ICEA Study Guide 5 – Reproduction and Healthy Lifestyles


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.



  1. Reproductive mechanisms


  • 4-1-1 or 5-1-1 rule – labor contractions are intense enough to require you to focus and breathe rhythmically through them, and are 4 or 5 minutes apart with each lasting at least 1 minute for a period of 1 hour. Pattern signals labor may be progressing and time to call caregiver.
  • Active labor – 2nd phase of 1st stage of labor. Cervix dilated to 4/5 cm, contractions usually reach 4-1-1 or 5-1-1 pattern. Dilation usually speeds up, contractions become painful (but manageable) and labor progresses with each contraction.
  • Acupuncture – ancient Chinese medicine technique that uses needles placed at strategic points along meridians, or energy flow lines, in your body to guide it toward wellness and balance.
  • Advanced practice nurse practitioner – maternity caregiver who provides prenatal and postpartum care, but doesn’t attend women during labor
  • Afterpains – as uterus contracts after birth to its non-pregnant size (called involution), may experience discomfort/pain. May need slow breathing to help manage in first few days.
  • Alveoli – glands in breast that produce/store milk
  • Amniocentesis – medical procedure in which a needle is used to withdraw a small amount of amniotic fluid from your uterus. Lab analyzes the surfactant levels in fluid to determine whether baby’s lungs are mature enough to function outside your womb
  • Amnioinfusion – procedure in which fluids are infused into your uterus to dilute any meconium that was expelled in amniotic fluid or to remove pressure of the cord caused by baby’s head/trunk
  • Amniotic fluid – fluid that surrounds baby in amniotic sac. Protects baby by absorbing bumps from the outside, maintaining an even temperature, providing a medium for easy movement, and allowing baby to develop her lungs by “breathing” the fluid
  • Amniotic sac – made up of membranes (amnion and chorion) that create the sac that surrounds baby. also called “bag of waters”
  • Amniotomy – see artificial rupture of membranes (AROM)
  • Analgesia– any effect that reduces yoru perception of pain.
  • Androgens – male hormones that signal development of a baby boy’s scrotum and penis
  • Anemia – red blood cells lower than normal, reducing blood’s capacity to carry oxygen
  • Anesthesia – indicates a loss of sensation, including pain sensation. Anesthetic medications block nerve endings from sending pain impulses to brain
  • Antibodies – proteins that protect your body from bacteria and toxins. During pregnancy and breastfeeding, your baby receives antibodies from you, which will protect him against diseases to which you’re resistant or immune
  • Apgar score – within 1 minute after baby’s birth and again at 5 minutes, caregiver will evaluate baby’s well-being by conducting routine newborn assessment, which assesses how well baby is adapting to life outside womb
  • Areola – darker skin surrounding each nipple
  • Arrest of labor – condition where labor stops progressing, as measured by cervical dilation
  • Artificial rupture of membranes (AROM)- caregiver breaks bag of waters with an amnihook in attempt to speed up labor process. Aka amniotomy
  • Asymmetrical – 1 side of body doing something different than other side. Lunge, side-lying, semi-prone positions
  • Asynclitic– position in which baby’s head is tilted and the top of it isn’t centered on the cervix. Can lead to a prolonged labor.
  • Augmentation- speeding up a slow labor by using self-help methods or interventions such as AROM or Pitocin
  • Auscultation- listening to sounds inside your womb, such as baby’s heartbeat. In labor, intermittent auscultation describes how nurse/caregiver listens to baby’s heartbeat during and between contractions with a Doppler ultrasound stethoscope. At same time, he may place hand on abdomen to feel your contractions, then count baby’s heartbeats, nothing whether they speed up or slow down and record the findings
  • Baby blues – emotional changes or mood swings that are common in new parents during the first few weeks after the birth of a baby. for example, going from elation to sadness in a matter of minutes isn’t uncommon for new parents
  • Benefit-risk analysis– process by which caregiver considers whether treatment will achieve the desired results or create problems, then weighs the treatment’s benefits against its risks before forming his or her recommendation for a treatment
  • Beta-endorphins – body’s natural painkillers, these hormones are secreted when you experience pain, stress and physical exertion. Aka “endorphins”
  • Birth ball – a large inflatable physical therapy or fitness ball that provides a soft yet firm place to sit comfortably. Used as a comfort tool in labor to enhance mobility and labor progress.
  • Birth doula – someone (typically woman) who’s trained and experience in supporting women and their partners during labor/birth
  • Birth plan – 1-2 page letter to caregiver and staff that describes your fears and concerns as well as your wishes and priorities for the treatment of you and your baby. aka “birth preference list”, “wish list” or “goal sheet”
  • Blastocyst- after conception, fertilized egg quickly divides from 1 cell into 2, then 4, 8, 16 and so on until it becomes a multicellular structure called a blastocyst, which begins to implant in your uterus about 5-9 days later. Once it’s fully implanted, a blastocyst is called an embryo.
  • Body Mass Index (BMI) – measurement of relative amounts of fat/muscle in body. Calculated using a ration of height to prepregnancy weight
  • Braxton-Hicks contractions – contractions of uterine muscle that become more frequent and intense in the 3rd trimester, and that make your uterus hard for about a minute but isn’t painful. Unlike labor contractions, they don’t cause changes in cervix
  • Breech presentation – when baby is positioned with buttocks, legs or feet over cervix, instead of head down
  • Castor oil – strong laxative that causes powerful bowel cramps and contractions, which may initiate uterine contractions to induce labor
  • Catecholamines – stress hormones, including epinephrine (adrenaline), norepinephrine, and dopamine. High levels of stress hormones can slow labor progress
  • Cephalopelvic disproportion (CPD)- condition in which baby’s head is believed to be too large to fit through pelvis. Diagnosis may be made by caregiver based on observations during pregnant or may be used as a retrospective diagnosis after a prolonged labor that resulted in birth of a large baby
  • Certified nurse-midwife (CNM) – maternity caregiver who has graduated from nursing school, passed an exam to become a registered nurse, and completed 1+ years of additional training in midwifery
  • Certified professional midwife (CPM)- maternity caregiver who has received training from a variety of sources, including apprenticeship, school and self-study and has been the primary attendant at 20+ births. She practices outside hospitals and provides care similar to a licensed midwife.
  • Cervical ripening balloon – silicone catheter that’s placed within cervix, then inflated with saline solution. Used to induce labor by accelerating cervical dilation.
  • Cervix – lower part of the uterus, which protrudes into the vagina
  • Cesarean birth – giving birth by surgical procedure in which baby is delivered through incisions in abdomen and uterus. Also called “cesarean section,” “C-section,” “cesarean delivery,” or “cesarean”
  • Circumcision – surgical removal of foreskin covering glans (tip) of penis
  • Code word – a word that you choose in advance and share with your caregivers. By saying the word during labor, you communicate that, despite your original plan to birth without pain medications, you now want help getting medicated pain relief.
  • Colic – prolonged crying in a young baby. typically defined as 3 or more crying episodes each week for 3 or more weeks, with each episode lasting 3 hours or longer.
  • Colostrum – the first break milk; a highly nutritious yellowish fluid that’s low in volume, but high in antibodies and the nutrients your baby will need for the first few days of life before you milk supply increases in volume
  • Combined spinal-epidural (CSE) – a method for delivering pain medication. CSE uses a spinal narcotic in early labor (which may allow for more mobility), then an epidural anesthetic later in labor, when you need more pain relief
  • Complicated labor – a labor that is longer, more painful, or more difficult than a normal labor, and may require medical help to ensure the well-being of you and your baby
  • Conception – occurs when a sperm fertilizes an egg. The beginning of pregnancy
  • Contraction – tightening of the uterine muscle. During labor, these muscle contractions help open your ripe, effaced cervix and help your baby descend. Contractions become more frequent and more intense as labor progresses
  • Corticosteroids – medications that may be given to speed up the maturation of your baby’s lungs if a preterm birth can’t be prevented
  • Corticotropin-releasing hormone (CRH) – comes from your baby, the placenta, and tissues within your uterus. Increased levels of CRH in late pregnancy may help initiate labor
  • Crowning – the 3rd phase of the 2nd stage of labor. It begins when the widest part of your baby’s head is visible at the vaginal opening and no longer retreats between pushes, and it ends with her birth
  • Delayed pushing – an option for the 2nd stage of labor, in which a woman who doesn’t have an urge to push (such as after receiving an epidural) may wait an hour or two, or until her baby’s head crowns, before pushing actively. Also called passive descent
  • Descent – the downward movement of your baby into your pelvis
  • Diagnostic test – term used to describe a test that is more specific and more reliable than a screening test in identifying a woman with pregnancy complication of a baby with a problem
  • Dilation – the opening of the cervix, which allows your baby to pass through for birth
  • Directed pushing – an option for the 2nd stage of labor, in which your caregiver tells you how long and how hard to push. This method is used if you can’t feel your contractions and delayed pushing isn’t an option or if spontaneous pushing isn’t effective
  • Doppler ultrasound – a device that uses sound waves to monitor your baby’s heart rate. Typically used at prenatal visits as well as during labor and birth
  • Due date – an estimate of when your baby will be born. The majority of babies are born in the period from 2 weeks before to 2 weeks after
  • Early labor – usually the longest phase of the 1st stage of labor, often because contractions are further apart, shorter and less intense than they’ll be later in labor. Contractions are generally more than 5 minutes apart, and you can walk and talk during them. Also called the latent phase
  • Ectopic – occurs when the fertilized egg implants itself outside the uterus, usually in the wall of a fallopian tube (called a tubal pregnancy) but sometimes in the cervix, ovary, or abdomen. Most can’t develop into a live birth and typically require medical intervention to manage
  • Effacement – the thinning and shorting of the cervix in preparation for birth
  • Elective induction – an induction done without a medical reason, either because a woman requested induction or because her caregiver recommended it. Also called a “social induction”
  • Electronic fetal monitoring (EFM) – used to monitor you baby’s heart rate and your contractions, to assess how your baby is responding to labor. There are 2 types of EFM. External EFM uses belts to hold two sensors on your abdomen and the less commonly used internal EFM uses 2 sensors placed inside your uterus
  • Embryo – by 2 weeks after conception, your baby is called an embryo
  • Engagement – about 2 weeks before the birth, your baby descends deeper into your pelvis. You may feel less pressure on your diaphragm and find breathing and eating easier. Also called lightening or dropping.
  • Engorgement – painful swelling of the breasts
  • Epidural catheter – a tube inserted into the epidural space near the spinal nerves and used to deliver pain medication
  • Episiotomy – a surgical incision of the perineum that enlarges the vaginal outlet. Once common practice, now the majority of caregivers use it only when medically necessary to deliver the baby quickly
  • Estrogen – a hormone that promotes the growth of the uterine muscles and their blood supply, encourages production of vaginal mucus, and stimulates the development of the ductal system and blood supply in the breasts. In late pregnancy, rising estrogen levels increase the uterus’s sensitivity to oxytocin and help start labor
  • Evert – to draw out your nipple to allow your baby to latch on well for nursing. Typically occurs when your baby suckles
  • Expression – removing milk from the breast by hand or by using a pump. May be used to relieve fullness, maintain milk supply, or store milk for your baby’s consumption
  • Expulsion breathing – a way to breathe during spontaneous bearing down. During the pushing stage, use relaxed breathing when you don’t have the urge to push. When you have an urge to push, you may briefly hold your breath and bear down, or you may exhale with an open throat while pushing
  • External version – a procedure used to attempt to manually turn a baby from a breech or transverse position to a head-down position (vertex)
  • Failure to progress – term used either to describe a labor that’s taking longer than expected for the cervix to dilate to 1- cm, or to describe a pushing stage that’s taking longer than expected. May be treated with augmentation or cesarean delivery; however, if your baby is handling labor well, you may also ask whether self-help measures can effectively help with labor progress
  • Fallopian tubes – provide the path for an egg to travel from your ovaries to your uterus
  • False positives – describes situations in which test results for a condition are positive, but the condition isn’t present (for example, the fetal heart rate pattern indicates distress, but your baby turns out to be fine)
  • Family physician – a physician who has graduated from medical school or a school of osteopathic medicine and has completed 2 or more years of additional training in family medicine, including maternity and pediatric care
  • Feeding cues – how your baby shows he’s hungry. Include rooting, mouthing, tongue thrusts, sucking, and increased activity levels. Crying is a late feeding cue, used when the other cues have gone unnoticed
  • Fetal intolerance of labor – see nonreassuring fetal heart rate; also called fetal distress
  • First stage of labor – the period that begins when contractions are becoming longer, stronger, and closer together (progressing) and ends when your cervix is completely dilated
  • Forceps – a tool (steel tongs) that’s used to assist with a vaginal birth
  • Foremilk- breastmilk produced early in the feeding. Foremilk is lower in fat and higher in sugar than hindmilk
  • Fourth stage of labor – begins after the placenta is delivered and ends 1 to several hours later, when your and your baby’s condition have stabilized
  • Freestanding birth center – a birth center unaffiliated with a hospital
  • Fundus – the top of your uterus
  • General anesthesia – a systemic medication that causes a total loss of sensation and consciousness
  • Gestation – another term for pregnancy, which lasts an average of 280 days or 40 weeks after the first day of your last menstrual period
  • Gestational age – the age of your baby from the first day of your last menstrual period. Note that conception occurs within 12-24 hours after ovulation, which typically occurs 14 days after the beginning of your last period. So, 2 weeks after conception your baby’s gestational age is 4 weeks.
  • Gestational hypertension – high blood pressure that develops during pregnancy, defined as at least 2 consecutive readings that are over 140/89. Affects 10% of pregnancy women in the U.S.
  • Glycemic index – an index that ranks foods according to how quickly and significantly they elevate your blood sugar
  • Group B streptococcus (GBS) – a type of bacteria. If you test positive for GBS in pregnancy, you may be given antibiotics during labor
  • Hemorrhoids – swollen varicose veins in the rectal area that may be as small as a pea or as large as a grape
  • Heparin Lock – involves inserting an IV catheter, but doesn’t require hooking it to an IV bag and pole until IV fluids are needed
  • Hindmilk – breast milk produced later in a feeding session, released with the let-down reflex. This milk provides most of the calories and contains more fat and protein than foremilk
  • Homeopathy – a complementary medicine technique that uses diluted derivatives of natural substances to stimulate your body to respond in a way that heals or corrects a specific problem, such as a labor that wont start
  • Human chorionic gonadotropin (hCG) – a hormone produced only during pregnancy. It ensures that your ovaries produce estrogen and progesterone for the first 2-3 months of your pregnancy, until your placenta matures and produces the appropriate amount
  • Hyperventilation – If you find yourself feeling lightheaded or dizzy while using a breathing technique, try either slowing down your breathing, focusing on the exhalation rather than the inhalation or breathing into your cupped hands
  • Immunization – see vaccination
  • Incompetent cervix – a cervix that shortens and opens in midpregnancy without preterm labor contractions
  • Incontinence – a condition that causes you to leak urine when you have a full bladder, exercise, cough, or sneeze (urinary) or uncontrollably pass gas of leak stool (fetal)
  • Induction – an intervention used to start labor
  • Infant cues – your baby’s nonverbal communication. For example, when she’s overstimulated, she may close her eyes, yawn, get glassy-eyed, turn away, or stiffen. If you miss these cues and continue to stimulate her, she may begin a prolonged bout of crying.
  • Informed choice – see informed decision
  • Informed consent – after becoming informed about an option or treatment, you agree to it
  • Informed decision – the decision you make to refuse or consent to a health care option or medical treatment, after becoming informed about it through research and consultation with your caregiver and other knowledgeable medical professionals, as well as with supportive friends and family.
  • Informed refusal – after becoming informed about an option or treatment, you refuse it
  • Inhalation medication – a gas you breathe to receive pain medication
  • Intervention – a medical procedure used to intervene in the natural labor process, such as induction, augmentation, episiotomy or cesarean surgery
  • Intramuscular (IM) medication – a shot given into a muscle to deliver medication
  • Intrathecal space – the space inside the dura (the membrane that surrounds your spinal cord) that’s filled with cerebrospinal fluid. Its where spinal medications are injected
  • Intravenous (IV) medication – an injection into a vein, often through an IV catheter, to deliver medication
  • Involution – after the birth, your uterus begins the 6 week process of contracting to its nonpregnant size
  • Jaundice – an excess of bilirubin that causes your baby’s skin or the whites of his eyes to become yellow by the 3rd or 4th day after birth
  • Kegel – an exercise used to maintain the tone of your pelvic floor muscles, improve blood circulation in that area, decreases the incidence and severity of hemorrhoids and incontinence and support your uterus and other pelvic organs
  • Lactation consultant – breastfeeding expert
  • Lanugo – fine, downy hair that develops on your baby’s arms, legs, and back while in the womb
  • Latch – your baby’s connection with the breast to feed. A good latch permits your baby to nurse effectively
  • Latent phase – see early labor
  • Lay midwife – a maternity caregiver who might or might not be legally registered with the state of province, and whose qualifications and standards of care might or might not meet state or provincial standards. Also called empirical midwife
  • Leopold’s maneuver – the technique your caregiver uses to determine the baby’s position by feeling your abdomen
  • Let- down reflex – suckling stimulates pituitary gland to release oxytocin during breastfeeding, which makes milk-producing cells contract and release milk for baby to drink
  • Leucorrhea – a thin, liquid mucus discharge from the vagina
  • Licensed midwifed (LM) – a maternity caregiver who has completed up to 3 years of formal midwifery training according to state requirements
  • Lightening – see engagement
  • Local anesthetic – injection or application of pain medication that affects a specific, relatively small part of your body
  • Lochia – the heavy red discharge that flows from your vagina in the 6 weeks after birth made of the extra blood and fluid that supported your pregnancy and the uterine lining that sustained your baby
  • Malposition – when baby is in an unfavorable position in the womb, which may lead to a prolonged labor. Can often be corrected by changing positions frequently
  • Mastitis – an infection of the breast
  • Meconium – baby’s first bowel movements, a collection of digestive enzymes and residue from swallowed amniotic fluid. Appears as a sticky, greenish-black substance
  • Membranes – the amnion and chorion membranes create the amniotic sac that surrounds your baby in the uterus
  • Miscarriage – the unexpected death and delivery of a baby before the 20th week of pregnancy. Also called spontaneous abortion
  • Misoprostol (Cytotec) – a medication used to induce labor
  • Montgomery glands – small bumps on your areolae that secrete a lubricating substance that keeps the nipple supple and prevents infection
  • Morning sickness – nausea and vomiting in the early months of pregnancy. Despite its name, morning sickness can occur at any time of day
  • Moxibustion – a version of acupuncture that doesn’t use needles but instead uses burning herbs placed close to the acupuncture points
  • Mucous plug – mucus that fills the cervical opening during pregnancy to provide a barrier to help protect your baby
  • Multipara – a woman who has given birth more than once
  • Multiples – 2 or more babies gestating in the same womb
  • Narcotics and narcotic-like drugs – medications that reduce the transmission of pain messages to the pain receptors in your brain
  • Naturopathic doctor (ND) – a health care provider who has completed 3-4 years of postgraduate training in natural medicine. May also have taken an additional year of midwifery training to be able to provide prenatal care and attend births
  • Neonatal intensive care unit (NICU) – a hospital unit where medically challenged newborns stay for monitoring and treatment until they can breathe on their own, stay warm at room temperature, and breastfeed or take a bottle
  • Neuraxial medications – drugs that are injected into the space surrounding the spinal cord (neuraxis), such as epidurals and spinal blocks
  • Nipple confusion – a condition experienced by some babies who have difficulty adapting to different sucking patterns and flows of liquid, when they’re fed alternately by a bottle and the breast
  • Nonreassuring fetal heart rate – when baby’s heart rate isn’t responding to contractions in a reassuring way. Doesn’t necessarily indicate that something is wrong with baby (there’s a high rate of false positives); however, it does indicate the need for closer monitoring and a possible need for intervention in labor
  • Nullipara – a woman who has never given birth
  • Obstetrician/gynecologist (OB-GYN) – a physician who has graduated from medical school or a school of osteopathic medicine and has had 3 or more years of additional training in OB/GYN
  • Occiput anterior – the back of the baby’s head (occiput) is toward front of body
  • Occiput posterior – back of baby’s head is toward mom’s back
  • Oral medication – pill or liquid you swallow to receive a medication
  • Ovaries – female sex glands where eggs are produced
  • Ovulation – when a ripened egg is released into your fallopian tubes. On average, this happens 14 days after 1st day of last menstrual period. If you have intercourse 4 days before and 1 day after ovulation, there’s a chance of conception
  • Ovum – an egg produced by a woman. When an egg is fertilized by a sperm, conception occurs
  • Oxytocin – a hormone produced in your pituitary gland, which stimulates uterine contractions to help trigger the onset of labor and promote labor progress. Also present during orgasm and during breastfeeding, it’s often called the love hormone
  • Pain modifiers – external stimuli that affect your awareness and perception of pain
  • Parity – describes the condition of having given birth
  • Passive descent – see delayed pushing
  • Patient-controlled epidural analgesia (PCEA) – a device that allows you to increase your epidural dosage when you need more pain relief
  • Pediatric and family nurse practitioner – a registered nurse who has additional training in pediatrics or family health. Provides well-child care and treats common illnesses
  • Pediatrician – a physician who specializes in children’s health care
  • Pelvic floor muscles- muscles attached to the pelvis that support your abdominal and pelvic organs. These muscles form a figure-eight around your urethra, vagina and anus
  • Perinatologist – an OB/GYN who has received further training and certification in managing very high risk pregnancies and birth
  • Perineal massage – a massage that stretches the inner tissue of your lower vagina. Can be used during pregnancy or the 2nd stage of labor to relax the tissue so it will stretch around your baby’s head
  • Perineum – the external genitals (labia, urethra, clitoris, vaginal opening) and anus
  • Phototherapy – a medical procedure used to treat jaundice that shines a special type of cool light on our baby’s skin, causing the bilirubin to drop
  • Pitocin – commonly referred to as “Pit”, this is a synthetic version of oxytocin
  • Placenta – an organ that develops in pregnancy, the placenta produces hormones and exchanges oxygen, nutrients, and waste products for your developing baby. it’s released and delivered shortly after your baby’s birth
  • Position – refers to where the back of your baby’s head (occiput) is in relation to your body
  • Positive signs of labor – include contractions that become longer, stronger and more frequent (progressing) and the rupture of membranes in a gush of amniotic fluid. These are the only reliable signs that labor has begun and your cervix is dilating
  • Possible signs of labor – occur in late pregnancy and may indicate that the hormonal changes described on page 170 are underway but cervical changes aren’t yet occurring. These signs occur intermittently for days of weeks, but they don’t indicate labor
  • Post-date pregnancy – a pregnancy that has lasted to at least 42 weeks. Although the average length of pregnancy is 40 weeks, many pregnancies last longer. Caregivers may misuse the term postdate as early as 40 weeks
  • Postmaturity – a condition in which placenta stops functioning well, the baby’s growth slows or stops, and the risk of stillbirth increases. True postmaturity is rare even in babies born 2 weeks after their due dates. Postmature babies at birth have an absence of lanugo, scant vernix caseosa; long fingernails and toenails; and dry, peeling or cracked skin
  • Postpartum depression – a condition that generally presents itself between 2 weeks to 1 year after the birth. Symptoms vary in severity among women
  • 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
  • Postpartum hemorrhage – the excessive loss of blood (more than 500 ML or 2 cups) during the first 24 hours after birth
  • Postpartum mood disorders (PPMD) – emotional conditions that can develop in the 1st year after birth, such as anxiety and panic disorder, obsessive-compulsive disorder, postpartum depression, bipolar disorder and posttraumatic stress disorder
  • Postpartum psychosis – a rare condition that occurs in women after the birth and requires immediate care and psychiatric treatment. Symptoms include severe agitation, mood swings, depression and delusions
  • Precipitate birth – a birth that results from a very fast labor. For a 1st time mother, may be defines as an entire labor that lasts 6 hours or less, but it’s more often applied to a labor that’s 3 hours or less. For a woman who has previously given birth, it’s 1 hour or less
  • Preeclampsia – high blood pressure and protein in the urine. A multi-organ condition with mild to severe symptoms that affects 5-8% of pregnancies. Previously called toxemia
  • Pregnancy induced hypertension – see gestational hypertension
  • Prelabor signs of labor – indicate that your cervix is probably moving forward, ripening, or effacing. These signs may progress into positive labor signs the same day they begin, or they may simply alert you that labor will begin in a few days or weeks
  • Prelabor – a period of hours or days in which you experience contractions, but your cervix isn’t actively dilating. Its likely that these contractions are getting your cervix ready to dilate by moving it forward and helping it ripen and efface.   Prelabor contractions may range from as little as thirsty seconds long and 20 minutes apart, to as much as 1 or 2 minutes long and 5-8 minutes apart. However, the contractions change very little in length, frequency and intensity over time (nonprogressing).
  • Premature – a baby that’s born before the 37th week of pregnancy
  • Presentation – describes the part of your baby that’s lying over your cervix and will emerge from your body first. Also called presenting part
  • Presenting part – see presentation.
  • Preterm labor – a labor that begins before the 37th week of pregnancy
  • Primigravida – a woman who is pregnant for the 1st time
  • Primipara – a woman who has given birth once
  • Progesterone – a hormone that relaxes your uterus during pregnancy, keeping it from contracting too much. It also relaxes the walls of blood vessels (helping you maintain a healthy blood pressure) and the walls of your stomach and bowels (allowing for greater absorption of nutrients)
  • Progressing contractions – contractions that become longer, stronger, and more frequent over time
  • Prolactin – a hormone that’s produced after the birth and stimulates the production of breast milk
  • Prolapsed cord – a rare condition that occurs when the water breaks and the umbilical cord slips below the baby so it’s either in the vagina or lying between the baby and the cervix. Requires a call to 911 and transport to the hospital for an immediate cesarean
  • Prolonged labor – a labor that progresses more slowly than expected. Diagnosis is somewhat subjective
  • Prolonged prelabor – prelabor that lasts longer than a day
  • Prostaglandin – a hormone produced in your amniotic membrane. Increased levels in late pregnancy ripen your cervix in preparation for labor and stimulate muscles in your uterus and bowels to begin labor
  • Quickening – describes the moment when you feel your baby’s movements for the first time, during the 2nd trimester
  • Regional anesthetic – pain medication that affects a large area of your body
  • Relaxin – a hormone from your ovaries that relaxes and softens yoru ligaments, cartilage and cervix, making these tissues more stretchable during pregnancy and letting your pelvic joints spread during birth
  • Respiratory distress syndrome (RDS) – a condition in which a newborn infant has difficulty breathing and is unable to get sufficient oxygen due to immature lungs. The most common complication of premature birth, it requires immediate medical treatment
  • Rhythm – women who cope well in labor rely on rhythm in various forms. Rhythmic activity calms the mind and lets a woman work well with her body
  • Ripening – the softening of the cervix
  • Ritual – the repetition of a meaningful rhythmic activity during contractions to increase your ability to cope
  • Routine – procedures or treatment that’s offered to all pregnant women and their newborns, regardless of medical status
  • Rupture of membranes – breaking of the bag of waters that may manifest itself either as the leaking of a small amount of amniotic fluid from the vagina, or as a gush of fluids. Rupture may happen before labor or may signal the onset of labor, or it can happen at any point during labor and birth
  • Screening test – a medical test that can rule out a particular condition or may indicate an increased change that the condition is present. In the latter case, a diagnostic test confirms the condition
  • Second stage of labor – the birth of your baby. this stage begins when your cervix is fully dilated and ends when your baby is born
  • Serial induction – medication to induce labor is given during the day, but is discontinued at night to allow you to eat and sleep
  • Shared decision-making – a collaborative approach to making an informed decision, in which you and your caregiver discuss the medical risks and benefits of treatment and any possible alternatives
  • Special care nursery – a hospital unit for newborns who need extra medical monitoring or support, but don’t need the intensive care of a NICU
  • Spinal block – an injection of anesthetic near the spinal nerves that takes effect quickly and lasts or an hour or two
  • Spit up – when a baby expels a dribble or more of milk (up to 2-3 tbsp is common) after a feeding
  • Spontaneous bearing down – an option for the 2nd stage of labor, in which you naturally bear down on strain for 5-6 seconds at a time and take several breaths between efforts. This type of pushing makes more oxygen available to your baby than if you hold your breath and bear down for as long as possible
  • Spontaneous rituals – methods of coping invented by you over the course of your labor and reinforced by your support team. May include positions, movement, repeated words or sounds, specific kinds of touch, and so on
  • Station – refers to the location of the top of your baby’s head (or other presenting part) within your pelvis. Descent is measured by station
  • Sterile water block – an alternative option for relief of back pain during labor. A caregiver or nurse injects tiny amounts of sterile water into 4 places on your lower back. The injections cause severe stinging for am minute or more, but then provide pain relief by rapidly increasing endorphin production
  • Sudden infant death syndrome (SIDS) – the sudden death of a baby younger than 1 year that remains unexplained after a thorough investigation. There are steps that can be taken to further reduce the rare chance of SIDS; however, for about 1 in 2000 babies, it appears to be impossible to predict or prevents
  • Supine hypotension – when lying on your back makes your uterus press on the abdominal vein that carries blood from your legs to your heart (inferior vena cava), causing a drop in blood pressures
  • Surfactant – a substance that allows your baby’s lungs to expand during an inhalation and remain partially inflated during an exhalation
  • Synthetic prostaglandins – medications that mimic the hormone prostaglandin
  • Systemic – describes a medication that affects your entire body
  • Tandem nursing – breastfeeding 2 children at the same time (such as twins or your baby and toddler)
  • Telemetry monitoring – wireless electronic fetal monitoring, which allows you to walk and use the shower or bath.
  • Tension spots – body areas that you habitually tense when stressed. For example, your shoulders, forehead, mouth, jaw or fists.
  • Third stage of labor – begins with the birth of your baby and ends with the delivery of the placenta
  • Three R’s: relaxation, rhythm, and ritual: a theory about how women cope with labor when given support and freedom to explore coping options. You stay as relaxed as possible throughout labor, until you discover your coping rhythm. Your partner’s role is to reinforce this ritual for as long as it continues to help you
  • Tocolytic medication – a drug used to slow or stop contractions; for example, during preterm labor.
  • Transition – final phase of the 1st stage of labor, which serves as the transition to the 2nd stage of labor. Your cervix is reaching complete dilation, and your baby is beginning to descend into your birth canal. Contractions are 90 sec – 2 min long and 2-3 min apart.
  • Transverse incision – the most common incision (cut) for a cesarean birth. Horizontal incision on the lower abdomen (at the “bikini line”) through the bottom of the uterus
  • Transverse lie – when your baby is positioned sideways in the uterus, with his back or shoulder closest to the cervix. Only occurs in 1/2500 births. Yoru caregiver will attempt an external version to turn your baby, and if unsuccessful, your baby will be delivered by cesarean
  • Triage – observation area in the hospital, where an admitting nurse assesses your condition, your pattern of contractions, your dilation (with a vaginal exam), and your baby’s well-being, in order to determine whether you’re ready to be admitted to the hospital, or whether you should return home with instructions on when to return
  • Trial of labor after cesarean (TOLAC) – when a woman with a prior cesarean chooses to let labor begin and progress, with the hope of having a vaginal birth after cesarean (VBAC)
  • Trimesters – pregnancy is divided into 3 trimesters, each one lasting about 3 months
  • Ultrasound – see Doppler ultrasound and ultrasound scan
  • Ultrasound scan – equipment that uses intermittent transmission of sound waves to help your caregiver “see” inside the uterus. Can be used as a screening test ora diagnostic test for evaluating your baby’s development
  • Umbilical cord – links the placenta to your baby’s navel and together they pass oxygen and nutrients from you to baby. while placenta provides a barrier against most (but not all) bacteria in bloodstream, most viruses and drugs cross to baby. placenta also exchanges waste produces from your baby, which your blood then carries to your kidneys and lungs for excretion
  • Urge to push – the most significant stage of 2nd stage of labor. You may find yourself holding your breath and straining or grunting during each contraction
  • Uterine atony – poor uterine muscle tone. The most frequent cause of postpartum hemorrhage
  • Uterine rupture – the separation of a uterine incision from a previous cesarean or uterine surgery
  • Uterus – a hollow, muscular organ the size and shape of a pear in which a baby develops
  • Vaccination – an administration of a vaccine to prevent illness. Also called immunization
  • Vacuum extractor – a tool (silicone suction cup) that’s used to assist with a vaginal delivery
  • Vaginal birth after cesarean (VBAC) – a vaginal birth after a previous cesarean, as a result of a successful trial of labor after cesarean (TOLAC)
  • Vernix caseosa – a white, creamy substance that protected your baby’s skin in your womb
  • Vertex – presentation in which the top of your baby’s head is down over your cervix
  1. Female reproductive organs and cycle
  2. Male reproductive organs
  3. Embryo development


  1. Sexuality and the childbearing year

YouTube Foramen Ovale and Ductus Arteriosus cFLi4&list=FLgH3azySd4MiajnyjVst6cQ&in dex=2 (wrong link) (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 Pregnancy1st 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.

  • Go on bed rest – ranges from complete bed rest to a slight decrease in activity level plus increased rest. Research doesn’t show it reliably stops preterm labor, but often seems to work, possibly because stress levels decrease. Warm tub may also reduce uterine activity.
  • Monitor uterine contractions – if hospitalized, electronic monitoring will determine if labor contractions progressing. If at home, caregiver will continue to check by hand and watch for other labor signs. Portable electronic monitors were used in past but because don’t reduce rate of preterm birth, use is rare today.
  • Restrict sexual activity (pelvic rest) – orgasm causes uterus to contract and semen contains prostaglandins, which can promote preterm labor in women at risk. Nipple stimulation can also initiate.
  • Medication to stop/postpone – if drugs are successful, caregivers stop treatment when pregnancy reaches 36-37 weeks. The muscle relaxants (Tocolytics) include nifedipine, magnesium sulfate and indomethacin. They stop preterm labor only occasionally but may delay birth for up to 7 days, providing time to administer other drugs to improve baby’s health. Progesterone may prevent prematurity when hormone is injected weekly in women with a prior preterm birth who show signs of cervical changes in the 2nd Certain infections increase risk of preterm labor; if you have one, caregiver may prescribe antibiotics to prevent contractions.
  • Cervical cerclage (surgical suturing) – incompetent cervix is when cervix shortens and opens in mid-pregnancy without preterm labor contractions. Relatively rare condition may occur if cervix has been weakened by injury or surgery such as conization or a D&C for an abortion. May be closed with suture thread in early pregnancy as a preventative measure or in mid-pregnancy (before 24th week) if cervical changes occur. Sutures are removed in late pregnancy.

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.


  1. Maintaining a healthy lifestyle is a lifelong process
  2. Pregnancy often provides motivation to initiate change


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;;;;;;;;;;;;;;

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

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. – new mothers to share info about their birth experiences.

Choosing a Birthplace

  • Hospital – most women in North America give birth in hospitals. Don’t allow pregnant women to choose who administers anesthesia – may be a nurse anesthetist, an anesthesiologist or a resident. Can find out credentials and experience of staff. Visit to view questions to ask a hospital; based on Coalition for Improving Maternity Services “Ten Steps of Mother-Friendly Care”. Visit for locations of baby friendly hospitals
    • Questions to Ask – see; ex ratio of patients to nurses during labor, birth plans, floating/traveling nurses, equipment to monitor baby’s heart rate, move around in labor, iv fluids, eat and drink during labor, anesthesia available at all times, non-drug methods of pain relief, bathtubs, doulas, visitors, usual stay, baby immediately after birth, breastfeeding specialist, postpartum/newborn follow-up
    • Hospital Tour
  • Outside hospital
    • Freestanding birth center – unaffiliated with hospital; for those permitting only essential interventions.
    • For low-risk pregnancies, planned out of hospital births are as safe for mothers and babies as planned hospital births – sometimes even safer.
    • Medicaid and many health insurance plans often cover cost
    • If a woman is transferred, insurance plans might not cover some costs
    • 15-25% of first-time mothers and 5-10% of 2nd tie mothers transferred
    • Almost all transfers (96%) are for non emergencies such as prolonged labor, meconium in amniotic fluid, prolonged ruptured membranes or desire for pain medication
    • 3-4% urgent transfers require immediate medical action such as cord prolapse, hemorrhage, or concerns about baby’s heart rate and oxygen supply.
    • After a home birth, just over 1% of mothers and just under 1% of babies require a transfer for reasons such as bleeding in mother, retained placenta and respiratory problems in baby
    • Midwives carry oxygen tanks, IV fluids and suctioning devices as well as medications to stop contractions temporarily, stop bleeding and lower blood pressure
    • Consider how far away your home or birth center is from hospital
    • com for list of questions to ask midwife/yourself for out of hospital birth

Choosing Caregiver

  • Physician
    • (OB-GYN) – a physician who has graduated from medical school or a school of osteopathic medicine and has had 3 or more years of additional training in OB/GYN
    • Perinatologist- an OB/GYN who has received further training and certification in managing very high risk pregnancies and birth
    • Family physician- a physician who has graduated from medical school or a school of osteopathic medicine and has completed 2 or more years of additional training in family medicine, including maternity and pediatric care
  • Midwife
    • Certified nurse-midwife (CNM) – maternity caregiver who has graduated from nursing school, passed an exam to become a registered nurse, and completed 1+ years of additional training in midwifery
      • Spend more time in prenatal visits with clients, individualizing care
    • Licensed midwifed (LM) – a maternity caregiver who has completed up to 3 years of formal midwifery training according to state requirements
      • 21 states recognize LMs; most provide care only for those planning home births or birth centers
    • Certified professional midwife (CPM)- maternity caregiver who has received training from a variety of sources, including apprenticeship, school and self-study and has been the primary attendant at 20+ births. She practices outside hospitals and provides care similar to a licensed midwife.
  • Other
    • Advanced practice nurse practitioner – maternity caregiver who provides prenatal and postpartum care, but doesn’t attend women during labor
    • Naturopathic doctor (ND) – a health care provider who has completed 3-4 years of postgraduate training in natural medicine. May also have taken an additional year of midwifery training to be able to provide prenatal care and attend births
    • Lay midwife – a maternity caregiver who might or might not be legally registered with the state of province, and whose qualifications and standards of care might or might not meet state or provincial standards. Also called empirical midwife

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

  • Birth is a normal physiological process and an emotionally transformative experience
  • A woman’s state of mind influences the labor process, so individualized care is necessary
  • Because a woman’s participation contributes to a healthy pregnancy, labor and birth, childbirth preparation is necessary
  • Low intervention and cesarean rates are desirable
  • Caregivers monitor the mother’s and baby’s well-being and provide education and support. If problems arise, they start with tools that cause the least intervention to regain a healthy physiological process

Medical Model of Care – designed to replace or alter the body’s own resources with medical and technological interventions

  • The natural childbirth process is unpredictable, unreliable and potentially unsafe. Routine care protocols for all women give the caregiver a sense of control over the birth process
  • Medical interventions improve labor and birth
  • Cesareans are no less safe for the mother or baby than natural labor and vaginal birth; in fact, they may be safe
  • Caregivers use routine interventions before problems arise. If problems arise, they intervene quickly with the tool most likely to have the quickest effect

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

  • Will I see you or another caregiver at each appointment? Does a nurse sometimes handle visits
  • Do caregivers share same philosophy of care? Chances of attending birth? Good idea do induce labor while you’re on call? Colleagues respect birth plan? Hospital staff?
  • Recommend childbirth prep classes? Doulas? Birth plans?
  • Do you support natural childbirth?   Use non-drug ways to relieve labor pain and avoid routine interventions? How many of clients attempt natural? How many succeed?
  • How often use interventions such as labor induction, IV fluids, AROM, continuous electronic fetal monitoring, episiotomy, forceps, and vacuum extractor?
  • How often perform unplanned cesarean with first time mothers? How many clients have one? What can I do to reduce likelihood?
  • If I develop complications, will you handle care or refer me? Who will you refer me to?
  • When and ho often will I see you for checkups after birth?
  • PCNguide for worksheet to record answers
  • if have concerns about respecting legal right to informed consent and refusal

Changing Caregivers if dissatisfied – it’s essential you feel comfortable

  • Express discomfort by using pronouns I instead of you
  • If doesn’t work, consider change but don’t drop until you’ve found someone who better suits you and who has agreed to be your caregiver
  • If you cant change and can’t discuss freely with caregiver, talk with office nurse, childbirth educator, doula or others

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:

  • Shorter labors, with less need for medication to speed up labor
  • More spontaneous vaginal birth (those that don’t require forceps, vacuum extraction, or cesarean)
  • Fewer requests for pain medications
  • Less dissatisfaction with birth experiences

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. 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

  • Pediatrician
  • Family physicians
  • Pediatric and family nurse practitioners
  • Naturopathic doctors

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.;

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)–

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 and for advice on evaluating. Give appropriate holiday gifts to caregivers.

10 Steps to Improve Your Chances of Having a Safe and Satisfying Birth

  • Exercise in moderation; eat well
  • Choose birth place with low cesarean birth and minimal routine interventions (fewer interventions in out-of-hospital setting
  • Caregiver with low intervention rates
  • Birth plan. See to read rights of childbearing women
  • Birth doula
  • Avoid labor induction for non-medical reasons. Ask about alternatives
  • Use medical interventions only when clearly necessary, not because routine. Avoid routine IV fluids, continuous electronic monitoring, augmentation with Pitocin or AROM.
  • *Learn to differentiate between early labor and active labor so you can delay hospital admission until active labor. Use labor-coping skills at home to manage pain. Eat, drink and rest as needed to keep up energy
  • Use variety of positions and activities during active labor, such as walking, dancing, rocking in a rocking chair or on birth ball, or taking a shower or bath
  • Push in positions that aid descent, unless birth is happening fast; then use positions that slow descent.


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

  • hCG – ensures ovaries produce estrogen and progesterone for first 2-3 months of pregnancy, until your placenta matures and produces appropriate amount
  • Estrogen – promotes growth of uterine muscles and their blood supply, encourages production of vaginal mucus, and stimulates development of the ductal system and blood supply in breasts. Changes in water retention, body fat buildup and skin pigmentation are related to estrogen levels. In late pregnancy, rising estrogen levels increase uterus’s sensitivity to oxytocin and help start labor.
  • Progesterone – relaxes uterus during pregnancy, keeping it from contracting too much. Helps maintain healthy blood pressure, greater absorption of nutrients/sometimes causing constipation. In late pregnancy, it has less effect on your uterus, letting contractions increase and start labor.
  • Relaxin – from ovaries relaxes and softens ligaments, cartilage and cervix, making them more stretchable during pregnancy and letting pelvic joints spread during birth
  • Prostaglandins – produced in amniotic membrane, increase in level during late pregnancy. They soften and ripen cervix in prep for labor and stimulate muscles in uterus and bowels.
  • Corticotropin-releasing hormone (CRG)- comes from baby, placenta, and tissues within your uterus. Increased levels in late pregnancy change ratio of estrogen to progesterone
  • Oxytocin – produced in pituitary gland, stimulates uterine contractions to help trigger onset of labor and promote labor progress. Responsible for urge to push at end of labor and for let-down reflex during breastfeeding.


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

  • Changes in Baby – normal human cell 46 chromosomes; blueprint at conception determines baby’s sex, blood type, eye and hair color, nose and ear shape and some personality traits and mental capabilities; also guides baby’s growth and development throughout her life. After conceptions, fertilized egg quickly divides from 1 cell into 2, then 4, 8, 16, and so on until it becomes a multicellular structure called a blastocyst. It makes it way along fallopian tube and implants in uterine lining in upper part of uterus. By 2 weeks, baby is an embryo and another part of the fertilized egg develops into placenta.
  • Changes in You – breast tenderness, slight ache in belly.

Weeks 5-14

  • Changes in Baby – nervous system and circulatory system are forming and heart is beating by 25th Has simple kidneys, a liver, a digestive tract and a developing umbilical cord.   At half the size of a pea, arm and leg buds appear and face begins to form. Male and female embryos appear same until ~9 weeks old. If male, produces androgens, male hormones that signal development of scrotum and penis. By 8 weeks, baby is structurally complete. Mouth has lips, a tongue, and teeth buds in his gums. Arms have hands with fingers and fingerprints. Legs have knees, ankles and toes, arms and legs move at this time, but coordinate movements don’t begin until ~14 weeks. Developing brain begins to send out impulses. Heart is beating strongly and can be seen easily during ultrasound. At 9 weeks old, called a fetus. During first 3 months, baby becomes quite active. Legs kick and arms move. Baby can suck thumb, swallow amniotic fluid and urinate drops of sterile urine into amniotic fluid, which is completely exchanged ~every 3 hours. Baby makes breathing movements – breathing amniotic fluid into lungs appears to help with lung development. 10-12 weeks, baby’s eyelids cover his eyes, which remain closed until 6th month.
  • Development of Placenta and Changes in Uterus – at end of first month, chorionic villi extend into uterine lining, becoming a primitive placenta. Baby’s blood circulates through chorionic villi, while blood circulates into spaces surrounding them (intervillous spaces). Thin membrane separates 2 bloodstreams, which normally don’t mix. Membranes (amnion and chorion) create amniotic sac that surrounds baby. Amniotic fluid protects baby by absorbing bumps from outside, maintaining an even temp, and providing a medium for easy movement. By 12 weeks, placenta is completely formed and serves as organ for producing hormones and exchanging nutrients and waste products. Most identical twins share same placenta. Fraternal twins have separate placentas, though placentas sometimes fuse into one large organ. Umbilical cord links placenta to baby’s navel and pass oxygen and nutrients from you to baby. Placenta provides barrier against most (but not all) bacteria in bloodstream, most viruses and drugs cross. Placenta also exchanges waste products from baby, which blood then carries to kidneys and lungs for excretion. By 14 weeks, uterus has grown to just above pubic bone. Cervix is ~4cm long and though softer than before pregnancy, still fairly firm. Mucous plug fills cervical opening provides barrier to help protect baby.
  • Changes in You – 5 weeks, pregnancy test shows positive result. Feel unusually tired and need more sleep because of changing metabolic rate and increased energy needs while growing a baby. urinate more often as enlarging uterus presses on bladder. Nausea, vomiting; morning sickness can occur at any time of day. Cause unknown but hormones produced by developing placenta play a role. Milk glands don’t develop fully until pregnancy. As hormone levels increase, breasts change in prep of providing milk for baby. Breasts enlarge, veins appear bigger, and nipples may be tender or have tingling sensation. Nipples and areolae enlarge and become darker. Little bumps on areolae (Montgomery glands) enlarge to produce more lubricant in prep for breastfeeding. Metallic taste, increased salivation, weight loss/gain up to 5 pounds. Difficulty seeing baby as real until proof by ultrasound scan or audible heartbeat (partner).


2nd Trimester Changes for You and Baby – “Development” period – baby’s organs and structures begin to enlarge and mature.

15th-27th Week

  • Changes in Baby: baby starts to grow hair, eyelashes and eyebrows. Lanugo develops on arms, legs and back. Fingernails and toenails appear. 18 weeks, baby can do all movements you’ll see her do as a newborn. Forming in baby’s intestines is meconium, collection of digestive enzymes and residue from swallowed amniotic fluid; won’t expel til after birth. Skin is wrinkled and covered in vernix caseosa. Feel baby move for first time (quickening). Light tapping/fluttering sensation that reminds you of gas bubbles. Some babies born at end of this trimester (25 weeks) survive. 23 weeks – heartbeat audible via regular stethoscope. 27 weeks eyes are open, begins to hear.
  • Changes in Placenta/Uterus – uterus expands into abdominal cavity to accommodate growing baby. length of pregnancy in weeks approximates distance in centimeters between pubic bone and top of uterus (fundus).   Uterus normally contracts periodically, although wont notice. Braxton hicks contractions make uterus hard for ~1 minute but aren’t painful; don’t cause changes in cervix.
  • Changes in You – milk glands in breasts begin making small amounts of colostrum by mid-pregnancy. Linea nigra may appear between pubic bone and navel. Skin around eyes may darken, especially after sun exposure; mask of pregnancy called chloasma usually disappears within a few weeks after baby’s birth.  Groin pain from round ligament contractions. Leg cramps.
  • Emotions – more sensitivity to kind word, beautiful sunset or touching photo. May affect sleep, recall more of dreams and may become introspective, distracted by need to examine thoughts and feelings. Swelling belly becomes more obvious; feel baby kick or wiggle. Being able to see evidence gets partner more involved.


3rd trimester changes for you and baby – “Growth period” – changes for an easy transition to life outside womb improve closer to due date.

  • Changes in Baby – in late pregnancy, baby’s lungs mature, antibodies pass through placenta to her providing short-term immunity to diseases to which you’re immune. Hair on head grows, lanugo disappears, and fat is deposited under her skin. Buds for permanent teeth appear behind her primary teeth. Baby has periods of sleep and awakeness. Becomes familiar with your voice and other sounds such as placental circulation, gurgling stomach, heartbeat and external sounds. After birth, baby will show a preference for familiar voice and sounds that mimic placental sounds – sloshing of water in dishwasher, vacuum, fan, shushing sounds often sooth baby. Less room to move around. Hiccups. Assumes favorite position – usually head down. Caregiver determines position by using Leopold’s maneuvers. Breathing movements present.
  • Fun – sing same song to baby or play favorite music. Read same children’s book/poem. Talk to baby. press on belly when you feel hand./foot. Try pressing twice and see if baby responds.
  • Changes in Placenta and Uterus – cervix softens, uterus becomes more sensitive to oxytocin and may notice more contractions. Volume of amniotic fluid decreases from 1.5 quarts at 7 months to 1 quart around due date. 31 weeks – uterus is 3 fingerbreadths above navel. 35 weeks – uterus is just below breastbone and ribs.
  • Changes in You – uterus expands causing shortness of breast or sore lower ribs. High levels of progesterone and pressure from uterus may cause indigestion, heartburn, varicose veins in legs, hemorrhoids or swollen ankles. More back pain as pelvic ligaments relax for birth and heavy uterus and growing baby change center of gravity. Small red bumps (vascular spiders) may appear on skin of upper body along with stretch marks (striae gravidarum) on abdomen, thighs, or breasts – reddish during pregnancy and become glistening white after birth; no evidence shows lotions/cream effectively work to reduce. Tingling/numbness in hands. Increased perspiration/feeling warmer. Changes in balance and agility. Swollen ankles. Anemia. Total weight gain 25-35 lbs.
  • ~2 weeks before birth, baby “drops” into pelvic cavity – engagement or lightening. May feel less pressure on diaphragm and find breathing/eating easier. Tradeoff is baby’s head on bladder so need to urinate more frequently. Some women leak colostrum.
  • Emotions – may feel tired most of the time. Get a big body pillow or use many pillows. Talk about fears; it doesn’t make them more likely to happen, instead someone can comfort you and put fears into perspective. Partner may have anxiety over support role in labor. Longing for relationship to return to normal. Frustration about inability to “fix” partner’s discomforts. Fear of harm to baby during sex. Choosing names.

39th/40th Weeks of Pregnancy

  • Changes in Baby – baby’s organs continue to mature in preparation for life outside uterus. Adds fat and gains 1 pound. Newborn avg 20 in (range 18-22 normal). Weighs ~7/7.5 lb (range 5.5-10); from time baby was a fertilized egg; weight has increased 6 billion times!
  • Changes in Placenta/Uterus – size of placenta varies on size/weight of baby. after birth, placenta appear round, flat and 1 inch . Moist, white umbilical cord has 2 arteries and 1 vein; measures 12-39 inches when pulled straight. At birth when baby begins to breath, her circulation pattern begins to change; blood flow through her umbilical cord shuts down and more blood flows to her lungs. Contractions become more obvious and frequent and enhance circulation in uterus, press baby against cervix and work with prostaglandins to soften and thin cervix.

41st Week of Pregnancy and Beyond – Post-Dates

  • Average length is 40 weeks but many last longer and are consider post-date. Caregiver determines whether baby/placenta are healthy by performing specific diagnostic tests. If all is well, labor can begin on its own.
  • Changes in Baby – baby might not be post-mature (doesn’t have symptoms such as an absence of lanugo; scant vernix caseosa; long fingernails and toenails; dry, peeling, or cracked skin; and unusual alertness at birth. True post-maturity is rare even in babies born 2 weeks after due dates.
  • Changes in Placenta: continues to support the growth and well0beging of baby. in rare cases when baby is truly post-mature, tests reveal that the placenta isn’t functioning as well, that the volume of amniotic fluid is dropping and that baby is showing signs of distress. Under these circumstances, baby’s health can’t wait for labor to begin on it’s own and caregiver either induces labor or performs a cesarean.
  • Changes in You – consider self-induction methods


Common Concerns and Considerations in Pregnancy

  • Age of Mother – in general, women between 18 and 35 have few problems
    • Teenage Pregnancy – teenager’s body usually fit. Young uterus probably strong and tissues are stretchy. Labor will likely progress normally and won’t need medical interventions. Go to prenatal appointments so that don’t birth too early and deliver baby with low birth weight – the main problem for teen pregnancies. Challenges: dealing with parents’ reactions, working with baby’s father, attending school with peers who can’t relate, deciding whether to keep baby or give up for adoption, decisions about health care
      • Books: Life Interrupted – juggling school and single parenthood; Your Pregnancy & Newborn – Guide for Teens; Unplanned Pregnancy Book for Teens and College Students
    • After 35: birth rate for moms in 30s increased 2x, 3x for women >34, 4x for women >40. Delayed pregnancy due to career, education priorities, financial considerations, infertility, lack of partner. Risks of high blood pressure, gestational diabetes, growth problems or inherited disorders in baby, preterm labor, problems with placenta, fibroids, labor complications and cesarean. Longer a woman lives, more likely poor health practices, accidents, illness or environmental hazards have affected body. High blood pressure and diabetes (2 most common) increase with age. As age, infertility becomes a problem. First time mothers who were older had increased risks of preterm labor, excessive bleeding, or cesarean. Pregnancy mothers who had birth before had increased risks of diabetes and chronic or gestational hypertension. Older women more likely to have baby with genetic disorder such as Down syndrome. Fathers age also risk – increases for fathers >35. Fathers >40 increased risk of certain rare congenital disorders such as dwarfism. Caregivers use age 35 as age to start recommend testing. At this age, potential benefits from invasive tests, such as amniocentesis and chorionic villus sampling (CVS) begin to outweigh risks. Now more noninvasive screening tests are available so younger women being offered. If 35+ what to do – unless have preexisting health problem such as high blood pressure or diabetes, do same as any other pregnancy women. Most women >35 give birth to healthy, full term babies.
  • Multiples: see PCN pgs 53-54 above


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.

  • Reality of Baby – first trimester its difficult to see many physical changes so might not think of baby as real. 16-20 weeks, changes in body become obvious and may begin to feel baby move. Many fathers comprehend baby’s existence when you see baby during ultrasound scan and hear baby’s heartbeat. Many men don’t begin to attach to babies until after birth.
  • Excitement, Stress and Worries of Becoming a Father – may begin to reflect on own mortality. Decide to buy more life insurance and write or update will. Some men experience empathy symptoms – weight gain, food cravings, abdominal cramps or bloating, nausea, vomiting, backaches, toothaches, loss of appetite and insomnia.
  • Changes in Relationship – may feel left out at times. Instead of you, she turns to friends and relatives for emotional support. May feel you’re expected to care more for her and your relationship but that she’s less available to you emotionally, physically and sexually.
  • Role during labor and birth – take a childbirth prep class, watch DVDs or read books and discuss and worries with other fathers and partner. Consider having a friend, relative or doula at birth.
  • Role as Father – hormone levels in expectant fathers change during pregnancy – lower levels of testosterone and cortisol and higher levels of estradiol.
    • May help to adjust to new role: read books, attend well-baby checkups, talk to other fathers about what to realistically expect during first few weeks after birth; consider priorities and those of family; maintain relationship with partner; find time for yourself; determine how you can get help that you and partner need after birth; how you can care for new baby – holding, rocking, diapering, comforting, playing and learn more about those skills
    • Books: The Birth Partner, The Expectant Father, Father’s First Steps, The New Dad’s Survival Guide
    • Classes: For dads to be, conscious father classes, boot camp for new dads


Nontraditional Families

  • If Partner Isn’t Baby’s Biological Parent – he/she may feel like pregnancy is “yours” not “ours”. Partner may questions role in making decisions and providing financial support for your growing family. If baby’s biological father involved, partner may feel even less sure about his/her role. Does partner want to adopt baby? what role will biological father play? If in heterosexual relationship with someone new since becoming pregnant, have to decide who will accompany you to prenatal appointments and who will be with you during labor and birth.
  • If Pregnant and Single – although common today, society often offers single parents little support. Not everyone reacts positively to your pregnancy. Usually take on role of 2 people. At times you may be relieved you don’t have to deal with added burden of an incompatible partner. May be times when you doubt whether you can – or want to – parent alone and wish for companionship and support of a reliable partner.


Special Challenges in Pregnancy – past traumatic experiences can present additional challenges

  • History of Childhood Trauma – early childhood trauma sometimes causes unexpected reactions during pregnancy, birth or afterward. Women physically, sexually or emotionally abused as adults can also experience these reactions. Many abused women have difficulty trusting others, especially those in authority (such as physicians or midwives).
    • Estimated that 25-40% of women were sexually, physically or emotionally abused in childhood.
    • Survivor may find vaginal exams, nakedness or prospect of a baby coming through her vagina extremely disturbing or even intolerable
    • May respond to inevitable loss of control over body that occurs in labor in same way she had as a child, when she was helpless to stop her abuser from hurting her
    • May equate though of giving another person total access to her breast, even for breastfeeding, to her inability to prevent her abuser’s violation of her body
    • Extent of these problems vary and may factors influence including nature of abuse, age at which it occurred, how long it lasted, presence or absence of other loving and trustworthy adults in her life. Psychotherapy and emotional support groups promote healing. Appendix C for list of resources for survivors of childhood abuse.
  • Pregnancy After Miscarriage or Stillbirth – knowing why a previous pregnancy ended may help you and caregiver plan. Offer more prenatal testing. Closely watch baby’s health by counting movements. Talk with family members, friends, grief counselors and medical professionals.
    • Books: Pregnancy after a Loss; Trying Again: A guide to pregnancy after miscarriage, still birth and infant loss
  • Disability – consult with physical or occupational therapist or with women you’re your disability who have managed a pregnancy and parenting. Search for online discussion forums

Key Points: 1st trimester – formation period; 2nd trimester – development period; 3rd trimester is growth period

  1. Developmental stages of pregnancy require adaptations.


III. Stress management

  1. Stress initiates hormonal changes 
1. Stress responses leads to biochemical changes 
2. Physical, emotional, and mental symptoms result from stress

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 –

  • Recognize stress response. Notice how you feel when anxious/stressed (overwhelmed, trouble sleeping, headaches, bowel problems etc)
  • Identify source – which person, situation or experience triggers
  • Try to eliminate source – transfer/quit stressful job, leave abusive home
  • Learn better ways to cope
    1. Stay away from people who trigger a stress response
    2. Get enough sleep and nap during day; fatigue makes everything worse
    3. Relaxation skills on pg 216-220. Slow breathing while resting, meditating or listening to soothing music
    4. Nourishing foods and drink plenty of water and other fluids
    5. Exercise regularly
    6. Discuss problems
    7. Nurture yourself – massage, manicure or facial. Take a walk through park. Spend time with people who comfort you


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. 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.

  1. Conserves energy and reduces fatigue – if you don’t consciously relax during contraction, you’ll probably unconsciously tense them. Tension wastes energy and increases pain/fatigue
  2. Reduces pain
- Relaxation allows more oxygen to reach contracting uterus, which may decrease pain because a working muscle becomes painful when deprived of oxygen. Consciously releasing tension focuses attention away from contractions and reduces awareness of pain.
  3. Calms the mind and reduces stress – Relaxed body leads to relaxed state of mind, which reduces stress. Anxiety, anger or fear causes stress in labor, which produces excessive catecholamines (Stress hormones) such as epinephrine (adrenaline) and norepinephrine (noradrenaline). High levels of these hormones can prolong your labor by decreasing the efficiency of your contractions and can harm your baby by decreasing the blood flow to your uterus.

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.

  • Practice with Partner: Observation (how do you look when anxious, uncomfortable, calm, content, asleep). Touch (muscles feel hard or soft). Floating a limb (heaviness that signals relaxation – like lifting sleeping baby’s arm).
  • Tighten body part and have partner find. Have him find different ways to relax it: warm compress, massage, reminding you to release. Discover which body parts tense most: shoulders, forehead, mouth, jaw, fists.
  • Relaxation Techniques: By focusing on different parts of the body and consciously releasing the tension in them, you can relax both your body and mind. Lie on side with plenty of pillows or sit in a comfortable chair; then try standing, walking. Begin in quiet calm area then try in more active surroundings. When done, stretch arms and legs.
  • Passive Relaxation: Try with a partner or relaxation CD – you’ll get used to the sounds and will find it familiar and relaxing during labor. Practicing: Lie on side or sit in semi-reclined position with floor or bed supporting head and limbs. Breathe slowly, easily and fully (how you breathe as you fall asleep). Body and mind release tension and thought, breathing slows and pausing slightly at the end of each inhalation an exhalation (watch someone as they fall asleep).

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.


  • Yawn or exhale completely.
  • Focus on your toes and feet. Feel how warm and relaxed they are.
  • Think about how floppy and loose your ankles are. They’re relaxed and comfortable.
  • Now focus on your lower legs. Let those muscles become loose and soft. Good.
  • Now focus on your knees. They’re supported and relaxed – you’re not holding your legs in any position. Wiggle them to see how relaxed they are.
  • Think about your thighs. Their large, strong muscles are soft and relaxed, and they’re fully supported. Good.
  • And now think about your buttocks and perineum. This area needs to be especially relaxed during labor and birth, so just let it become soft and yielding. When the time is right, your baby will travel down the birth canal, and the tissues of your perineum will spread to let your baby make her way out. You’ll release, letting your perineum relax and open for your baby.
  • Focus on your lower back. Imagine that someone with strong, warm hands is giving you a lovely backrub. It feels so good. Your muscles are relaxing, and your lower back is comfortable. Notice the tension leaving your back.
  • Let your thoughts turn to your belly. Let those muscles relax. Let your belly rise and fall as you breath in and out. Good. Now focus on your baby within your uterus. She’s floating or wiggling and squirming in the warm water of your womb – a safe place where you’re meeting all you baby’s needs for nourishment, oxygen, warmth, movement, and stimulation. You baby hears your heartbeat, your voice, my voice and other interesting sounds. What excellent care you’re giving your baby.
  • Now focus on your chest. As you inhale, your chest swells easily, making room for the air. As you exhale, your chest relaxes to help the air flow out. Breathe easily and slowly, letting the air flow in and flow out, almost as though you’re asleep. Good. Now try inhaling through your nose and exhaling through your mouth – slowly and easily, letting the air flow in and out. At the top of an 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.
  • Focus on your shoulders and upper back. Imagine you’ve just had them massaged. Let those muscles release. Feel the warmth as the tension slips away.
  • Now focus on your arms. As you exhale, let your arms go limp – from your shoulders, all the way down your arms, to your wrists, hands and fingers. Let them become heavy, loose and relaxed.
  • And now your neck. All the muscles in your neck are soft because they don’t have to hold your head in any position. Your head is either comfortable balanced or completely supported, so just let your neck relax. Good.
  • Focus on your lips and jaw. They’re slack and relaxed. You’re not holding your mouth closed or open. It’s comfortable; no tension there.
  • And now your eyes and eyelids. You’re not keeping your eyes open or closed. They’re the way they want to be. Your eyes are unfocused and still. Your eyelids are relaxed and heavy.
  • Focus on your brow and scalp. Think about how warm and relaxed they are. You have a calm, peaceful expression on your face, reflecting a calm, peaceful feeling inside.
  • Take a few moments to enjoy these feelings of calmness and well-being. You can relax this way anytime – before bedtime, during an afternoon rest, or during a quiet break. This is how you’ll want to feel in labor. Of course, during labor you won’t lie down all the time. You’ll walk, sit up, shower and change positions. But whenever a contraction comes, you’ll let yourself relax all the muscles you don’t need to hold a position, and you’ll let your mind relax, giving you a confident, peaceful feeling. This feeling will help you yield to contractions, letting you focus on breathing and finding comfort through each one.
  • Now its time to end the exercise. Gradually open you eyes, stretch, tune in to your surroundings, and slowly rise. Take your time. There’s no need to rush.

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.

  • Roving Body Check (sometimes you think you’re relaxed but are still holding tension in body): inhale nose, exhale mouth. Focus on one area of body with each breath. Inhale and notice tension in area. Exhale and release. Move from: brow/eyes/eyelids, jaws/lips, neck/shoulders, right arm and hand, left arm and hand, upper back, lower back, buttocks and perineum, right leg and foot, left leg and foot. Use during or between contractions.
  • Relaxing in Different Positions and While Active: practice in different positions because will be in different positions during labor. For example, can’t relax legs while standing, but can relax shoulders and face.


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

  • 1st or 2nd Stage: Standing (makes contractions less painful and more productive; may increase urge to push during 2nd stage); Walking (can tire if walk for too long); Leaning forward (sitting or standing, relieves back pain, good for back rub, more restful than standing, encourages to rotate baby OP); slow dancing (comfort, back pressure), Lunge (widens one side of pelvis, encourages rotation if OP, standing or kneeling, foot on chair); Sitting upright (good resting, uses gravity, birth ball, desk chair), Sitting or rocking in chair (rocking may speed up labor), Open knee chest (if baby OP, will rotate, relieve back pain, encourage cervical dilation, reduces pressure on cervix if swollen in later labor), semi prone (may help baby rotate; one knee bent up on pillow); toilet (effective pushing, prevents holding back), semi sitting (knees pulled to chest; may increase back pain and does not allow expansion of pelvis); hands and knees (helps relieve back pain, helps rotate if OP, pelvic rocking, takes pressure off hemorrhoids, may reduce premature urge to push, may slow rapid 2nd stage bc of gravity), side lying (good for rest, may reduce back pain, safe if pain med, neutralizes effects of gravity, useful for slowing rapid labor, pressure off hemorrhoids, sacrum to shift to create wider opening)
  • 2nd stage: Squatting (relieve back pain, gravity, widens pelvic outlet but may diminish pelvic inlet so good for 2nd not 1st), rotate in difficult birth; helpful if don’t feel urge to push), Lap squatting (reduces strain on knees and ankles, more support and less effort, loved ones touch), Supported Squat (greater mobility of pelvic joints, lengthens trunk, allowing more room for baby to maneuver, baby’s head movement to change shape of pelvis), dangle (partner is supported so easier to sustain).


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.

  • In early labor, you’ll likely use slow breathing for as long as it relaxes you. You may switch to light breathing or some variation in late labor.
  • During pregnancy, try to master the breathing techniques described in the following sections, even though you might not use them all. Practice in positions show on pgs 221-223. Can combine with other comfort measures, such as moaning, movement, massage, tension release, hot or cold packs, bath shower etc.


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.

  • As soon as contraction begins, inhale fully and easily and sigh as you exhale, releasing all tension. Use this as you “organizing” breath or as a signal to your partner. If partner is timing contractions, he will note time.
  • Focus your attention (See pgs 208-209)
  • Inhale slowly through nose and exhale completely through mouth. Pause for a moment before you inhale. Take about 5-12 breaths per minute (half normal breathing rate).
  • Inhale quietly, but keep mouth slightly open and relaxed when exhaling so someone nearby can hear your breath. In labor, you may also vocalize or moan as you exhale.
  • Keep should down and relaxed. Relax your chest and belly so they can swell as you inhale. Partner should touch you, move around you and talk to you in rhythm with you breathing
  • Signal to your partner as contraction ends or take a final deep breath. May prefer to yawn to mark end of a contraction
  • Completely relax, change positions, sip liquids, and do whatever you need to feel comfortable

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.

  • As soon as you feel contraction begin, take a quick, shallow inhalation and signal to your partner that the contraction has begun. Exhale quickly to release all tension – go completely limp.
  • Focus your attention (pgs 208-209)
  • Take short, light and shallow breaths, inhaling and exhaling through mouth – one breath every second or two. Keep inhalations quiet (so you don’t hyperventilate) and exhale audibly either by emitting short “puffs” or air or by making light sounds. Continue light breathing in a steady rhythm. Let contraction guide rate and depth of breathing. Keep mouth and shoulders relaxed. Continue breathing in this way until contraction ends.
  • When contraction ends, use last exhalation to “Sigh” the contraction away. Then tell partner contraction is over.
  • Completely relax and do whatever you need to feel comfortable, such as change positions, sip liquids and so on.

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

  • Open Knee-chest: hands and knees, lower head and chest to floor/bed. Move knees back enough so hips are high in air. 30 min.   Partner can support you. Best in prelabor or very early labor to eliminate back pain and reposition baby.
  • Leaning Forward – may help baby get into OA position and keep him there. Lean over birth ball, labor bed, counter (kneeling, standing, sitting). Hands and knees also effective. These relieve back pain by easing pressure of baby’s head against sacrum.
  • Pelvic Rocking – while kneeling and leaning forward over birth ball or chair seat, rock pelvis forward and back or move hips in a circle. Helps ease baby up out of pelvis and position encourages to rotate out of OP
  • Abdominal Lift – standing, interlace fingers and place hands palms up, beneath belly and against pubic bone. During contractions, bend knees (to tilt pelvis slightly) and use hands to lift abdomen up and slightly in. Relieves back pain and improves position of baby. Partner can help with woven shawl or rebozo. 5 in wide, position around waist and below belly. Partner stands behind you and crosses ends of shawl behind back. During the contraction, your partner will pull on each end of the shawl to lift your belly. Adjust both the shawl and strength of partner’s pulling so the lift feels good. Caution: if baby wiggles a lot during abdominal lift, he may be experiencing uncomfortable pressure so discontinue
  • Standing, Walking, Slow Dancing, Stair Climbing: take advantage of gravity and align baby with upper part of pelvis (pelvic inlet) and encourage descent into birth canal. Moving allows pelvis to change shape slightly, which encourages baby to rotate.


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.

  • Lunge – usually done during contractions. Find a sturdy armless chair that wont move when you lean against it. Stand in front of the chair, facing to the side. Lift the foot that’s closest to the chair and set it on the seat, with your toes pointing to the back of the chair (90 degree angle from direction body is facing). Remain upright, lunge sideways towards chair and return to start. Should feel a stretch in both inner thighs. Rest when contraction is over. Repeat for 5-7 contractions. If uncomfortable, use other leg.
  • Sidelying: lie on side with hips flexed and knees bent. Place pillow between knees. Switch every 30 min when you’re awake for as long as baby’s heart rate is normal.
  • SemiProne: lie on side with lower arm behind you and lower leg out straight. Flex hip of upper leg and bend knee, resting it on doubled up pillow. Roll slightly toward your front. Alternate with side lying when you must remain in bed.


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.

  • Counterpressure – use fist or heel of your hand to steadily press on partner’s lower back – as much pressure as she wants. If on hands and knees, can hold front of her hips with one hand and press steadily in one spot on her lower back 4-6 inches below her waist, slightly away from her spine. Exact spot will vary over the course of labor. Between contractions, rest or massage the area you pressed.
  • Double Hip Squeeze– have mom kneel and lean forward on a birth ball, chair or besides bed. If on floor, place pad beneath knees. During a contraction, stand close behind her, then press on the roundest part of each buttock with your palms. Apply steady pressure (instead of pressing and releasing repeatedly) as you try to press her hips together to relieve pelvic pressure and ease back pain. Try other places on her hips to press. If another person is available to help, the 2 person double hip squeeze is easier to do. Each person stands on each side of her, facing each other. Place one hand on roundest part of closer buttock, then together press on her buttocks – coordinate timing and amount of pressure.
  • Knee Press– sitting upright in chair that won’t slide. May have to elevate feet so thighs are parallel to floor. Kneel in front of her and cup a hand over each knee. Lean toward her so you hands press straight back toward her hip joints. Keep pressure steady throughout contraction.

Other Comfort Measures to Reduce Back Pain – heat and cold, baths, showers and:

  • Rolling Pressure – move a rolling pin over your lower back. Soothing way to relieve back pain and muscle tension during and between contractions. Can use a can of frozen juice, cold can of soda, or hollow rolling pin filled with ice because cold helps numb the area. Use cloth between back and object.
  • Transcutaneous Electrical Nerve Stimulation (TENS) – relieves back pain during contractions by creating tingling, buzzing or prickly sensations. Reduces awareness of pain by increasing your awareness of pleasant or distracting stimuli. Gradually increases endorphin production in area where it’s applied. If TENS begins in early labor, the level of endorphins in lower back will increase by the time labor intensifies.


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 – 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 –

  • As contraction begins, start slow or light breathing
  • Focus on a positive image, such as baby moving down and out of uterus
  • Breathe rhythmically as contraction intensifies. When you can no longer resist urge to push, bear down or strain while holding your breath or while slowly releasing air by grunting or vocalizing, whichever feels best. Relax your pelvic floor! Partner may need to remind you to relax perineum
  • Exhale when urge passes (usually after 5-7 seconds) and breathe rhythmically for several seconds until you feel another urge to push. Then, bear down again. The urge to push will come in waves during the contraction, giving you time to “breathe for your baby” (that is, to oxygenate your blood to provide enough oxygen for your baby between urges)
  • When contraction ends, slowly lie or sit back (or stand up if squatting) and take 102 relaxing breaths.

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:

  • You’ve had an epidural and don’t feel contractions
  • You don’t have an urge to push or you’re not pushing effective when spontaneously bearing down, even after trying gravity-enhancing positions such as squatting, sitting, dangling, lap squatting, or standing upright
  • Directed pushing is routine for your hospital or caregiver

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

  • At beginning of contraction, take 2 or 3 breaths. When told to push, inhale and hold your breath. Curl forward, tucking your chin on your chest, and bear down, tightening your abdominal muscles
  • Relax your pelvic floor muscles. Bear down for 5-7 seconds. Quickly exhale as directed, then take another few breaths
  • Repeat steps 1 and 2 until contraction subsides
  • When contraction ends, slowly lie or sit back (or stand up if squatting), rest and breathe normally

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.

  • Get into a semi-sitting position (partner can be behind you) or stand with 1 foot on side of tub or chair
  • Use a squeeze bottle to squirt vegetable oil on thumb (dipping fingers can contaminate). Wheat herm oil has high vitamin E content, which may be soothing on skin. Can also use another vegetable oil or water-based lubricant such as K-Y. don’t use baby oil, mineral oil, petroleum jelly or hand lotion because skin may not tolerate well.
  • Place thumb, or have partner place index finger( 1 at first, 2 when more comfortable) well inside your vagina (up to 2nd knuckle). Do a few Kegel exercises so you can feel pelvic floor muscles tense. Relax the muscles. Curl your thumb and gently pull outward and downward toward anus, then rhythmically move it within your vagina in a U motion. Focus on relaxing your pelvic floor muscles. 3 minutes. At first, vaginal wall will feel tight. After a few days, it will relax and stretch more easily
  • Concentrate on relaxing muscles as you feel pressure and stretching. As you become comfortable, increase pressure just enough to make tissue begin to sting or burn slightly. (The same sensation will occur as baby’s head is being born)
  • If you have questions after trying, ask caregiver, childbirth educator or someone familiar with technique


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. for a practice guide. Practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.

  • Conditioning exercises (pg 95). Continue practicing until birth
  • Comfort measures for discomforts (pg 103). Use as needed
  • Body awareness exercises (pg 215)
  • Passive relaxation (pg 216)
  • Relaxation countdown (pg 218). At first, use several breaths to relax, then work toward relaxing with one breath
  • Perineal massage (pg 235). During last 5-6 weeks of pregnancy, do 5-6x a week
  • Slow breathing (224)
  • Touch relaxation (219)
  • Roving body check (219) practice by self and with partner
  • Slow breathing with roving body check (224, 219)
  • Attention focusing (208)
  • Crisscross back massage (213)
  • Possible positions for 1st stage of labor (221-222). Practice slow breathing in each position
  • Light breathing (pg 225). Experiment with depth and rate of you breathing
  • Adaptations of slow and light breathing – contraction-tailored, vocal, slide and variable breathing (226-227)
  • Variety of positions for first stage of labor (221-222) while practicing breathing adaptations
  • Ways to decrease back pain in labor (229-232). Double hip squeeze, counterpressure, abdominal lift, open knee-chest position, knee press and lunge. Combing with breathing patterns
  • Ways to avoid pushing (228)
  • Spontaneous bearing down and directed pushing (232-234). Practice gently bearing down and incorporate the bulging exercise (p 96). Occasionally, practice panting to avoid pushing in middle of practice contraction
  • Positions for 2nd stage of labor (222-223). Try while practicing spontaneous bearing down (expulsion breathing)
  • Labor rehearsal: practice all the coping techniques during a series of pretend contractions. Partner can help by observing and helping your fully relax in all positions.


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.

Stress Symptoms

  • Physical: perspiration/sweaty hands; increased heart rate; trembling; nervous tics; dryness of throat and mouth; tiring easily; urinating frequently; sleeping problems; diarrhea, indigestion, vomiting; butterflies in stomach; headaches; premenstrual tension; pain in the neck and lower back; loss of appetite or overeating; susceptibility to illness.
  • Behavior – stuttering and other speech difficulties; crying for no apparent reason; acting impulsively; startling easily; laughing in a high-pitched and nervous tone of voice; grinding teeth; increased smoking; increased use of drugs and alcohol; being accident-prone; losing appetite or overeating
  • Psychological – feeling anxious/scared/irritable/moody; low self-esteem; fear of failure; inability to concentrate; embarrassed easily; worrying about the future; preoccupation with thoughts or tasks; forgetfulness

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.

  1. Culturing appropriate coping responses is a valuable life skill for pregnancy, labor, birth, and 


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:

  • Physiologic response in mother: decreased blood flow to uterus, suppression of oxytocin effects, decreased uterine contractions, increased duration of 1st stage of labor, decreased blood flow to placenta
  • Maternal psychological response: increased negative or pessimistic perception of events and words of others, increased need for reassurance and support, protectiveness toward fetus
  • Physiologic response in fetus: increased fetal production of catecholamines, fetal conservation of oxygen, fetal heart rate decelerations

Excessive catecholamine levels in 2nd stage labor:

  • Maternal effects: alertness, renewed energy and strength
  • Fetal effects: same as listed above; fetal ejection reflex (rapid expulsion of fetus)


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”

Websites – Stress and pregnancy


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:

  • Progressive relaxation helps students become aware of how a muscle feels when it is contracted, stretch and released. Work 1 muscle at a time from head to toe. Ask students if its easier to release a muscle after tensing, stretching or neither (pg 104 handbook)
  • Selective relaxation reinforces muscle isolation. not all muscles are tense or all released at the same time. In labor, it is beneficial for some women to focus on relaxing other muscles as the uterus contracts
  • Touch and massage techniques should be demonstrated and practiced so each student learns to perform them. Different types of massage are described on pg 26 in handbook. Allow time for each to be the giver and receiver of the massage, and to feed back to one another they type of touch each prefers. Practicing massage is a popular homework assignment
  • Visual imagery is a useful tool to help a woman reduce stress, relax, cope with her pain, and to think positively. It can even help labor progress. When using imagery, remember to: consider environment (space, music, lights, temp, pillows); suggest distractions are fewer if they close their eyes; begin the image in the room where they are grounded and safe; address distracting thoughts – they may put them away and have them back after the exercise; suggest a range of sensations they may experience; end the image envisioning the same scenes passed as they left the room; follow up with class discussion of the experiences of those who will share

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:

  • Reduce fear of unknown and fear due to prior conditioning and misinformation, with education. Show images of women coping well with labor and birth, and discuss positive birth stories
  • Reduce tension by teaching relaxation techniques, the benefits of warm showers and baths, and active birth strategies such as walking, changing positions, and rhythmic movements
  • Reduce pain by reducing the fear and tension, and by teaching coping strategies and how they work
  1. Nutrition

(Consider ICEA certification program Dr. Sears L.E.A.N. for 
additional training in this topic dr-sears-lean-certified-health-coach)

  1. Nutritious snacks in class


  1. Food diaries and dietary self-evaluation

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

To analyze daily diet, visit – 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.

  • If don’t like milk, try yogurt and cheese, or foods made with milk – cream soups, custard, pudding, ice cream
  • If lactose intolerant – try lactose free milk or take lactase enzyme. Try cultured forms of milk such as cheese, yogurt or acidophilus milk
  • If choose not to consume – eat dark green leafy veggies, nuts and seeds, calcium fortified juice, rice milk or supplements

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

  • If choose not to eat meat/fish – get protein from eggs, dairy, beans, nuts, seeds, tofu. If vegan take 1 microgram of vitamin B

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


  • Protein – builds body’s cells. Requirement 71 g in pregnancy (23 grams more). Growing volume of blood and amniotic fluid, plus rapid growth of placenta, uterus and baby require more. Get it only from food sources – not protein supplements, which can lead to nutritional imbalance.
  • Fats – healthy fats essential for baby’s brain growth, nervous system development and aiding absorption of vitamins A, D, E, and K. the healthiest fats are omega-3 fatty acids, which may reduce preterm labor, hypertension, and depression.   Can find them in flaxseed oil and fish, soybeans, walnuts, pumpkin seeds, pecans hazelnuts and omega 3 eggs. Next best fats are from plants such as nuts and vegetable oils. Total fat shouldn’t be more than 30% of diet and shouldn’t exceed 85 grams.
    • Fat substitutes – olestra found in some brands of chips and crackers. It depletes body of fat-soluble vitamins A,D,E, and K.
  • Fluids – help deliver nutrients to baby. help prevent constipation and UTIs. Drink at least 64 oz each day until urine is pale yellow. Caffeine is a diuretic, which means it increases amount of fluid in urine and decreases fluid retention in body, so don’t count full volume in fluid log. If drinking more is hard, try over ice cubes, at room temp, warm, with squeeze of lemon/lime/strawberry/fruit, drink with a straw or water bottle.
  • Carbs/Sugars – main source of energy – 200 grams or more you consume each day make up 45-70% of total calories. Majority should come from complex carbs such as whole grains, legumes, starch vegetables, citrus fruits and nuts. Some can come from simple carbs such as fruit, dairy, unsweetened but refined cereal, bread and pasta. Minimize consumption of sugars. Excess sugar leads to tooth decay, obesity, decreased immune function, diabetes, and osteoporosis. Eat foods with sugar lower on glycemic index so don’t rapidly rise blood sugar. Artificial sweeteners appear safe but anyone with PKU should avoid aspartame because it may cause severe health problems
  • Salt – caregivers used tor restrict because thought water retention caused high blood pressure, but now experts know that gradual, moderate water retention is not only normal, but extra fluid is necessary for adequate volume of blood and amniotic fluid. Consume adequate amount to maintain fluid balance. Salt food to taste
  • Folate and Folic Acid (Vitamin B9) – folate is a B vitamin found in leafy green vegetables and some fruits. Essential for baby’s growth and especially important in early pregnancy to prevent certain birth defects. Folate helps form blood cells and promotes normal development of baby’s brain and spine. Synthetic folate called folic acid. Recommend supplement of 400 micrograms prepregnancy and 600 mg during
  • Calcium – important for growth of baby’s bones and teeth. Especially vital in 3rd trimester, when baby requires 2/3 more calcium that he did earlier in his development. It is stored in your bones as a reserve for breast milk production. Should consume 1200 milligrams each day.
  • Iron – required for production of hemoglobin, which carries oxygen through bloodstream to your baby and your cells. During last 6 weeks, baby stores enough iron to supplement her needs for first 3-6 months after birth. Foods rich in vit C enhance iron absorption, which some antacids and caffeine interfere with it. If having nausea or constipation, try taking with food, a different brand or reduce dosage and take throughout day.
  • Vitamin A – forms and maintains healthy teeth and bones, soft tissue, mucous membranes, and skin. Promotes good vision. Getting too little (less than 770 micrograms per day) can lead to preterm birth and an underdeveloped baby. Getting too much (more than 3000 micrograms per day) in first 7 weeks can lead to higher incidence of birth defects.


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.

  1. Nutrition research and facts for pregnancy, birth and lactation 
1. Macro Nutrients – Protein, Fats, Carbohydrates
2. Hydration
3. Other nutrients – Salt, Folic acid, calcium, iron, Vitamin A 4. Nutritional changes for pregnancy and lactation



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.

  • Old wives tales – women avoid eating cabbage, broccoli and spicy foods to avoid colic – no evidence to support.
  • Foods you eat flavor breast milk.
  • Babies drink more when mothers took garlic capsules.
  • Breastfeed babies eat peas/beans more than formula fed. Increasing volume of fluids doesn’t increase milk production.
  • Less than 1% of caffeine you consume appears in breast milk; may be sensitive to it postpartum.
  • Concentration of alcohol in blood approx. equals alcohol content in breast milk – drink only occasionally until after baby is weaned. Babies consume less after mothers drink. Don’t drink more than 8 oz of wine, 2 beers or 2 oz of liquor per day. Breastfeed baby before having a drink.
  • By 3 months after birth, many women burned 5-7 lbs; may only need 300 more calories per day while breastfeeding. Limit weigh loss to 1 lb per week.
  • Consume at least 1500 calories a day and avoid liquid diets and diet medications. Severely restricting calories compromises nutritional health and may make you produce less milk

  1. Weight gain


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.

Initial Visit

  • Prenatal Interview – first prenatal visit longer and more detailed than future visits. Comprehensive health history emphasizing current pregnancy, previous pregnancies, family, psychosocial profile, physical assessment, diagnostic testing and overall risk of assessment.
    • Nurse includes those that visit with mother in first interview. Data gathered on woman’s age at menarche, menstrual history, contraceptive history, any infertility or reproduction system conditions, history of STIs, sexual history and detailed history of her pregnancies including present one and their outcomes. Date of last Pap test and result are noted. Date of LMP obtained to calculated EDB
  • Health History – diabetes, hypertension or epilepsy requires special care. Allergies and reactions, medication use and immunization. if women had uterine surgery of extensive repair of pelvic floor, a cesarean birth may be necessary. Appendectomy rules out appendicitis as cause of right lower quadrant pain. Spinal surgery may contraindicate use of spinal or epidural anesthesia. And injury involving pelvis from a motor vehicle accident or childhood nutritional deficit. Women who have chronic or handicapping conditions often forget to mention during assessment because they’ve become so adapted to them. Special shoes or a limp can indicate existence of pelvic structural defect.
  • Nutritional History – dietary practices, food allergies, eating behaviors, practice of pica (consumption of nonfood substances); obese women should receive counseling about weight gain, physical activity and healthy food choices. Women with a history of bariatric surgery are nutritionally at risk and should be followed throughout pregnancy.
  • History of Drug Use – past and present use of drugs (legal, OTC and prescription, vitamin supplements, herbal, caffeine, alcohol, nicotine). Many substances cross placenta and can therefore pose a risk to developing fetus. Immunization record should be reviewed for rubella, varicella, flu, Hep B and pertussis that can pose a particular risk to pregnant women or infants during pregnancy and immediately following birth.
  • Social /Occupational– pregnancy wanted, potential parenting problems, depression, lack of family support, inadequate living situations. Attitudes toward unmedicated or medicated labor. Occupation – past and present because some can adversely affect maternal and fetal health – heavy living and exposure to chemicals and radiation. Standing for long periods at retail checkout or in front of a classroom associated with orthostatic hypotension. Long hours working at a desk carpal tunnel or circulatory stasis in legs.
  • History/Risk of Intimate Partner Violence – all women should be assessed fro abuse in all forms – physical, sexual or psychological because likelihood increases during pregnancy. Should be done at first visit and at least once a trimester and postpartum. Adolescents can be trapped in an abusive relationship because of inexperience, dependence on abuser, and separation from family and friend support systems. Victims of human trafficking and victims of IPV can show signs such as scars, bruises, burns, unusual bald patches or tattoos that can be a sign of branding. Likely to be accompanied by someone who never leaves them alone and speaks for them. They may not speak English and may lack ID. If woman is alone, she may have cell phone in speaker mode so person can hear everything. Nurses must get creative to get women in for questioning – send other to front for paperwork, interviewing women in restroom, saying no cellphone. National Human Trafficking Resource Center.
  • Physical – height of fundus is noted if first exam done after first trimester. Potential threatening condition – supine hypotension – low BP that occurs while woman lying on back, causing feelings of faintness. Particular attention to size of uterus because indicates duration of gestation. 1 vaginal exam during early pregnancy recommended than another late in third trimester.
  • Lab Tests – urine, cervical and blood samples at initial visit. If woman refuses HIV, should be documented. Screening for HIV (transmission 25% without treatment; 1% with HAAART) syphilis, chlamydia, and gonorrhea repeated in 3rd trimester for those high at risk. Urine tested for protein, glucose and leukocytes. Some may choose to undergo genetic testing. GBS test 35-37 test for infection. 24-28 weeks gestational diabetes. Cardiac evaluation for those with history of hypertension or cardiac disease.


1. Normal weight, underweight, overweight, and obese clients

  1. Weight gain distribution during pregnancy
  2. Special needs groups in the childbearing year 
1. Adolescents
2. Vegetarian
2. High blood pressure 3. Diabetes in pregnancy 4. Low income 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

2. Heartburn

3. Constipation

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:

2nd trimester

  • Heartburn – sip milk for temp relief; drink herbal tea
  • Varicose veins (Varicosities) can be associated with aching legs and tenderness. Avoid lengthily standing or sitting. Rest with legs and hips elevated, warm sitz baths, local app of astringent compresses
  • Round ligament pain (tenderness) – caused by enlarging uterus – not preventable. Use good body mechanics. Relieve cramping by squatting or bringing knees to chest
  • Backache – get back rubs

3rd trimester

  • Leg cramps (gastrocnemium spasm), esp when reclining – stand on cold surface, oral supplement wit calcium carbonate or calcium lactate; aluminum hydroxide gel with each meal removes phosphorous by absorbing it
  • Ankle edema – ample fluid intake for natural diuretic effect

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

  • Magnesium – as many as half of pregnant and lactating women may have inadequate intakes. 400 mg RDI. Dairy products, nuts, whole grains and green leafy veggies are good sources.
  • Sodium – need increases slightly because body water is expanding (expanding blood volume). Essential for maintaining body water balance. Grain, milk, meat products are significant sources of sodium. Sodium restriction can stress adrenal glands and kidneys as they attempt to retain adequate sodium; restriction necessary only if woman has a medical condition such as renal or liver failure or hypertension that warrants it. Adequate intake 1.5g/day with upper limit of 2.3g/day. Table salt is richest source with 2.3g in 1 teaspoon. Large amounts found in processed foods, including smoked or cured meats, cold cuts, and corned beef; frozen entrees and meals; baked goods; mixes for casseroles or bread products; soups and condiments. Products low in nutritive value and excessively high in sodium include pretzels, potato and other chips (except salt free), pickles, catsup, prepared mustard, steak and Worcestershire sauces, some soft drinks and bouillon.
  • Potassium – reduced risk for hypertension. 8-19 servings on unprocessed fruits and veggies daily, along with moderate amounts of low-fat meats and dairy products, reduces sodium intake while providing adequate amounts of potassium
  • Zinc – deficiency associated with malformations of central nervous system in infants. RDI 11mg/day. Women with anemia who receive high dose iron supplements also need supplements of zinc and copper.


Fat Soluble Vitamins – include vitamins A, D, E and K. High potential for toxicity, so take supplements only as prescribed.

  • Vit A– Deep yellow and dark green veggies – leafy greens, broccoli and carrots. Fruits such as cantaloupe and apricots provide sufficient amounts of carotenes that can be converted in body to Vit A. Spina bifida and cleft palate associated with excessive amounts of Vit A.
  • Vit D – plays role in absorption and metabolism of calcium. Produced in the skin by action of UV light in sunlight. Severe deficiency can lead to neonatal hypocalcemia and tetany, as well as to poor development of tooth enamel. Lactose intolerant at risk for deficiency.   Other risk factors – dark skin (African American at high risk), clothing that covers most of skin and living in northern latitudes. SPF fating of 15+ reduces skin Vit D production by as much as 99%.
  • Vit E – needed to protect against increased oxidative stress associated with pregnancy. Veg oils and nuts good sources as well as whole grains and green leafy veggies


Water-Soluble Vitamins – body storage much smaller and readily excreted in urine unlike fat soluble. Toxicity less likely. Must be consumed frequently

  • Folate/Folic Acid – increase in RBC production, growing fetus/placenta, should consume 50% more than nonpregnant or .6mg (600mcg) daily. Enriched grain products must contain at a level of 1.4 mg/keg of flour.
  • Vit C – or ascorbic acid plays role in tissue formation and enhances iron absorption. RDI 85 mg/day. 1-2 daily servings of citrus fruit or juice. Women who smoke need more
  • Vit B6- pyridoxine essential for carb, protein and fat metabolism and involved in synthesis of RBC, antibodies and neurotransmitters. RDI 1.9mg/day, larger doses effective for some women in reducing nausea and vomiting
  • Vit B12 – production of nucleic acids and proteins. Formation of RBCs and neural functioning. Naturally only in animal products. Commercial dried cereals, plant milks and vegan products fortified. RDI 2.6 mcg/day.


Other Nutritional Issues During Pregnancy

  • Alcohol – teratogen; can cause birth defects, impaired cognitive and psychomotor development and emotional and behavioral problems. Low levels not an indication for terminating pregnancy
  • Caffeine – safety not yet clear. Excess can contribute to intrauterine growth restriction (IUGR). Daily intake of no more than 200 mg
  • Artificial Sweeteners – Aspartame (Nutrasweet, Equal), acesulfame potassium (Sunett), and sucralose (Splenda) have not been found to have adverse effects. Aspartame contains phenylalanine and should be avoided by those with PKU. Stevia – no acceptable daily limit. Agave – little known about safety in pregnancy
  • Pica/Food Cravings – consuming nonfood substances – clay, soil, laundry starch or excessive amounts of foodstuffs low in nutritional value ( cornstarch, ice, freezer frost, baking powder, baking soda) influence by woman’s cultural background. Cornstarch popular among African-American women. Overuse can contribute to development of gestational diabetes and can interfere with absorption of nutrients, especially minerals. Women with pica have lower hemoglobin levels than those without. Nonfood items contaminated with heavy metals. Mexican American consumption of tierra- soil and pulverized Mexican pottery. Lead contamination of soils and soil based products has caused high levels of lead in pregnant women and newborns. Include in interviews. Possibility considered when found anemic. Discuss Healthy alternatives for cravings, eating small amounts of craved foods, and using distraction to curb craving (walk, call to a friend).
  • Adolescent Pregnant Needs – many not adequate in calcium and iron. Increased risk for complications during pregnancy and birth. Growth of pelvis is delayed – why cephalopelvic disproportion and other mechanical problems associated with labor common. Competition for nutrients between adolescent and fetus can cause poor outcomes. Those who have not given birth more likely to be obese.
  • Physical Activity – improve muscle tone, potentially shortening course of labor and promote sense of well being. 30 min of moderate exercise on most, if not all days. Liberal amount of fluid before, during and after. Dehydration can trigger preterm labor.

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 ( 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.

  1. Preparing to succeed with breastfeeding (they have roman numerals wrong)
  2. The importance of breastfeeding


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.

  1. The Baby-Friendly Hospital Initiative

The Ten Steps to Successful Breastfeeding are:

  • Have a written breastfeeding policy that is routinely communicated to all health care staff.
  • Train all health care staff in the skills necessary to implement this policy.
  • Inform all pregnant women about the benefits and management of breastfeeding.
  • Help mothers initiate breastfeeding within one hour of birth.
  • Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
  • Give infants no food or drink other than breast-milk, unless medically indicated.
  • Practice rooming in – allow mothers and infants to remain together 24 hours a day.
  • Encourage breastfeeding on demand.
  • Give no pacifiers or artificial nipples to breastfeeding infants.
  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.


  1. Exercise
  2. ACOG guidelines

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

  • Standing – imagine you’re wearing a crown. Lengthen spine. Remind yourself during day to keep crown on head. Avoid standing for long periods; it may slow blood flow from legs to heart and head, making you feel faint or lightheaded. If you must stand for long times, shift weight from leg to leg, march in place, rotate your ankles or rock back and forth. Place one foot on a stool, chair rung or opened drawer.
  • Sitting – put small firm pillow at small of back and a stool under your feet. During late pregnancy, avoid sitting for long periods; it can affect blood circulation in your legs. Shift position often, rotate your ankles and avoid crossing at the knees. To help decrease swelling, sit with feet proper up and calves supported on another chair or ottoman.
  • Lying Down – may experience heartburn or shortness of breath while lying on your back, especially near end of pregnancy. Lying on back can make you feel dizzy or lightheaded; if this happens, roll to left side or sit up. For some women, it causes supine hypotension, in which uterus presses on abdominal vein (inferior vena cava) that carries blood from legs to heart and causes a drop in blood pressure. It can reduce blood flow to placenta and restrict oxygen to baby. for this reason, caregivers recommend lying on side after 26th week of pregnancy.   When lying on side, place pillow between your knees and another under head to keep body in alignment. In late pregnancy, can put one under belly.
  • Lifting Objects – lifting heavy objects while pregnant increases likelihood of back injury. Avoid heavy lifting whenever possible. Teach toddler to climb into his car seat or onto your lap instead of picking him up.

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.

  • Physical Benefits: good respiration, circulation and posture. Ease common discomforts of pregnancy, such as constipation, heartburn, shortness of breath, leg cramps, fatigue, swollen ankles and insomnia. Helps recover energy level, strength, and prepregnancy size after birth
  • Mental/Emotional Benefits: decrease mental stress/fatigue. Aerobic activities release pain-relieving endorphins that improve sense of well-being, help stabilize hormone-driven mood swings, and can decrease risk or severity of depression and mood disorders during pregnancy and afterward
  • Spiritual – connect with baby. Ideal time for meditation, relaxation/visualization, yoga is after aerobic exercise, when body experiences calmness
  • Social – prenatal exercise connects with other pregnant women and may learn about pregnancy, birth, postpartum period, and newborn care through shared experiences

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

  • Aerobic: low-impact aerobic is best – brisk walking, cross-country skiing, cycling, and low impact aerobics. Dance classes, belly dance and Nia good. Elliptical and stationary bikes safe but spinning classes can quickly elevate heart rate and body temp. swimming or water aerobics provide total body workout with lowest possible impact because water reduces force of gravity on body. Standing or sitting in water that reaches your shoulders reduces swelling (edema) by pushing tissue fluid into your circulation (and eventually out of your body through urination). Ideally, done 3x/week – 5 min warm up, 30 min exercise, 5 min cool down.
  • Anaerobic– yoga, Pilates (avoid doing advanced abdominal exercises which can aggravate or cause abdominal separation), tai chi, weightlifting
  • Sports and High-intensity activities: pregnancy isn’t time to take up new sport or activity that requires good balance or sudden movements, or puts you at risk for falling. Avoid downhill skiing, water-skiing, snowmobiling and horseback riding. Avoid potentially dangerous activities such as skydiving, scuba diving, springboard diving, surfing, rock or mountain climbing (esp at elevations >6000 feet)


Guidelines for Safe Effective Exercise

  • Exercise 3-7x per week. Always include warm up and cool down
  • Toward end of pregnancy, decrease intensity as needed
  • Don’t hold breath while exercising
  • Drink water, before during, and after. Keep water bottle with you
  • Don’t exercise vigorously in hot, humid weather or when you have a fever. Body temp shouldn’t exceed 101F

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

  • Transverse Abdominal Contractions – Inhale. Exhale. Hold contraction for 20 sec without holding breath. Variation – during 20 sec, pulse contraction by releasing it slightly as you inhale and tightening as you exhale. Pulse 10-20x. 2 sets of 10 and add more as you become strong. Becomes more difficult in late pregnancy
  • Pelvic Tilts I, II and III – with an exhalation, tighten abdominal muscles and hold contraction for 5-10 seconds. 10 each day
    • I – lying on back
    • II – On hands and knees – cat cow
    • III – standing

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

  • Posture Check – check postures several times throughout the day
    • Shoulder Circles – raise up towards ears, then back down, then forward and up. Feel tension release. As many times during day as comfortable
  • Pectoral Stretch – to lengthen pectoral muscles, which naturally shorten during pregnancy or with poor posture – elbow at shoulder level, forearm on wall, turn body away until feel chest stretch. Hold for 15-30 sec. repeat other side (2x each side)
  • Hip Flexor Stretch – to stretch muscles in front of your hips that naturally tighten in pregnancy. Put right leg forward, knee slightly bent, left leg back (knee straight). Contract left buttock and pull front of pelvis upward. 15-30 sec. switch. 2x each side

Yoga Poses to Align Body, Mind and Spirit – yoga focuses on practicing movements, not mastering them. Sequence of poses mimics rhythms of labor.

  • Cat Pose – may help baby assume a head-down position for birth. Flatten mid back with inhalation, making sure belly doesn’t sag. 5 inhales and 5 exhales.
  • Opposite Limb Extensions – 5 times each side (on hands and knees)
  • Child’s Pose – widen pelvis, stretch groin and torso; 5 inhales and exhales
  • Downward Dog – stretch calf and hamstring muscles (which become tighter as pregnancy progresses), reduce fatigue, and improve circulation in your legs. Helps relieve tension in shoulders and spine. 5 inhales and exhales
  • Half-Dog Pose – to stretch back, release tension in shoulders, and stretch hamstrings. Can use as alternative to down dog 5-10 inhales and exhales (bent over, arms touch wall)
  • Corpse Pose – actively lengthen body from heels, through arms and head then relax all muscles. 5-10 min.
  • 5 min meditation – embrace “going with the flow” and connect with baby. quiet any distracting thoughts by focusing on breathing. Thank hardworking body’s end baby loving energy, and honor yourself as well as your partner and family.
  • Sequence: tailor sit with eyes closes while focusing on breathing, quieting mental distractions and concentrating on being with baby, cat pose, child’s pose, opposite-limb extension, child’s pose, down dog, child’s pose, half dog, final pose for relaxation (corpse, side-lying or legs up on wall) or tailor sit.


Comfort Measures for Common Discomforts in Pregnancy

  • Lower Back Pain – over course of pregnancy, abdominal muscles lengthen up to 120%. To maintain balance and alignment, lower back muscles and hip flexors shorten and tighten, which may cause lower back pain. Maintain good posture.
    • To relieve pain from muscular tension, use heating pad or hot water bottle or take warm bath or shower.
    • Use ice pack to decrease inflammation and relieve pain
    • Get professional massage or have partner give soothing backrub
    • Exercises for lower back pain: half dog, cat pose, child’s pose, pelvic tilt on hands and knees, tailor sitting, squatting, knee to shoulder exercise (hold for slow count of 5, 5x)
    • Relieve severe back pain – physical therapist or chiropractor who specializes in pregnancy. Ice packs, heat, hydrotherapy, massage, techniques to mobilize joints. Special garment or belt to support abdomen and lower back
  • Upper Back Pain – as pregnancy progresses, breast become heavier and pectoral (chest) muscles shorten as upper back muscles lengthen. Shoulder and neck muscles may try to compensate for these changes by working harder. Maintain proper posture, stretch pectoral muscles regularly and do movements to reduce tension in shoulders, neck and jaw. Several times a day, take a deep breath, relax jaw and relax shoulders back and down.
    • Shoulder Circles, half dog pose increase circulation, stretch tense muscles and decrease back pain. Upper body stretch – tailor sit or stand, raise arms in front of you to shoulder height. Cross at elbows. Feel upper back stretch. Inhale and raise hands toward ceiling and gradually uncross as if putting on a shirt. 5x
  • Tingling on Numbness in Arms or Hands – during night or morning after awakening, excess tissue fluid in some women puts pressure on nerves and blood vessels. If confined to hands, called carpal tunnel. If entire arm, called thoracic outlet syndrome.
    • Lie on side without lying on arm or use pillows
    • Shoulder circles and upper body stretch
    • Several times a day, stretch 1 arm upward, wiggle fingers for slow count of 5. Repeat with other arm
    • If severe carpal tunnel, wear a splint (doesn’t work for thoracic)
    • For thoracic, try raising arms to shoulder height, bending elbows and placing one hand on top of the other on forehead
  • Aching Legs, Swollen Feet and Ankles or Varicose Veins – hormonal changes and increased body weight often affect blood circulation
    • Avoid prolonged standing or sitting; sit or walk intermittently
    • Several times a week, take a walk, swim or use stationary bike/treadmill
    • When sitting, elevate feet. If can’t, rotate ankles and don’t cross legs at knees. If sit for a while, rock in rocking chair to exercise muscles in legs/feet
    • Lie on side or elevate feet when resting during day
    • Pelvic tilt on hands and knees. Reduces weight of uterus on blood vessels in pelvis and abdomen. Rocking movement promotes blood flow
    • Walk or play in deep water for an hour every other day. Weight of water presses on swollen tissues, reducing swelling and promoting urination to void excess fluid. Benefits last 48 hours
    • Wear support stockings, esp if job has lots of standing. Best time to put on is right out of bed because welling it at its minimum after been in horizontal position for extended time
    • Legs up on wall pose – hold for 5 min, can also do V shape
  • Lower Legs and Foot Cramps – common when resting/asleep. Pressure on leg nerves, dehydration, impaired circulation, fatigue in calf muscles or mineral imbalance may cause (too little calcium or magnesium or too much phosphorus – found in soft drinks/processed foods). Eat well, drink plenty of water, avoid pointing toes or standing on tip toes.
    • Relieving lower leg cramps – stand with weight on cramped leg.   Step forward with other foot and bend that leg. Lean forward
    • Relieving foot cramps – stretch toes up and back toward shin
  • Sudden Groin Pain – round ligaments connect front of uterus to each groin. These ligaments contract and relax like muscles but much more slowly. When in labor, design is beneficial. As uterus contracts, these ligaments contract and pull uterus forward, aligning it and baby with vagina for efficient birthing. When stand up quickly or sneeze/cough, may stretch ligaments too quickly, causing them to contract rapidly and causing pain in lower abdomen or groin. Move slow. Before sneeze/cough, flex hips to bring thighs near belly to reduce pull on ligaments.

Work out 3-7 days per week!

  1. Diastasis recti abdominis


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.


  1. In-class teaching
 Exercises that enhance comfort in pregnancy and labor — Kegel, pelvic tilt, squat
  3. Postpartum exercises


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

Teaching Points

  • Exercise decreases physical discomforts, hastens recovery, does not increase risk of exercise related injury
  • Women who exercise have shorter, less complicated labors and recover more quickly after childbirth
    • 1 study shows women who exercised vigorously had significantly less ob interventions including highly significant reductions in both elective and indicated labor stimulation, episiotomy and use of epidural anesthesia as well as both vaginal and abdominal operative delivery
    • reduced risk for cesarean
    • levels of endorphins are increased during pregnancy in women who exercise; exercisers decreased need for epidural
  • Benefits of prenatal yoga to release tension, easy pregnancy discomforts, decrease preterm births and even decrease length of labor. Many childbirth educators say women who do yoga seem more in tune with bodies and more confident about ability to cope with labor
  • Reduce back pain – weak abdominals, esp with growing belly can cause pain in lower back, whereas strong muscles will reduce it
  • Numerous benefits of Kegels – see pg 19 in workbook
  • Quick-flicks and extended Kegels – 10-20 sec after potty break; easier to remember than red light. Pg 18 of handbook
  • Incontinence doesn’t have to be result of pregnancy. In addition to Kegels, strengthen abs, inner thighs and buttocks. Core can be strengthened through pilates, yoga or other programs that help to align and tone body

Music – “Do the Kegel”. Vulva Puppet.

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

  • Snack on exercise, with several short bouts a day
  • Begin slowly and increase gradually
  • Avoid excessive fatigue and dehydration
  • Use support for abs and breasts for comfort
  • If it hurts, stop and evaluate
  • If it feels good, it probably is

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.

  • Stand near wall and do wall stretch; add standing pelvic tilt and Kegel, calf stretch; wall squat
  • Sitting – do tailor reach, shoulder stretch, circulation exercise, cross leg with ankle on opposite knee, gently press downward to release tension
  • Lying down – back flexion, leg stretch, curl down, pelvic tilt
  • Hands and knees – pelvic tilts and circles, tail wagging
  • Ball to rock, bounce and stretch. Replace chair at desk with it

Demonstration/return demonstration – introduce 1 new exercise a class instead of all at one. Spiral info

  • Class 1 – Kegel. Wall stretch with standing pelvic tilt for reducing backache and good posture. Pelvic tilt on all 4s to reduce backache. May increase comfort during labor and help rotate baby in posterior position
  • Class 2 – pelvic tilt on all 4s, adding back massage and Kegel. Passive pelvic tilt side lying
  • Pelvic tilt all positions. Kegel with and without tilt
  • Awareness of tension in pelvic floor. Various pushing positions. Abs contracted
  • Pelvic tilts – walking, leaning against wall, hands and knees, over birth ball, side lying and pushing
  • Pelvic tilts to postpartum lifting/bending over baby

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



  1. Healthy pubococcygeal muscle (pelvic floor)

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

  • Attend regular prenatal care appointments
  • Learn warning signs of pregnancy complications
  • Eat nutritious foods and gain healthy amount of weight
  • Maintain general fitness
  • Reduce harmful stresses
  • Avoid harmful substances and exposure to hazards
  • Treat harmful conditions and illness before pregnancy and those that develop during

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. PCNGuide

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

Every visit

  • Urine test to detect bacteria, protein and sugar (at first visit, urine test can confirm pregnancy)
  • Blood pressure check to screen for high blood pressure
  • Weight check to monitor nutritional status and detect sudden weight gain (which can indicate preeclampsia)
  • Abdominal exam – to measure uterine growth or fundal height (which indicates baby’s growth) and estimate baby’s position
  • Fetal heart tones – listen to confirm baby’s well being

Specific Visits

  • Pelvic exam – confirm pregnancy, estimate size of mother’s pelvis, check for infection or perform Pap smear. In late pregnancy, reveals cervical changes
  • Blood test – at first visit to confirm pregnancy, determine blood type, test for anemia, and assess exposure to infection. For women with diabetes, caregivers check blood glucose levels periodically throughout pregnancy
  • Breast exam – screen for breast cancer and assess for conditions affecting breastfeeding


Other Exams/Screening

  • Dental – by dentist to check for tooth decay; check for gum infection which is associated with preterm labor
  • Fetal movement counts (kick counts) – done by you
  • Ultrasound – confirm pregnancy, estimate due date and baby’s size, detect/rule out complications
  • Integrated prenatal screening – assess risk of down syndrome and neural tube defects such as spina bifida. Combination of first trimester screening tests (ultrasound and blood tests) and second trimester blood tests. If results outside range, diagnostic test.
  • Genetic screening – checks for cystic fibrosis, tay-sachs, thalassemia and sickle cell anemia. If blood/saliva tests reveal risk, recommend diagnostic tests.
  • Glucose screening – detect high glucose levels, which may indicate gestational diabetes between 24th and 28th After sugary drink, blood is drawn. If blood sugar high, recommend glucose tolerance test
  • Group B streptococcus (GBS) screening – presence of GBS bacteria in secretions swabbed from vagina and anus and cultured in lab

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

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:

  • Vaginal bleeding – miscarriage, placenta previa, placenta abruption, preterm labor
  • Abdominal Pain – ectopic pregnancy, miscarriage, placental abruption, preterm labor contractions. May indicated medical problem such as appendicitis or gallbladder disease
  • Continuing, intermittent abdominal cramping or uterine tightening (contractions) – preterm labor
  • Constant and severe abdominal pain and a hard abdomen, with or without vaginal bleeding – placental abruption
  • Leaking or gushing of fluid from vagina – rupture of membranes
  • Sudden puffiness or swelling of face, hands or fingers – preeclampsia
  • Severe, persistent headache – gestational hypertension or preeclampsia
  • Problems with vision (seeing spots or flashes, blurring or blind spots) – preeclampsia
  • Severe and persistent dizziness, lightheadedness – preeclampsia; supine hypotension
  • Noticeable reduction or change in baby’s movement or activity after 28th week of pregnancy – fetal distress
  • Painful area in leg, swelling or redness over affected area, or pain in leg when standing/walking – blood clot in leg or inflammation of vein (venous thrombosis)
  • Severe pain in pubic area and hips, with trouble moving your legs – strain or separation of pubic symphysis joint or sciatica (pain in lower back from pelvic joint stress)
  • Painful urination or burning sensation, with or without the urgent and frequent need to urinate – UTI or STI
  • Irritating vaginal discharge, genital sores or vaginal itching – vaginal infection or STI
  • Fever (temp over 102) when feeling sick – infection
  • Persistent nausea/vomiting – hyperemesis gravidarum; infection

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

  • Headache – instead of taking aspiring, Tylenol, ibuprofen, take a warm bath, have a massage or do tension-reducing exercises such as should circles and relaxation techniques. Heat or cold – hot pack across shoulders or back of neck or cold pack on forehead. Hunger, dehydration and fatigue can cause them. Eat frequently, drink enough fluids, get more sleep and arrange for periods of rest and relaxation in your daily routine.
  • Cold, hay fever, runny nose or cough – additional sleep/rest, cool-mist vaporizer, saline nose drops, drink plenty of fluids, swallow mixture of honey and lemon juice
  • Nausea/Vomiting – eat several small meals a day to prevent empty stomach and keep blood sugar stable. Include protein rich food with each meal. Don’t drink a lot of fluids with meals; drink between meals. Keep bland food such as crackers by bed and eat some just before getting up. Trust food preferences. Identify and avoid odors that make nausea worse. Smell peppermint oil or fresh lemon slices. Ginger – in foods, candied or pickled, drink ginger tea or ginger ale. Increase food rich in vit B – whole grains, cereals, nuts, seeds, legumes. Supplements. Intake shouldn’t exceed 100 mg. acupressure wristbands – relieve motion sickness. Passes within 3-4 months. Condition hyperemesis gravidarum may require Zofran or hospitalization
  • Back pain – common so maintain good posture, good body mechanics and do exercises that strengthen abdominals and decrease curve in lower back. Rest, massage, warm baths, hot or cold packs. Avoid taking aspirin, ibuprofen and muscle relaxants unless severe pain.
  • Sleeplessness – common in late pregnancy. Exercise or take a brisk walk each day (not just before bedtime). Take warm bath, drink warm milk, have massage or listen to soothing music at bedtime. If awaken at night, read, write thoughts in journal or use relaxation techniques. Avoid watching TV or using computer, which stimulate brain and make you feel more awake.

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.

  • OTC Medications – look at ingredients. PCNguide has current info on common OTC medications and effects on pregnancy
  • Medications to Avoid – a few are extremely harmful to baby. many are teratogens, which can cause birth defects, deformities or even death. Chemotherapy drugs (methotrexate and aminopetrin); oral drugs to treat severe acne, such as isotretinoin (Accutane) and Vit A derivatives (Vit A in vitamin pills is safe in pregnancy). Topical drug doesn’t appear to increase rate of birth defects, but may want to avoid. Radioactive isotopes such as x-ray and MRI
  • Potentially harmful: some medications used to treat hyperthyroidism (propylthiouracil, methimazole or iodide), certain medications used to treat seizure disorders (phenytoin, valproic acid or Depakote), bipolar disorders (lithium)

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.

  • Alcohol – crosses placenta and enters baby’s blood in same concentration as in your blood, increasing her risk of serious birth defects and long-term problems with her development. Depends on amount you drink, how often and when in pregnancy. In first trimester, when baby’s organs are forming, excessive alcohol can cause organ defects, facial abnormalities or miscarriage. 2nd trimester can affect nerve formation in brain and 3rd trimester can interfere with development of nervous system. May also cause preterm labor. Of babies whose mothers drank heavily while pregnant, 4% develop FAS, a cluster of physical, mental and behavioral disabilities that include growth problems, heart defects, mental retardation, facial abnormalities, and problems with muscle and nerve development.
    • Heavy drinking – some say 4+ a day; other say 2+ a day or binge drinking more than 3 drinks on one occasion. Standard drink is ½ oz of distilled alcohol, one can of beer or 4 oz glass of wine. Avoiding before pregnancy may help you conceive.
  • Smoking – pregnant smokers have a greater risk of miscarriage, placental abruption, stillbirth or infant death. If she has family history of clubfoot, cleft lip or cleft palate, she increase risk. The more she smokes, the greater risk of placenta previa or ectopic pregnancy. Often give birth to babies with low birth weight (with health problems) because of intrauterine growth restriction and a higher risk of preterm birth. Increased risk of SIDS. If live with smokers, risk of SIDS increases even more depending on number of smokers and amount of time exposed to secondhand smoke. Respiratory problems later in life. don’t use smoking substitutes (nicotine patch, gum or nasal spray) during 1st trimester; can increase risk of malformations in baby if used when organs and structures are forming.
  • Illegal Drugs and Prescription Drug Abuse – in 1st trimester baby may develop defect or deformity or may have miscarriage. In 3rd trimester, baby may have intrauterine growth restriction of IUGR (grow slowly) or suffer effects of prematurity because of a preterm birth. Each drug has its own effect and a combination may compound damage to baby. prescription drugs can be just as dangerous to babies as illegal drugs. PCNguide


Potentially Harmful Substances and Herbs in Food

  • Caffeine – can raise heart rate and blood pressure, constrict blood vessels, affect ability to sleep, and make you jittery. Also a diuretic (urinate more fluid, more often) and increases amount of calcium you expel in urine. Of coffee, tea, energy drinks, colas and other soft drinks, coffee has most caffeine but amount differs depending on how its made and serving. An 8 oz may have 65-120; decaf has 2-4 mg. 12 oz soda has 54 mg. Several OTC medications have it and chocolate contains a small amount of a caffeine-like chemical. Read labels. Researchers haven’t found any connections between caffeine and birth defects or delayed childhood development, babies in womb probably experience stimulating and diuretic effects. Caffeine can elevate baby’s heart rate and reduce amount of fluid and calcium available for optimal growth. Evidence on connection to miscarriage, intrauterine growth restriction and stillbirth is conflicting and controversial. Various factors influence including woman’s unique susceptibility – when in pregnancy, how much etc. Large amounts at any time may harm baby; more than 200 mg in 1st trimester may increase risk of intrauterine growth restriction or miscarriage.
  • Herbal Tinctures, Teas and Capsules – FDA hasn’t tested or approved and safety uncertain. Some caregivers recommend red raspberry leaf to tone uterine muscles. Some recommend herbs that can start labor – blue cohosh, evening primrose and black cohosh; however, women should avoid these uterine stimulants in early pregnancy because they may cause miscarriage. Can also have dangerous side effects; blue cohosh may cause elevated blood pressure, irritated mucous membranes and multi-organ injury from lack of oxygen. Some Chinese herbal medicines, specifically An-Tai-Yin and huanglian, may cause congenital malformations. If allergic to ragweed and related plants, may develop allergic symptoms after drinking chamomile tea. Licorice root tea can increase water retention and decrease potassium. Ginseng can cause swollen and painful breast. Be aware of ingredients of herbal tea before drinking.

Mercury; Other substances that cause harmful illnesses such as listeriosis and toxoplasmosis – pg 121

Environmental Hazards and Harmful Situations – abusive relationships, workplace stress

  • Abuse/Domestic Violence – (any combination of verbal, psychological, emotional, sexual, economic or physical) can happen regardless of socioeconomic, educations etc. when pregnant, abuse increases risk of serious pregnancy problems such as high blood pressure, vaginal bleeding, severe nausea or vomiting, UTIs, preterm birth, a baby with low birth weight, or a baby who needs intensive care. Risk of being killed by an abusive partner increases during pregnancy. You are not at fault; goal of abuse is to leave you feeling confused, ashamed, powerless, hopeless and out of control. Suggestions for coping with stress pg 72-73. 800-799-SAFE. Make an escape plan.
  • Insecticides, Herbicides and Pesticides – avoid frequent, sustained exposure to chemicals that kill insects (insecticides), weeds (herbicides), or unwanted insects, bugs or animals (pesticides). Presence of these in the air and on food may cause miscarriage, poor growth in baby, birth defects, and childhood neurobehavioral problems. To avoid exposure, wash fruits and vegetables well.
  • Occupational Hazards – potential harm of some workplace chemicals such as anesthetic agents, benzene, cancer treatment (cytotoxic) drugs, carbon monoxide, ethylene oxide, ethylene glycol ethers, formaldehyde, ionizing radiation (x-ray), lead, methyl mercury, organic solvents, polybrominated biphenyls (PBRs), and polychlorinated biphenyls (PCBs). Can cause miscarriage, birth defects, low birth weight, preterm birth, developmental delays and childhood cancers. People who encounter include health care workers (dental/veterinary), pharmacists, batter makers, solderers, welders, radiator repairers, industrial painters, home remodelers, and atomic and electronic workers. Farm workers exposed to pesticides.
  • Chemicals Used for Hobbies – see Material Safety Data Sheet (MSDS) from store that sells it
  • House Paint – discourage women from using spray paint (because inhale paint particles), but rolling/brushing probably safe. Use low VOC or no VOC paints, which contain fewer (or no) harmful volatile organic compounds. Wear gloves. If home contains lead-based paint (older homes), don’t remove or paint over yourself. Professional can come and handle toxic paint and dust without harm to you.
  • Hair treatments – some studies show link between it an increased risk of childhood brain tumors, but results aren’t statistically significant. Other studies find no evidence that dyes cause birth defects. No direct evidence that wave solutions or hair relaxers are harmful.
  • Saunas, Hot Tubs and Heat Wraps – may raise baby’s temperature along with yours. Once overheated, baby takes much longer than you to cool down. In early pregnancy, high temps can cause birth defects or even miscarriage. Later in pregnancy, can raise your body temp and produce fever in baby and may cause baby to develop neurological disorders such as seizures. Keep temp below 102.2 and keep should and arms out of water. Consider warm bath instead where less of body is submerged in water.
  • Electric Blankets – emit low-frequency electromagnetic energy, may harm pregnancy if exposure is prolonged and close to body. Consider using down comforter or wool blankets instead.
  • Ionizing Radiation – X rays for medical and dental diagnoses use much less radiation than does radiotherapy for cancer treatment. Because risk of defects from one diagnostic x ray (about 1 radiation absorbed dose, or rad) during first 4 months is tiny, many don’t consider it dangerous. Try to avoid x-rays in first trimester, when radiation may interfere with baby’s organ development.
  • Infectious disease – toxoplasmosis, Lyme disease, rubella (German measles), chicken pox, fifth disease (parovirus B19), listeriosis, hepatitis, and STIs (pg 132-133)
  • Father’s Exposure to Hazards and Drugs – mans exposure months before conception may increase miscarriage risk, childhood brain tumors, and other problems. Research differs about effect of smoking on male fertility
  • Internet Resources, , , , , ,

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

Common Concerns

  • Nausea and Vomiting – aka “morning sickness”; any time throughout day. Production of hormones that support pregnancy increases, may feel nauseated until body adjusts to increased levels (some women also experience diarrhea in early pregnancy, which may be due to hormones or dietary changes). In first trimester, it’s common in women who haven’t eaten for several hours, who smell certain odors, or who encounter other triggers. Unless vomiting severe and unusually frequent, it doesn’t harm baby. women who are healthy when conceive has sufficient reserves to nourish growing baby, even if she can’t eat well for first several months.
  • Heartburn – burp up stomach acid, causing burning feeling in chest/throat. Late pregnancy many women experience from increased pressure from growing uterus and hormonal effects that relax muscular opening at top of stomach and cause stomach to empty more slowly.
    • Avoid fatty, spicy or foods that produce gas/heartburn. Eat several small meals. Drink only small amount of fluid with meals. Eat slowly and avoid eating before bedtime. Semi-sit rather than lie flat on back. Antacids, but take only when necessary.
  • Constipation – food moves through intestines more slowly to let body absorb more nutrients and water. Pressure from growing uterus on large intestine magnifies problem. Can aggravate hemorrhoids.
    • Exercise regularly, consume plenty of fluids and high fiber foods such as fruits and veggies, whole grains, bran and prune juice. Easy way to increase fiber is to add spoon of flax meal to food. Metamucil or Fiberall – OTC high fiber products; avoid taking intestinal stimulants (laxatives) – body may become dependent. If it’s iron supplement, change to another one
  • Food Cravings/Pica – Food cravings usually harmless unless interfere with good nutrition. Pica – craving/eating nonfood items common; cravings for ice, baking soda, flour, cornstarch, dirt, clay, cigarette ashes etc. cravings to smells such as gasoline, nail polish remover, bleach and ammonia. Can cause mild to severe side effects in mother/baby

Food Safety –

  • Mercury – metallic element that can harm baby’s developing brain and nervous system found in large, long lived fish.
    • Eat up to 12 oz per week: anchovies, catfish, clams, cod, crab, flounder, herring, oysters, Pollock, salmon, sardines, scallops, shrimp, sole, tilapia and trout
    • Eat up to 6 oz per week: halibut, snapper, lobster, tuna and mahi-mahi
    • Avoid completely – shark, tilefish, mackerel, swordfish, grouper, marlin and orange roughy
  • Food Bourne Bacteria- more susceptible to listeriosis, salmonella, and toxoplasmosis; can sicken women and cause miscarriage, preterm labor and stillbirth. Live in undercooked meats, fish and eggs, unpasteurized milk and cheeses and unwashed fruits and veggies. Cook hot dogs and lunch meats until steaming. Refrigerator to 35-40F and freezer 0-4F. food at room temp no longer than 2 hours. Eat leftovers within 2 days.
    • Avoid unpasteurized milk products – including soft cheese made from it (Brie, camembert, blue, feta, Mexican fresh)
    • Avoid raw fish, especially raw shellfish
    • Avoid refrigerated pates or meat spreads
    • Avoid raw vegetable sprouts such as alfalfa/bean

Nutrition for Special Circumstances

  • Multiples – twins – increase prenatal vitamin dosage by 50% and get extra 600 calories each day. Gain 35-50 lbs. when pregnant with multiples, gain at least 24 lbs by 24th week to reduce risk of preterm birth and babies with low birth weight
  • Teenage – consume enough calcium phosphorous and magnesium
  • Pregnant within a year of birth – can temporarily deplete reserves of certain nutrients such as calcium and iron
  • Anorexia/Bulimia – difficulty accepting weight gain. Psychological and nutritional counseling; support groups
  • High blood pressure – gestational hypertension – isn’t totally preventable. Eat healthful diet, drink plenty of fluids, exercise regularly, avoid alcohol and caffeine. Several nutrients may reduce risk – protein, calcium, magnesium, zinc, vit C and E and omega 3 fatty acids
  • Diabetes – carbs shouldn’t make up more than 40% of daily calorie intake. Several small meals to keep blood sugar stable
  • Low Income


Discussion Points

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; pg 9 handbook; Canadian rainbow guide, 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

  • “1 for the road” – never leave house without snack for road – trail mix, nuts, seeds, raisins, cheese and crackers, banana, apple
  • “Colorful plate is a healthy plate” variety of fruits/veggies; brown bread doesn’t necessarily mean whole grains – read labels
  • “Eating for 2” – get plenty of calcium; caffeine decreases absorption of calcium. Iron supplements for healthy blood. It’s difficult to get enough iron even in well planned diet. Protein necessary for baby’s growth and brain development. Want good birth weight and well-nourished tissues with increased energy for mom.
  • Books – Your pregnancy and childbirth; expect the best: your guide to healthy eating before, during and after pregnancy; eating for pregnancy: the essential nutrition guide and cookbook for today’s mothers to be
  • Web:


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,, and Office of Women’s Health Research website


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 ( 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.

  1. Alcohol, nicotine, and caffeine
  2. Legal and illegal drugs
  3. Hot tubs, saunas, electric blankets
  4. Infectious diseases — toxoplasmosis, Lyme disease, listeriosis

VIII. Additional references for Part 5

  1. ICEA Dr. Sears certification program

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

  1. “CERTIFICATION’ tab Dr. Sears Certified Health Coach 
same as above
  2. ICEA Prenatal Fitness Educator Certification Program 
 – currently unavailable

  1. ICEA Teaching Papers: Suggestions for Labor Rehearsals – ICEA Teaching Idea Sheet #4

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.

  1. Mom and her support person are walking across the parking lot to the hospital and a hard contraction begins.
  2. In transition, they are coping well when the fetal heart rate drops and the electronic monitor’s alarm goes off; no nurse comes into the room.
  3. While driving to the hospital and breathing though a contraction, the bag of water ruptures.
  4. After six hours of hard labor, the cervix is still at 2 cm and the fetus has had short periods of distress. The physician says, “Ms. Smith, you need a cesarean.”
  5. During active labor, using high chest breathing, the mother begins to feel short of breath and has tingling sensations around her lips and tongue.
  6. In transition, the mother develops the shakes, nausea and vomiting. She says, “I can’t go on. I can’t. I just can’t.”
  7. Analgesics are given and cause heavy drowsiness.
  8. The mother is experiencing continuous low back pain.
  9. On admission to the hospital, hard contractions are coming every three minutes and the mother is feeling the urge to push. The admission clerk says, “Now Mr. Smith, I need you to stay here and fill out these forms. The nurse will take Mrs. Smith to the labor area in the wheel chair.”
  10. The bag of water ruptures but labor has not begun. After six hours the physician says they will order a Pitocin drip to induce labor.
  11. In active labor, the anesthesiologist comes into the room during a contraction and immediately says, “Are you ready for your epidural?”
  12. It is 3:00 AM; they are asleep at home. The mother wakes up to go to the bathroom and has some diarrhea. She goes back to bed and is up again at 3:15 AM with another bathroom trip. She feels different and cannot go back to sleep; backache.
  13. It is now 6:00 AM and contractions have been coming every twenty minutes since 3:15 AM, but they are very mild, requiring only conscious release for comfort.
  14. During active labor in the hospital, a contraction begins; the nurse enter the room and asks, “How are things going, Ms. Smith? How often are your contractions coming? Would you like some medication to take the edge off?” (Contraction is on- going)
  15. Half an hour ago, the mother was at 5 cm. On the next contraction, “Oh I have to go to the bathroom.”
  16. Two hours ago she was at 4 cm; she is still at 4 cm currently. The instructor role plays the nurse who says she will need to examine the mother during a contraction and does so; she is still at 4 cm.
  17. Labor begins when the couple is not together and she cannot get in touch with the partner.
  18. When they get to the hospital after ten hours of labor at home, her cervix is dilated to 1 cm.
  19. They are at home; it is midnight and contractions have been coming every five minutes for an hour but they are mild. What now? If they suggest calling the doctor, the instructor role-plays the doctor on the telephone.
  20. After pushing for two hours, the baby is still high in the pelvis. The doctor suggests that a cesarean may be needed.
  21. She finds it very difficult not to push during the birth of the head.

The Body as the Teaching Tool – ICEA Teaching Idea Sheet #6

Best teaching tool is her own body.

  • Fertilization – Form ovary with left hand clenched slightly. Suddenly ovulation takes place, your fist opens releasing the egg into the waiting fallopian tube. The fimbria are the moving fingers of your right hand; the egg travels up the tube (which is your right arm) and finally implants itself in the uterus, formed as your head drops forward and your upper body becomes the waiting uterus.
  • Relaxation: Tension and relaxation can be presented by tightening face, then smoothing out tension with fingers to demonstrate progressive relaxation and the use of touch.
  • Effacement: Nose can serve to illustrate consistency of the cervix before labor begins, firm but flexible and not at all effaced. Tug on your nose with your thumb and forefinger to illustrate this; contrast this with an image of full effacement by using the skin tightly stretched between your thumb and index finger. How thin and stretchy!
  • Contractions: Can use your nose again to give the class the idea of how the abdomen feels with a mild contraction. The forehead can be the consistency of the abdomen when the contractions become stronger.
  • Dilation: Dilating the cervix from 0-10 cm can be pictured by using closed, pursed lips, then stretching your mouth wide open to simulate full dilation. Everyone in the class can see the difference in each other as they return the demonstration. Slide your index finger along the dilated cervix that is your open mouth to demonstrate a vaginal examination during labor.
  • Pelvis: Let’s build a pelvis! Place your thumbs together for the pubic arch; your index fingers touch to form the oval shape of the inlet. Now bend the remaining three fingers on each hand to represent the ischial spines. Ask the class to do this with you and then have everyone look down into the pelvis just as the baby does when labor begins. They can see the wider transverse diameter of the pelvic inlet and the roomier anterior-posterior diameters of the outlet. The explanation of the internal rotation of the head to fit into the pelvis, past the spines and under the pubic arch is easier to visualize.
  • Progress of Labor: Clench fingers tightly into a fist to show the cervix at the beginning of labor, allowing only a fingertip to pass through. As labor progresses and the contractions become stronger and more effective, the thumb and the forefinger of the fist begin to relax and show progressive dilation. Both hands together now with thumbs and index fingers overlapped, you can progress from 0-10 cm.
  • Pushing: Use your body to form the J, demonstrating the angle which will produce the most effective pushing. Start the pushing demonstration sitting flat on the floor, using an over-turned straight-back chair as your backrest to simulate being semi-reclined in a hospital bed. Ask for suggestions from the class about improving your pushing. They could tell you to get out of bed, squat, turn to the right or left lateral positions. Have someone support you as you push. Demonstrate everything they suggest, illustrating that there are many ways to push and no one “right” way that works for every birth
  • Perineum: Have each class member pull his/her forefingers to the outside corners of the fully opened mouth. The burning sensation will simulate the feeling in the perineum just before the head is born. Remember the stretched skin between the thumb and index finger? Use this now to demonstrate the taut perineum. If an episiotomy is indicated, you can show the difference between the midline and mediolateral episiotomy by drawing two lines down from the vaginal opening across the stretched perineum.
  1. Using BioDots – ICEA Teaching Idea Sheet #3

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:

  • Black indicates that skin temp is ~87F or lower.
  • Amber – 89.6F
  • Yellow – 90.6F
  • Green – 91.6F
  • Turquoise – 92.6F
  • Blue 93.6F
  • Violet 94.6F

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.

  1. Anatomy of pubococcygeus muscle (pelvic floor muscle) or PC muscle _muscle

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.

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