disorientation and hallucination and fetal asphyxia, they were replaced w newer narcotics: alphaprodine (Nisentil), butorphanol (Stadol), and nalbuphine (Nubain), which were shorter acting and safer.
Deliver in lithotomy position, perhaps w hands in restraints. Episiotomy routine and forceps used bc mom not able to bear down. Baby delivered by Dr. and would have mouth suctioned, be held upside down and spanked to stimulate crying then handed to nurse. Nurse moved baby to heated crib and would begin admission procedures – silver nitrate eye drops, umbilical cord care, footprinting, weighing, measuring, Vit K injection and sometimes other lab tests that required puncturing newborn’s heel to obtain blood. Baby bathed head to toe w antiseptic soap, diapered, and dressed.
Mom not able to hold baby until transferred to postpartum ward, commonly many hours after birth. Baby given test feed of sterile water to ensure no congenital tacheoesophageal fistula existed. Even if mom planned to breastfeed, glucose water or formula was given in nursery as first feed while mom rested.
Model of OB care remained norm in U.S. in several decades and was exported to medical training institutions and hospitals throughout the developing world.
Natural Childbirth Movement in the West – by late 1950s, growing # of moms began questioning care. Natural childbirth movement has roots in work of British OB Dr. Grantly Dick-Read. He had attended many births at home in England and recognized that they birthed more naturally, free of fear and need for pain meds. Compared home birth patients to hospital births and concluded much of fear and pain reinforced by hospital environment. 1944 – published Childbirth Without Fear. Women in U.S., England and Europe eagerly read this book. Book describes physiologic basis that fear can interfere w labor and increase pain and anxiety and gives relaxation techniques and exercises to increase comfort.
In 1959, Marjorie Karmel published Thank You, Dr. Lamaze, which set stage for first childbirth preparation movement in U.S. Lamaze method of childbirth based on Pavlovian principles of conditioned reflexes. If women conditioned to expect pain w contractions, they will experience pain. If deconditioned through education and support and relaxation in labor, pain can be averted/lessened. Using technique of psychoprophylaxis, women can learn and practice breathing and relaxation techniques before labor that when used during contractions will keep pain under control. Integral is supportive labor coach who assists in reminding her to breathe, rest between contractions, and change breathing patterns in response to her contractions.
In into to 2nd edition, childbirth education pioneer Elisabeth Bing writes that Karmel’s book helped American women and their partners to become the proselytizers of an entirely new approach to childbirth. ASPO founded a few months later. Following year, ICEA formed. Both shared mutual aims of furthering natural, family-centered maternity care.
La Leche League International – before Karmel’s book, LLLI had been making links between childbirth practices and breastfeeding since 1956. 7 women in Chicago founded LLLI, whose mission is to provide info and support, through mother to mother help, to women who want to breastfeed there babies.
Includes series of 4 basic meetings w different topic for each discussion. In 1956, these topics were: 1) Advantages of Breastfeeding 2) Overcoming Difficulties 3) Arrival of Baby and 4) Nutrition and Weaning.
Loose-leaf booklet – The Womanly Art of Breastfeeding created by LLLI made direct links between birth and early breastfeeding. Book promotes alert participation, supportive presence of one’s husband, and immediate holding and breastfeeding of baby. These recommendations predate by almost 3 decades the early initiation recommended of Baby Friendly Initiative by UNICEF and WHO in 1991.
On Nursing the Newborn – How Soon, published in 1972, described negative impact of labor pain medicines on early breastfeeding and included research from Russia done in 1955 documenting that sucking reflex is at its height 20-30 min after birth. LLLI led the way in both the popular and scientific communities in advocating natural birth, breastfeeding and keeping mom and baby together. LLL has always included childbirth topics at its international conferences.
In its 50 year history, LLLI has accredited over 43,000 volunteer leaders and supports over 25000 mother to mother support groups in 68 countries.
The Natural Childbirth Movement Grows – flourished in U.S. during 1970s and early 1980s. hospitals began to build natural birth rooms and freestanding birth centers began to spring up. Ina May Gaskin’s 1977 Spiritual Midwifery served as handbook for many of those interested in home birth.
Before early 1980s, babies were routinely removed from moms immediately after birth for observation and procedures. Early mother-baby contact eventually gained scientific credibility thanks to pioneering work of Marshall Klaus and John Kennell.
% of women who breastfed rose from all-time low of 22% in 1972 to 56.3% in 1987. By 2005, 74.2% of American mothers initiated breastfeeding, 43.1% were still breastfeeding at 6 months and 21.4% were breastfeeding at 12 months.
When birth interventions, esp epidural began increasing in late 1980s, breastfeeding initiation rates continued to rise, but exclusive breastfeeding rates have not kept pace w imitation rates. Exclusive breastfeeding has remained at 31% at 3 months and 11.9% at 6 months (2005). To reach global and national health goals of exclusive breastfeeding for 6 months, the mother and baby must first achieve exclusive breastfeeding for the first 6 days.
By mid 1990s, a rising # of women accepted routine IVs, EFM and epidural to reduce pain of labor. Rise in medical malpractice insurance premiums was one justification for EFM to ensure continuous paper documentation of labor events and cesarean rate rose sharply. Hospitals actually closed alternative birthing rooms and set up LDR rooms which had advantage of keeping women in 1 place for entire labor and delivery. These rooms had homey atmosphere but also all medical technology stored in bedside closets and cupboards.
Breastfeeding Rates Are Tracked Separately from Birth Outcomes – breastfeeding rates in U.S. decreased in late 1980s and early 1990s and then steadily increased. 2005 – Initiation rate of 74.2% which is an all-time high. 8 states achieved all 3 Healthy People 2010 objectives for breastfeeding.
In 1989, WIC initiated major program shift w funds to support variety of breastfeeding activities – extra nutrition supplements, breastfeeding aids including pumps, counseling services and other program supports. Almost ½ of babies born In U.S. are enrolled in WIC and breastfeeding rates among WIC are rising faster than rates in comparable population groups.
AAP policy – recommends exclusive breastfeeding 6 months and breastfeeding for at least 1 year. 2005 policy – “avoid procedures that may interfere w breastfeeding or that many traumatize the infant, including unnecessary, excessive and overvigorous suction of oral cavity, esophagus and airways to avoid oropharyngeal mucosal injury that may lead to aversive feeding behavior.”
1985 marked birth of lactation consultant profession. As of 2008, more than 19,000 IBCLCs practicing in 75 countries.
Nov 2008 – CDC National Immunization Survey – 74.2% moms initiated breastfeeding; 43% breastfeeding at 6 months and 21.4% still breastfeeding at 12 months.
Unfortunately, many mom-baby dyads still experiencing difficulty initiating breastfeeding, even though evidence since 1950s that labor drugs affect breastfeeding, that early initiation and skin to skin facilitates breastfeeding and that formula supplements undermine breastfeeding. 2007 surveys found that 76% of moms received epidurals, 63% for babies were not in moms arm in 1st hr after birth and 25% of U.S. infants still given formula supplement w/in 2 days of birth.
Global Perspective on Birth, Breastfeeding and Maternal and Infant Survival – international trend toward institutionalizing labor and delivery process, even for uncomplicated pregnancies. In U.S. between 1938 and 1948 shift to hospital birth, with drop from 45% to 10% of births occurring in home. During same decade, drop in maternal mortality of 71%, a dramatic figure. Infant mortality dropped at a similarly impressive rate. More recently, trend appears to be going backward: 2007 CDC reported increase in maternal mortality for first time in decades. Rise in # of cesareans – now 29% of all births – could be factor. CDC reported “U.S. infant mortality rate is higher than those in most other developed countries and gap between U.S. rate and rates for other countries w lowest infant mortality appears to be widening. Increases in preterm birth and preterm related infant mortality account for much of lack of decline in U.S rate for 2000-2005”
Decrease infant/child mortality worldwide – GOBI actively promoted in 1980s, with (G) growth monitoring through routine weighing of infants, (O) oral rehydration therapy (ORT) for diarrhea, (B) breastfeeding promotion and (I) immunization for prevention of childhood disease. Although dramatic increases in immunization coverage worldwide and oral rehydration salts became available in most remote villages in world, breastfeeding rates were starting to decline.
The Baby Friendly Hospital Initiative (BFHI) – in 1989, UNICEF and WHO issued joint statement “Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services” in which maternity hospitals were targets for strengthening breastfeeding in the prenatal and early postnatal periods. It recommended 10 principles, came known internationally as “Ten Steps to Successful Breastfeeding”
They launched the Baby Friendly Hospital Initiative in 1991, putting forth these steps as international best practices. BFHI was launched in response to Innocenti Declaration’s call for action, considering that there were very few countries that dedicated national-level breastfeeding support activities.
Ten Steps to Successful Breastfeeding (see below)
Among priority facilities targeted were large government, university and teaching hospitals, with intention to influence academic health sector and assist in influencing practice, education and policy at country level.
1989 Joint Statement discusses importance of maternal nutrition and health during pregnancy and the impact of labor and delivery management, noting that “a woman’s experience during labor and delivery affects her motivation towards breastfeeding”
According to WHO, “Breastfeeding, esp exclusive breastfeeding, is central to achieving the Millennium Development Goal (MDG) for child survival. Today, after nearly 17 years of WHO endorsement and UNICEF country-level support, most countries have breastfeeding or infant and young child feeding (IYCF) authorities or BFHI coordinating groups.
In 2006, added sections on HIV and infant feeding, mother-friendly childbirth practices and support for women who aren’t breastfeeding. As of mid-2009, >20,000 hospital and birth centers in 136 countries had been designated as Baby Friendly, including 80 in U.S.
Several countries have implemented the 5 recommended Mother-Friendly practices specifically to improve breastfeeding outcomes. BFHI has been called UNICEF’s single most successful initiative.
Significant changes in clinical practice worldwide have occurred in handling of newborns at birth, in early initiation of breastfeeding, in encouraging minimal or no separation of newborns from mothers and in longer periods of exclusive breastfeeding. However, same emphasis on mother’s health, her emotional integrity, her sense of empowerment and her participation in decisions about her care still falls short around the world.
Safe Motherhood and Other Initiatives – During same time as BFHI, Safe Motherhood Initiative (SMI) launched in 1987 to reduce unacceptably high rates of maternal mortality and morbidity in many developing countries. 4 pillars: family planning (FP); antenatal care (ANC); clean, safe delivery; and essential obstetric care (EOC). In 2996 expansion of BFHI, Mother-Friendly module added 5 specific elements of supportive care during labor/birth.
1985- 4 years before publication on Protecting, Promoting and Supporting Breastfeeding, meeting in Fortaleza Brazil by PAHO and WHO European (WHO Joint Conference on Appropriate Technology for Birth) with specific recommendations for encouraging mom’s mobility in labor and choice of position for delivery, abolishing routine episiotomies, discouraging routine AROM, questioning high rates of oxytocin induction of labor, and suggesting that facility cesarean rates above 10-15% were not justifiable. Recommendations, which supported breastfeeding, included initiation of breastfeeding and no separation of mom and baby.
Professional Responsibility for Breastfeeding Success – OB and pediatric medical/nursing education programs do not yet systematically and thoroughly include evidence-based management of breastfeeding.
In theory, midwifery training is an exception because taught to provide care to healthy woman and baby during pregnancy, birth and lactation. WHO identified midwife as most appropriate and cost effective type of health provider to be assigned to care of normal pregnancy and normal birth. Some research suggests midwife care preserves normal breastfeeding. Midwifery education programs, like OB and pediatric education programs, do not necessarily ensure their graduates have received in-depth, current and evidence-based knowledge of breastfeeding management, and midwives care of breastfeeding dyad usually does not extend past 6 weeks.
Innocenti Declarations of 1990 and 2005: Call to Action – in 1990, WHO, UNICEF and other key health funding agencies convened a high level consensus meeting of global policy makers in Innocenti, Italy to set up operational targets for “protection, promotion, and support of breastfeeding.” Outcome was Innocenti Declaration of 1990, which sets a global goal for optimal maternal and child health and nutrition.
“Efforts should be made to increase women’s confidence in their ability to breastfeed. Such empowerment involved the removal of constraints and influences that manipulate perceptions and behavior towards breastfeeding, often by subtle and indirect means. This requires sensitivity, continued vigilance, and a responsive and comprehensive communications strategy involving all media and addressed to all levels of society. Furthermore obstacles to breastfeeding within the health system, the workplace and the community must be eliminated”
Innocenti Declaration of 2005 - the 2005 meeting called on government organizations, manufacturers of products, and public interest groups to strengthen and renew their commitment to the 1990 goals. 5 target goals were added, supporting 6 months of exclusive breastfeeding, improving appropriate complementary feeding, addressing infant feeding in extraordinary circumstances and considering legislative implementation of the International Code of Marketing of Breastmilk substitutes.
Calls for removal of obstacles within the health system, which include reducing use of birthing practices that compromise breastfeeding outcomes. Evidence based care of mother clearly improves breastfeeding outcomes and also preserves mothers self-esteem, sense of being in control, and empowerment throughout her pregnancy, birth and breastfeeding experience.
Back to…the Future– Solid scientific evidence shows that minimizing interventions in birth and policies that preserve normalcy associated w faster, easier births; healthier more active and alert moms and newborns and dyads physiologically optimally ready to breastfeeding. Birth is a normal function of women, and normal birth supports normal breastfeeding.
The Ten Steps to Successful Breastfeeding are:
Feeling Good and Staying Fit – maintaining good posture helps prevent back pain
Maintaining Good Posture and Moving with Care – maintaining good posture is essential for keeping your balance, preventing back pain and reducing fatigue
Exercise in Pregnancy – protects against back pain, reduces intensity of common pregnancy discomforts and boosts energy level, mood and self-image. During last trimester, regular exercise increases body’s production of endorphins (natural pain relievers), which can help you cope with labor.
Finding Motivation to Exercise – motivation may ebb and flow as energy level rises and falls. Find what time of day works best and schedule for that time. Hearing/reading encouraging words or listening to favorite music can motivate you. If have trouble making time on your own, sign up for a class or make an appointment with someone.
Exercise Options – aerobic exercise increases heart rate for an extended time, which improves endurance and strengthens heart and lungs. Anaerobic focuses on strengthening muscles and improving balance and flexibility. Growing belly shifts your center of gravity forward. Changes in cardiovascular system increases heart rate more quickly and boy temp and metabolic rate (rate at which you burn calories) are higher
Guidelines for Safe Effective Exercise
Core Exercises to Prepare You for Labor – core muscles include abdominal muscles, pelvic floor muscles, and back and hip muscles
Conditioning Pelvic Floor Muscles – pelvic floor muscles form a figure 8 around your urethra, vagina and anus. During pregnancy, increased weight of uterus and relaxing effect of hormones may make these muscles sag. Hemorrhoids may emerge. Exercising pelvic floor muscles can reduce heavy, throbbing feeling you may experience in the area. Can make sex more enjoyable
Pelvic Floor Contraction (Kegel or Super Kegel) – improve blood circulation in pelvic floor muscles. Try not to tighten muscles in buttocks, thighs or abdomen. Hold tightly for 10 seconds. Relax and rest for 10 sec before tightening for another 10 seconds. Super Kegel – hold for 20 seconds, tightening again when contraction begins to fade. Several sets of 10 per day.
Pelvic Floor Bulging – to prepare for pushing baby out. H old breath and bear down gently. Hold for 3-5 seconds, then stop bearing down. Inhale, contract pelvic floor muscles then exhale and rest. 1-2x per week
Conditioning Abdominal Muscles – late pregnancy, avoid double leg lifts or abdominal crunches
Mobilizing Pelvic Joints by Squat – during late pregnancy, helps condition your pelvic joints. To birth vaginally, joints need to be flexible enough to allow baby to move from uterus through vagina. When push baby out, squatting can help baby descend into vagina. If you problems with hips, knees, ankles pelvis or have hemorrhoids, avoid. If having trouble getting back up, tighten thighs and buttocks or try wall sitting. Increase amount of time in squat to 90 sec, which is roughly length of long labor contraction. If can’t maintain balance, use piece of furniture or use partner. If difficult to keep heels of floor, calf muscles are tight. Try \ with feet further apart, put book under each heel or rolled up map. Many birthing beds in hospitals have bars to grip while squatting. After 35th week, squat 10x each day.
Postural Exercises to Align Your Body – strengthening and stretching these muscles helps relieve lower back pain and other discomforts that can arise when your body is out of alignment
Yoga Poses to Align Body, Mind and Spirit – yoga focuses on practicing movements, not mastering them. Sequence of poses mimics rhythms of labor.
Comfort Measures for Common Discomforts in Pregnancy
Work out 3-7 days per week!
Nursing Care of Family During Postpartum Period- Assist mother with rest and recovery from labor and birth. 4th trimester – first 3 months after birth.
Information that must be communicated to postpartum nurse include woman’s name, age, identify of health care provider; gravidity and parity; anesthetic used; any medications given; duration of labor and time of rupture of membranes; whether labor was induced or augmented; type of birth and perineal repair; blood type and Rh status; group B streptococcus (GBS) status; statue of rubella immunity; HIV; Hep B and syphilis serology test results; other infections identified during pregnancy (gonorrhea, chlamydia) and whether these were treated; type and amount of IV fluids, physiologic status since birth; description of fundus, lochia, bladder, and perineum; sex and weight of infant; time of birth; name of pediatric care provider; chose method of feeding; any abnormalities noted and assessment of initial parent-infant interaction. Newborn’s Apgar scores, weight, stooling and whether fed since birth.
Body Mechanics – proper body mechanics can prevent some common discomforts of pregnancy.
Visual Aids – illustrations of body mechanics and all exercises are included on PowerPoint CD
Have 1 student read instructions for 1 of actions as another performs
Role Play – with partner wearing empathy belt, have him perform activities suggested by class – tie shoe, roll over on bed, pick up item etc
Play correctly getting into out of car/bed, working at desk or other daily activities
DVD: Celebrate birth! Moving with pregnancy and birth
Book: Exercising Through Your Pregnancy.
Prenatal dance classes gaining popularity; prenatal yoga helps to tune in to bodies and better cope with everyday stress in lives with added benefit of camaderie with other pregnant women
Music – “Do the Kegel”. Vulva Puppet. www.dothekegel.com
Handouts – Kegel stickers around classroom. Neon labels – 30 to a page. Master for printing stickers included on CD
Guidelines for exercise – rather than list of don’ts, use remember to on page 100 in workbook. Benefits of slow stretching alone or with an aerobic sequence
Sample Stretch breaks – pg 16-17 of handbook. Break up every hour of sitting with a few min of activity. Stretches should be done daily at work/home. Reinforce benefits of stretching throughout day and teach in class.
Demonstration/return demonstration – introduce 1 new exercise a class instead of all at one. Spiral info
Diastasis recti – or diastasis is separation of ab muscles along midline. Before end of pregnancy, many women develop. As ab muscles stretch as uterus grows, hormones softer muscles. Strain on vulnerable muscles causes them to separate. May be possible to avoid if 1 avoids excess stress on tense muscles by exercising and moving properly.
How to Check – lie on back with knees bent, lift head and shoulders off floor, feel for soft bulge between 2 sheaths of ab muscles; 1-2 finger width not uncommon in 3rd trimester. If more than 2, corrective exercises should be done
How to Correct – in book Essential Exercises for Childbearing Year, recommends doing morning and night and in postpartum 5x a day until correction accomplished. Back with knees bent, support abs with crossed hands. Slowly exhale and you raise head toward chest until just before bulging begins. Pull in abs with hands while breathing out
Perineal Massage – reduces likelihood of perineal trauma (mainly episiotomies) and reporting on ongoing perineal pain and generally well accepted by women. Pg IV-25 handout
Books – Fit & Pregnant: pregnant woman’s guide to exercise; fitness for pelvic floor; exercising through pregnancy; beyond Kegels, breathe your way through birth with yoga; fit & healthy pregnancy: how to stay strong and in shape for you and your baby
Cystocele and Rectocele
Cystocele is the protrusion of the bladder downward into the vagina that develops when supporting structures in the vesicovaginal septum are injured. Anterior wall relaxation gradually develops over time as a results of congenital defects of support structures, childbearing, obesity or advanced age.
Rectocele is the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum; it appears as a large bulge that may be seen through the relaxed introtius.
Clinical Manifestations – cystocele and rectoceles often are asymptomatic. Complaints of a bearing-down sensation or “something is in my vagina.” Other symptoms include urinary frequency, retention and incontinence as well as possible cystitis and UTIs. Pelvic exam reveals a bulging of the anterior wall of the vagina when the woman is asked to bear down. Unless the bladder neck and urethra are damaged, urinary continence is unaffected. Women with large Cytoceles complain of having to push upward on the sagging anterior vaginal wall to be able to void.
Rectoceles may be small and produce few symptoms, but some are so large that they protrude outside of the vagina when the woman stands. Symptoms are absent when the woman is lying down. A rectocele causes a disturbance in bowel function, the sensation of bearing down, or the sensation that the pelvic organs are falling out. With a very large rectocele, it may be difficult to have a bowel movement.
Medical and Surgical Management – treatment for a cystocele includes use of a vaginal pessary or surgical repair. An anterior repair (colporrhaphy) is the surgical procedure done for large symptomatic cystoceles. An anterior repair is often combined with a vaginal hysterectomy. Use of Kegel exercises helps strengthen pelvic floor muscles. Small rectoceles may not need treatment. A woman with mild symptoms may get relief from a high-fiber diet and adequate fluid intake, stool softeners, or mild laxatives. Vaginal pessaries and Kegel exercises may be useful. A posterior repair (colporrhaphy) is the usual procedure. Even though the surgery corrects the anatomic position, the woman may still have problems with defecation.
VII. Potential threats to pregnancy
Having a Healthy Pregnancy – making positive lifestyle choices, ideally begin avoiding hazards before pregnant
Caring for Yourself and Your Baby during Pregnancy –
Note to Fathers/Partners: support mom’s efforts by making changes to your lifestyle as well. If you smoke, you can quit so partner and baby avoids harmful effects of secondhand smoke. Exercise regularly and avoid consuming unsafe foods and substances. Get involved in partners pregnancy – attend some or all prenatal appointments, show interest in prenatal tests and results. Do laborious household chores.
Prenatal Care – schedule once you know you’re pregnant; the wait tog et an appointment with some caregivers can be several weeks. At 1st/2nd visit, will get complete physical exam and numerous tests. Ask questions about current life situation and family medical history. Appointment every month; at end of pregnancy, every 2 weeks; every week as due date approaches. If you want a longer appointment, request in advance. At end of pregnancy, schedule long visit to talk about birth plan. If there’s a group, try to meet others.
Info to include in medical history: prior surgeries/illnesses, hereditary conditions, including birth defects (heart defects) mental retardation, blindness, deafness, stillbirth, miscarriages, mental health conditions – depression/eating disorders, ethnic or cultural traditions, current prescription medications, drug allergies and drug reactions, prior negative experience with a hospitalization, prior sexual abuse, domestic violence or any other significant mistreatment, heavy use of alcohol, tobacco, recreational drugs or other harmful substances.
Prenatal Tests – screening test is a quick, easy and inexpensive way to rule out a particular condition. If results are positive, may need further testing to confirm you have condition. If additional testing determines you don’t have the condition, your screening test gave a “false positive” reading. Diagnostic test is more specific and more reliable; more invasive, expensive and usually have more side effects, so caregivers usually only give if indicated by screening.
Benefits, Risks, Alternatives to test/how test is done/ how reliable/accurate/ how will results influence prenatal care/ cost/insurance cover cost/ consequences of not having.
Routine Exams and Screening Tests–
Understanding Ultrasound – 2 forms: Doppler and diagnostic scan. Doppler monitors baby’s heart rate, uses continuous transmission of sound waves to detect motion of baby’s heart as it beats. Done via hand-held device. Scan helps “see” inside uterus, using intermittent transmission of sound waves for less than 1% of the time during the test. For the rest of the test, the equipment receives the echoes of the sound waves, which indicate differences in tissue density. See PCN guide http://www.pcnguide.com/wp-content/uploads/2016/03/2-Routine-Prenatal-Examinations-and-Screening-Tests.pdf
Studies found no evidence that they harm mother or baby and that benefits outweigh risks. Estimating baby’s age and weight more reliable in early pregnancy. First sight of babies inspires many parents to make an effort to heave a healthy pregnancy and birth.
Warning Signs of Pregnancy Complications:
Fetal Movement Counting – some caregivers ask only those women with high-risk pregnancies to count their babies’ movements. Baby doing well in uterus have several active, wakeful periods during the day. Healthy babies move slightly less often toward end of pregnancy due to space restrictions within uterus but don’t markedly reduce activity unless there is a problem. If baby becomes noticeable less active, call caregiver.
The Count to Ten Method – after 28th week, count baby’s movements each day at roughly same time. PCNguide has template. Length of time it takes to complete 10 movements varies among babies. Focus not on how baby’s movements compare with other babies’ but on whether his activity has slowed down compared to his usual pattern. Try waking baby up with a loud noise or wait until you feel baby move. Call caregiver if it takes a longer time than usual to make 10 movements or if baby doesn’t move at least 10x or have an active period within the next 12 hours.
Reducing Stress – see pgs 71-73 above
Treating Illness and Discomforts during Pregnancy –
Medications – what are benefits, risks and alternatives; if benefits clearly outweigh risks ask about dose, max dose in 24 hr period and other foods/drugs to avoid while taking. How long to take.
Substances and Hazards to Avoid during Pregnancy – everything affects baby from caffeinated coffee and herbal teas to dangerous situations such as abuse and domestic violence. Depends on amount and frequency of exposure as well as what trimester you’re in when exposed.
Potentially Harmful Substances and Herbs in Food
Mercury; Other substances that cause harmful illnesses such as listeriosis and toxoplasmosis – pg 121
Environmental Hazards and Harmful Situations – abusive relationships, workplace stress
Traveling During Pregnancy – in last month, caregiver may suggest staying within an hour’s travel time from home. Get copy of medical history to take while traveling. Some airlines limit in week before a due date. Avoid flying at altitudes >7000 feet in small planes without pressurized cabins; the oxygen available to baby may be reduces. If traveling internationally see about vaccines – only a few considered safe in pregnancy.
Long trips by car, bus, plane or train may limit movement, which can affect circulation, increase swelling in legs, and increase risk of developing a blood clot in leg vein. Walk every hour or so. Wear seat belt. Fasten low on hip and below belly. Constant motion may aggravate morning sickness/nausea. Air travel, hot climates and places with forced air ventilation may increase dehydration. Drink lots of fluids, eat well, walk around and get plenty of rest
Nutrition for Special Circumstances
Health Recommendations flyer pg IV-12 includes exercise 30 min a day, caffeine, fish/mercury, listeriosis, and cesarean increased risk when induced
Nutrition – early pregnancy, this is great topic. Baby’s brain is growing, protein is important, hints for 3rd trimester nutrition can be integrated with snack time, openers, puzzles and quizzes. Beneficial weight gain pg IV-17; ChooseMyPlate.gov pg 9 handbook; Canadian rainbow guide www.hc-sc.gc.ca/fn-an/food-guide-ailment/index-eng.php, class to suggest healthy snacks and easy nutritious meal; Healthy Eating Quiz pg IV-15. Bring snack of a particular nutrient to share with class or for show and tell; research on what to bring for their assigned or chosen nutrient – Refreshment Sign Up Sheet in Section I
Workbook Puzzle – Nutrition Crossword Puzzle pg 101. Diet evaluation on pg 103. Awareness of what nutrients they are consuming; tell them to record what they eat for several days. How much protein, fat, calcium etc they normally consume. Mention serving size when counting nutrients. Counter on page 102.
Quotes to remember
Pregnancy in teenager who is 16 years or younger often introduces additional stress into an already stressful developmental period. Teens have impulsiveness and self-centered behavior, and often place primary important on beliefs and actions of peers. Their thinking processes do not include planning fur future and many teens do not realize the consequences of their behavior.
Teenagers lack financial resources to support a pregnancy and may not have maturity to avoid teratogens of have prenatal care and instruction or follow up care. Children of teen mothers may be at risk for abuse or neglect because of teen’s inadequate knowledge of growth, development and parenting.
Parenthood after Age 35 – woman after 35 doesn’t have different physical response per say but health status changes as result of time and normal aging. Type 2 diabetes may not have had expression at 22 but may have full-blown disease at 38. Risk for certain genetic anomalies – down syndrome. Can get genetic testing.
Late Reproductive Age – divorce rates are high at this age, and children leaving home may produce an “empty nest syndrome” resulting in increased levels of depression. Perimenopause (bleeding irregularities and vasomotor symptoms). Health maintenance screenings such as breast disease or ovarian cancer.
Social, Cultural, Economic and Genetic Factors – some diseases are more common among ethnicities (sickle cell anemia in African-Americans, Tay-Sachs disease in Ashkenazi Jews, adult lactase deficiency in Chinese, beta thalassemia in Mediterranean people, cystic fibrosis in N Europeans). May have food taboos or frequencies, methods of hygiene, effects of climate, care-seeking behaviors, willingness to undergo screening and diagnostic procedures and conflicts in values.
Perinatal and maternal deaths, preterm births and LBW babies higher in disadvantaged populations. Social consequences for poor women as single parents are great because caught in bind of insufficient income to afford child care. Few resources increases risks for health problems. Multiple roles for women produce overload, conflict and stress, resulting in higher risks for psychological illness.
Substance Use and Abuse – addition to substances is seen as a biopychosocial disease, with several factors contributing to risk – biogenetic predisposition, lack of resilience to stressful life experiences, and poor social support. Women less likely than men to abuse drugs, but rate in women is increasing significantly.
See healthywomen.org, WomensHealth.gov, smokefree.gov and Office of Women’s Health Research website http://orwh.od.nih.gov
Smoking – leading cause of preventable death and illness. Linked to cardiovascular disease, various types of cancers (especially lung and cervical), chronic lung disease, and negative pregnancy outcomes. Premature death in 443k people annually because of being exposed to secondhand smoke. Women who smoke decrease their life span by 14.5 years compared with nonsmokers. 17.3% of women are smokers, smoking in pregnancy is known to cause a decrease in placental perfusion and is one cause of LBW in infants. If a pregnant woman is able to stop smoking during the first trimester, she decreases chances of having a LBW baby. smoking impairs fertility in both women and men, may reduce age for menopause and increase risk for osteoporosis after menopause. Passive, or secondhand, smoke contains similar hazards and presents additional problems for smoker and harm for nonsmoker.
Alcohol – women ages 35-49 have highest rates of chronic alcoholism, but women 21-34 have highest rates of specific alcohol-related problems. 1/3 of alcoholics are women. Prenatal alcohol exposure has been found to increase the chance of birth defects significantly, with 1 study reporting a fourfold increase. Consequences include increased risk for miscarriage, stillbirth, preterm birth and SIDS. 2020 health objective to have 98.3% of pregnant woman abstain from alcohol use (HealthyPeople.gov). 40k babies per year born with FASD; recent research reveals multivitamin supplement use during pregnancy may lessen effects. Severe facial deformities of FAS occur at day 20 of conception when women may not even suspect they are pregnant.
Caffeine – stimulant that can affect mood and disrupt body functions by producing anxiety and sleep interruptions. Hearth dysrhythmias may be made worse by caffeine and there can be interactions with certain medication such as lithium. High intake related to slight decrease in birth weigh and may also increase risk for miscarriage. No more than 200 mg/day, equivalent to 12 oz cup of coffee.
Prescription Drug Use – used by estimated 2% of American women. Depression and anxiety are most common mental health problems (depression used to be #1 but now its anxiety). Psychotherapeutic drugs have some affect on fetus and must be monitored carefully.
Gynecologic Conditions – women at risk throughout reproductive years for pelvic inflammatory disease, endometriosis, STIs and other vaginal infections, uterine fibroids, uterine deformities such as bicornuate uterus, ovarian cysts, interstitial cystitus and urinary incontinence related to pelvic relaxation. Risk for most cancers is low in pregnancy.
Female Genital Mutilation – practiced in more than 34 countries, the majority of which are in Africa. Partial or total removal of external female genitalia for non-medical reasons. Untoward consequences – severe pain, shock, hemorrhage, tetanus or sepsis, urine retention, open sores and injury to nearby genital tissues. Long term consequences include bladder and UTIs, cysts, infertility and increase risk for complications during childbirth and newborn death. It is an attempt to control women through controlling their sexuality. FGM is supposed to remove sexual desire so that the girl will not become sexually active until marriage. In U.S., it’s punishable by fines, prison and deportation. Ob may incise the closed labia to allow for a vaginal birth, or remove cysts but may not sew the labia back to it’s previous state. If performed on a minor, considered child abuse. In growing number of women who have emigrated from Middle East, Asia and Africa. Must be sensitive, esp if women have concerns about maintaining or restoring the intactness of the circumcision after childbirth
Violence Against Women – intimate partner violence (IPV) is the most common form of violence experience by women worldwide, with a reported incidence of 1 of every 6 women having been a victim of domestic violence. 1 in 4 in US has experience severe physical violence by a current of former intimate partner. Pregnancy often a time when violence begins or escalates. Most underreported data as a result of fear, lack of understanding and stigma surrounding violent situations.
VIII. Additional references for Part 5
Dr. Sears Wellness Institute Health Coach Training & Certification is a highly respected educational course that has been approved by a variety of health and wellness organizations that require their members to obtain a certain number of credits toward Continuing Education. Requirements for Continuing Education vary by organization and from state-to-state.
Approved through the International Childbirth Education Association for 24 CEUs
Use the labor rehearsal to review information taught in previous classes. They describe a situation or phase of labor and couples are asked what they would do.
If they have actually gone through the body movements needed to respond to a proposed situation, they are more likely to respond in a similar manner in the real situation.
Encourage thinking about the alternatives to a given situation. What are several ways that they could cope with this development? What tools, what skills what knowledge do they have that could be used here? Arrange your labor rehearsals so that there are positive outcomes. Present them with problems and difficulties, but make the results successful.
Use a timer to indicate the beginning of each contraction. During transition, set the timer to go off every two minutes for four or five contractions, each lasting at least ninety seconds; don’t allow discussion to interrupt the contractions.
The Body as the Teaching Tool – ICEA Teaching Idea Sheet #6
Best teaching tool is her own body.
Microencapsulated crystals which respond to temperature of skin. Tense person will have lower skin temp in extremities than a relaxed person. “Having cold feet” – fear/reluctance to do something.
Shouldn’t be relied upon to prove/disprove relaxation, but can be used as a guide. Cold hands/feet may result from medical condition (poor circulation) for from long-term, underlying tension that may not be recognized by individual. Specific relaxation techniques could help raise skin temp.
Color changes range from black to violet:
Room temp should be 70F -75F. If lower, skin may remain too cold. If too warm, dot may indicate relaxation even though person is tense.
May be placed anywhere but frequently put on dominant hand, just above webbing between thumb and forefinger. Not as easily dislodged as might be from fingertip. Experiment w different locations.
Class Use – good ice breaker when distributed at beginning of class. Tool for increasing one’s body awareness. Can notice changes in discussion of birth complications, when called upon to do a return demonstration or when acting as labor supporter. Can show which relaxation techniques provide most skin warming.
Can use outside of class when driving, confronting unpleasant person/situation or cuddling new baby or one’s partner.
Hammock-like muscle, found in both sexes, that stretches from pubic bone to coccyx (Tail bone) forming floor of pelvic cavity and supporting pelvic organs. Controls urine flow and contracts during orgasm as well as assisting in male ejaculation. It also aids in childbirth as well as core stability. A strong pubococcygeus muscle has also been linked to a reduction in urinary incontinence and proper positioning of the baby’s head during childbirth.
Kegel exercises – series of voluntary contractions of all the perineal muscles. done in an effort to strengthen all the striated muscles in the perineum’s area. named after their founder, Dr. Arnold Kegel. In men, also engages the cremasteric reflex, which lifts the testicles up. Although this does not occur in all men. They have been prescribed to ameliorate erectile dysfunction due to venous leakage and to help control premature ejaculation and treat urinary incontinence in both sexes.