Read this book if: you want a complete overview of pregnancy, childbirth and the newborn. This is the main book used for studying to be a childbirth educator. It is comprehensive. Please read instead of “What to Expect”. Another great option is Ina May’s Guide to Childbirth.
If you like the summary, support the author by purchasing a copy.
*My summary is not complete as of 10/16/16
Chapter 1 – You’re Having a Baby!
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
Chapter 2- So Many Choices
Informed Decision Making: www.childbirthconnectionorg; www.motherfriendly.org; www.birthcenters.org/fine-a-birth-center; www.acog.org/member-lookup; http://familydoctor.org; http://cfmidwifery.org; http://acnm.org/find.cfm; www.mana.org; http://cfmidwifery.org/find; www.icea.org; www.lamaze.org; www.bradleybirth.com; www.birthingfromwithin.com; www.dona.org; www.doulamatch.net
If disagree with caregiver: in U.S and Canada, a pregnant woman has legal right (in most circumstances) to change caregivers, and caregiver has right to discontinue care if there are other options for pregnant woman
BRAN – Benefits– problem were trying to identify/prevent/fix; how is it done; how likely is it to work, Risks – possible risks/side effects for baby/me. Other tradeoffs/disadvantages such as additional procedures or precautions; cost, Alternatives-other options available; other procedures that may work; delay treatment or choose not to; risks and benefits of alternatives and effectiveness (low risk options sometimes less effective), Next Steps– if it solves problem, what can we do after; if it doesn’t, what after?
Health Care Coverage – licensed midwife may charge as little as $2,500 for uncomplicated home birth. Midwife for prenatal/birth center – $4000-$4500. OB uncomplicated birth $7,500. Cesarean complicated can cost more than $20,000.
Contact insurance company representative to understand coverage. See work sheet on PCNguide.com
Some insurance plans cover but don’t pay directly for midwifery care, childbirth prep, birth or postpartum doulas, home birth and breastfeeding assistance, but you pay and they reimburse you. Can also use a FSA (flexible spending account).
~25% of people in U.S. can’t afford health insurance or don’t work for employers who offer it as a benefit. Medicaid coverage can help cover costs although only a limited number of caregivers and birth places.
www.thebirthsurvey.com – new mothers to share info about their birth experiences.
Choosing a Birthplace
Models of Care – Midwifery vs Medical
A caregiver’s philosophy of care typically follows one or the other.
Midwifery Model of Care – designed to maintain and enhance a woman’s physiological and psychological resources for giving birth
Medical Model of Care – designed to replace or alter the body’s own resources with medical and technological interventions
Interviewing a Potential Caregiver – when scheduling, make it clear it’s only to learn more about the caregiver and his or her practice
Questions to Ask a Potential Caregiver
Changing Caregivers if dissatisfied – it’s essential you feel comfortable
Choosing Childbirth Prep Classes – hospitals, colleges and universities, nonprofit community organizations, groups of caregivers, and independent childbirth educators offer
Hospitals usually have provider oriented about hospital which avoid discussion of reasonable alternatives or controversial topics.
Birth Doulas – Cochrane Library issued a report about dehumanization of women’s birth experiences. Review found that support was most effective when provided by women who weren’t hospital staff.
Most studies show that continuous support benefits laboring women, especially when the support begins in early labor and is given by someone whose only role is to provide it. Benefits include:
A few hospitals provide doula services at low cost or no cost to the patient, and some charitable agencies or public health departments cover doula’s fees for women who can’t afford; health insurance plans rarely cover.
www.dona.org/mothers/how_to_hire_a_doula.php for lists of questions to ask
Baby’s Health Care – make decisions about baby’s health care before birth. Ex: circumcision and vaccinations
Choose a caregiver before birth –
Health Care Coverage for baby – cost depends on plan. Children’s health clinics usually cost less than private practices, but they may have longer waiting times. If clinic is associated with a medical school, its staff may change frequently. Community health clinics or well-child clinics associated with a public health department offer free or low-cost checkups and vaccinations, but they usually don’t provide care for sick children.
Questions to Ask Potential Caregiver – do you support breastfeeding, formula feeding, work with lactation consultants, thoughts on circumcision, vaccinations, comfortable with home remedies, use of antibiotics, available for phone consultation, do you have hospital privileges, examine baby after birth. PCNguide.com; http://www.pcnguide.com/wp-content/uploads/2016/03/4-Questions-to-Ask-Potential-Caregivers.pdf
Schedule an interview w 1 or more caregivers before birth – check with insurance to see if it covers such appointments; if it doesn’t, see if caregiver will charge a fee.
Finding Help After Baby’s Birth – family members and friends help by cooking meals, running errands, doing laundry, housecleaning and watching baby so parents can sleep/relax. Babys nurses or nannies can take care of baby while you do other activities and mother’s helpers cook and clean but don’t help with baby care or give advice.
Postpartum doula – someone (typically a woman) who’s trained and experienced with helping a woman and her family adjust to postpartum life by teaching them about newborns’ needs and abilities, and about infant feeding, sleep and cues, while providing assistant with household tasks; potential costs may seem daunting but help and care are well worth the price. Health insurance plans rarely cover. Put aside money during pregnancy.
Questions to Ask Potential Postpartum Doula (try to hire before birth)– www.dona.org/mothers/how_to_hire_a_doula.php
Training/education/experience; criminal background check; TB test, DTap vacc, CPR cert, philosophy, meet before birth, additional services, call with questions before birth; when do services begin after birth; experience with breastfeeding, fee, refund policy
Returning to Work – see if possible for family to delay returning to work (you or partner), if one can work part-time/job share, work from home, costs of returning to work – child care, more visits to baby’s caregiver (daycare), income exceed total costs making it worthwhile, how will person who works feel about other staying at home? See PCNguide
Finding Child Care for Baby – arrange well before birth; try to wait 3-4 months after birth before returning to work. Allow at least a month to find child care that best suits your needs. Ask coworkers/other working parents about child care. Consider sharing nanny/babysitter. Ask family members/friends. Stagger you and partners work schedule or work part time. Some works have day cares. If outside your home – see saferchild.org/caregiver.htm and www.childcareaware.org for advice on evaluating. Give appropriate holiday gifts to caregivers.
10 Steps to Improve Your Chances of Having a Safe and Satisfying Birth
Chapter 3- 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 aeola; fullness, bloating, ache in lower abdomen; fatigue and drowsiness; feeling lightheaded or faint; nausea, vomiting, frequent urination, increased vaginal secretions
Confirming Pregnancy – hCg – human chorionic gonadotropin, hormone only produced during pregnant. Take 1 test after missed period and another a few days later. Confirm via blood test.
Calculating Due Date – Pregnancy/Gestation lasts average 280 days or 40 weeks after first day of last menstrual period. Difficult to know exactly when ovulation occurred. Simple formula – subtract 3 months from date of last period and add 7 days. Optional ultrasound in early pregnancy to help estimate due date. Babies born healthy and normal any time from 3 weeks before to 2 weeks after; most babies born within 10 days; 5% born on due dates. Due date important to determine best time to do genetic testing, whether results of lab tests within normal range, to diagnose preterm or post-date pregnancy, or see if baby is growing more slowly or rapidly than normal.
Hormonal Changes During Pregnancy – placenta is the major source of hormones
First Trimester Changes for You and Your Baby – first trimester is “formation” period because by end of it baby’s organ systems are formed and functioning.
First 4 Weeks
2nd Trimester Changes for You and Baby – “development” period – baby’s organs and structures begin to enlarge and mature.
3rd trimester changes for you and baby – growth period – changes for an easy transition to life outside womb improve closer to due date.
39th/40th Weeks of Pregnancy
41st Week of Pregnancy and Beyond – Post-Dates
Common Concerns and Considerations in Pregnancy
Note to Expectant Fathers – may never felt so important yet so ignored, so committed yet so abandoned and so deeply in love and sexual yet afraid of sex. Share with other expectant fathers casually or in group.
Special Challenges in Pregnancy – past traumatic experiences can present additional challenges
Key Points: 1st trimester – formation period; 2nd trimester – development period; 3rd trimester is growth period
Chapter 4 Having a Healthy Pregnancy – making positive lifestyle choices, ideally begin avoiding hazards before pregnant
Caring for Yourself and Your Baby during Pregnancy –
Note to Fathers/Partners: support mom’s efforts by making changes to your lifestyle as well. If you smoke, you can quit so partner and baby avoids harmful effects of secondhand smoke. Exercise regularly and avoid consuming unsafe foods and substances. Get involved in partners pregnancy – attend some or all prenatal appointments, show interest in prenatal tests and results. Do laborious household chores.
Prenatal Care – schedule once you know you’re pregnant; the wait tog et an appointment with some caregivers can be several weeks. At 1st/2nd visit, will get complete physical exam and numerous tests. Ask questions about current life situation and family medical history. Appointment every month; at end of pregnancy, every 2 weeks; every week as due date approaches. If you want a longer appointment, request in advance. At end of pregnancy, schedule long visit to talk about birth plan. If there’s a group, try to meet others.
Info to include in medical history: prior surgeries/illnesses, hereditary conditions, including birth defects (heart defects) mental retardation, blindness, deafness, stillbirth, miscarriages, mental health conditions – depression/eating disorders, ethnic or cultural traditions, current prescription medications, drug allergies and drug reactions, prior negative experience with a hospitalization, prior sexual abuse, domestic violence or any other significant mistreatment, heavy use of alcohol, tobacco, recreational drugs or other harmful substances.
Prenatal Tests – screening test is a quick, easy and inexpensive way to rule out a particular condition. If results are positive, may need further testing to confirm you have condition. If additional testing determines you don’t have the condition, your screening test gave a “false positive” reading. Diagnostic test is more specific and more reliable; more invasive, expensive and usually have more side effects, so caregivers usually only give if indicated by screening.
Benefits, Risks, Alternatives to test/how test is done/ how reliable/accurate/ how will results influence prenatal care/ cost/insurance cover cost/ consequences of not having.
Routine Exams and Screening Tests–
See PCN Guide
Understanding Ultrasound – 2 forms: Doppler and diagnostic scan. Doppler monitors baby’s heart rate, uses continuous transmission of sound waves to detect motion of baby’s heart as it beats. Done via hand-held device. Scan helps “see” inside uterus, using intermittent transmission of sound waves for less than 1% of the time during the test. For the rest of the test, the equipment receives the echoes of the sound waves, which indicate differences in tissue density. See PCN guide http://www.pcnguide.com/wp-content/uploads/2016/03/2-Routine-Prenatal-Examinations-and-Screening-Tests.pdf
Studies found no evidence that they harm mother or baby and that benefits outweigh risks. Estimating baby’s age and weight more reliable in early pregnancy. First sight of babies inspires many parents to make an effort to heave a healthy pregnancy and birth.
Warning Signs of Pregnancy Complications:
Fetal Movement Counting – some caregivers ask only those women with high-risk pregnancies to count their babies’ movements. Baby doing well in uterus have several active, wakeful periods during the day. Healthy babies move slightly less often toward end of pregnancy due to space restrictions within uterus but don’t markedly reduce activity unless there is a problem. If baby becomes noticeable less active, call caregiver.
The Count to Ten Method – after 28th week, count baby’s movements each day at roughly same time. PCNguide has template. Length of time it takes to complete 10 movements varies among babies. Focus not on how baby’s movements compare with other babies’ but on whether his activity has slowed down compared to his usual pattern. Try waking baby up with a loud noise or wait until you feel baby move. Call caregiver if it takes a longer time than usual to make 10 movements or if baby doesn’t move at least 10x or have an active period within the next 12 hours.
Reducing Stress – see pgs 71-73 above
Treating Illness and Discomforts during Pregnancy –
Medications – what are benefits, risks and alternatives; if benefits clearly outweigh risks ask about dose, max dose in 24 hr period and other foods/drugs to avoid while taking. How long to take.
Substances and Hazards to Avoid during Pregnancy – everything affects baby from caffeinated coffee and herbal teas to dangerous situations such as abuse and domestic violence. Depends on amount and frequency of exposure as well as what trimester you’re in when exposed.
Potentially Harmful Substances and Herbs in Food
Mercury; Other substances that cause harmful illnesses such as listeriosis and toxoplasmosis – pg 121
Environmental Hazards and Harmful Situations – abusive relationships, workplace stress
Traveling During Pregnancy – in last month, caregiver may suggest staying within an hour’s travel time from home. Get copy of medical history to take while traveling. Some airlines limit in week before a due date. Avoid flying at altitudes >7000 feet in small planes without pressurized cabins; the oxygen available to baby may be reduces. If traveling internationally see about vaccines – only a few considered safe in pregnancy.
Long trips by car, bus, plane or train may limit movement, which can affect circulation, increase swelling in legs, and increase risk of developing a blood clot in leg vein. Walk every hour or so. Wear seat belt. Fasten low on hip and below belly. Constant motion may aggravate morning sickness/nausea. Air travel, hot climates and places with forced air ventilation may increase dehydration. Drink lots of fluids, eat well, walk around and get plenty of rest
Nutrition for Special Circumstances
Feeling Good and Staying Fit – maintaining good posture helps prevent back pain
Maintaining Good Posture and Moving with Care – maintaining good posture is essential for keeping your balance, preventing back pain and reducing fatigue
Exercise in Pregnancy – protects against back pain, reduces intensity of common pregnancy discomforts and boosts energy level, mood and self image. During last trimester, regular exercise increases body’s production of endorphins (natural pain relievers), which can help you cope with labor.
Finding Motivation to Exercise – motivation may ebb and flow as energy level rises and falls. Find what time of day works best and schedule for that time. Hearing/reading encouraging words or listening to favorite music can motivate you. If have trouble making time on yoru own, sign up for a class or make an appointment with someone.
Exercise Options – aerobic exercise increases heart rate for an extended time, which improves endurance and strengthens heart and lungs. Anaerobic focuses on strengthening muscles and improving balance and flexibility. Growing belly shifts your center of gravity forward. Changes in cardiovascular system increases heart rate more quickly and boy temp and metabolic rate (rate at which you burn calories) are higher
Guidelines for Safe Effective Exercise
Core Exercises to Prepare You for Labor – core muscles include abdominal muscles, pelvic floor muscles, and back and hip muscles
Conditioning Pelvic Floor Muscles – pelvic floor muscles form a figure 8 around your urethra, vagina and anus. During pregnancy, increased weight of uterus and relaxing effect of hormones may make these muscles sag. Hemorrhoids may emerge. Exercising pelvic floor muscles can reduce heavy, throbbing feeling you may experience in the area. Can make sex more enjoyable
Pelvic Floor Contraction (Kegel or Super Kegel) – improve blood circulation in pelvic floor muscles. Try not to tighten muscles in buttocks, thighs or abdomen. Hold tightly for 10 seconds. Relax and rest for 10 sec before tightening for another 10 seconds. Super Kegel – hold for 20 seconds, tightening again when contraction begins to fade. Several sets of 10 per day.
Pelvic Floor Bulging – to prepare for pushing baby out. H old breath and bear down gently. Hold for 3-5 seconds, then stop bearing down. Inhale, contract pelvic floor muscles then exhale and rest. 1-2x per week
Conditioning Abdominal Muscles – late pregnancy, avoid double leg lifts or abdominal crunches
Mobilizing Pelvic Joints by Squat – during late pregnancy, helps condition your pelvic joints. To birth vaginally, joints need to be flexible enough to allow baby to move from uterus through vagina. When push baby out, squatting can help baby descend into vagina. If you problems with hips, knees, ankles pelvis or have hemorrhoids, avoid. If having trouble getting back up, tighten thighs and buttocks or try wall sitting. Increase amount of time in squat to 90 sec, which is roughly length of long labor contraction. If can’t maintain balance, use piece of furniture or use partner. If difficult to keep heels of floor, calf muscles are tight. Try \ with feet further apart, put book under each heel or rolled up map. Many birthing beds in hospitals have bars to grip while squatting. After 35th week, squat 10x each day.
Postural Exercises to Align Your Body – strengthening and stretching these muscles helps relieve lower back pain and other discomforts that can arise when your body is out of alignment
Yoga Poses to Align Body, Mind and Spirit – yoga focuses on practicing movements, not mastering them. Sequence of poses mimics rhythms of labor.
Comfort Measures for Common Discomforts in Pregnancy
Work out 3-7 days per week!
Chapter 6: Eating Well – before & during pregnancy has huge impact on health baby’s well being
Good Nutrition during Pregnancy – include plenty of fresh fruits and veggies, whole grains, dairy, protein and 2 quarts of liquids. Eat small, frequent meals to keep blood sugar level stable, reduce morning sickness in 1st trimester and reduce heartburn in 3rd trimester. Beginning in 2nd trimester, consume 200 more calories a day (assuming you exercise for 30-60 min). in 3rd trimester, consume 400 more calories, ideally from high-protein, high-calcium and iron0rich foods.
MyPlate: Recommended Food Groups – has customized information for specific audiences, including pregnant/breastfeeding www.myplate.gov
To analyze daily diet, visit www.mypyramidtracker.gov – how much of each nutrient you’ve consumed
Grains – wheat, rice, oats, cornmeal, barley or rye. Contains iron, b vitamins, minerals and fiber and some are fortified with folic acid. Try to make half of grains whole. Try to limit refined grains. Whole grains – brown rice, oatmeal, popcorn, barley millet, quinoa, spelt, buckwheat, bulgur and wile rice. Or if ingredients list whole-wheat flour, whole oats.
Veggies – try to vary. Dark green (Broccoli, kale, lettuce, spinach), orange (Carrots, sweet potato), dried beans and peas (legumes – black beans, chickpeas, pinto beans, lentils), starchy veggies (corn, potatoes), other veggies (Artichokes, asparagus, brussel sprouts, cauliflower, cucumber, eggplant, onions, peppers, tomatoes, zucchini)
Fruits – eat a variety. Rich in fiber, potassium, Vit C and folate
Milk and Milk Products – calcium for you and baby for strong bones. Protein, potassium, vit A, B, D.
Meats and Beans – contain protein, which builds muscles, skin, enzymes, hormones, and antibodies. Also contain B vitamins, Vit E, iron, zinc and magnesium. Choose lean cuts of meat, drain grease after cooking, choose meats that don’t include excess salt/fat. Eat fish 2x a week – choose seafood low in mercury and high in omega3
Choose organic fruits and veggies when possible. Some have more pesticide residue – apples, peppers, potatoes, spinach, strawberries. Choose fresh local produce in season. More recently picked, more nutrients. Raw fruits and veggies have higher nutrition than cooked. Best to worst for preserving nutrients: steam microwave, stir fry, roast, bake, boil.
Get nutrition from food vs supplements – books: In Defense of Food; Food Rules Michael Pollan
Weight Gain during Pregnancy – depends on prepregnancy weight and height, quality of diet before and during pregnancy, ethnic background and number of previous pregnancies.
Figure out prepregnancy BMI to gauge total body fat. BMI equals weight multiplied by 703 and divided by height in inches squared. Many women gain more or less and their babies are fune. 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.
Chapter 7 – When Pregnancy Becomes Complicated
Pg 129 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.
PCN Pgs 126-127 Chronic Conditions That May Affect Your Pregnancy – chances of having healthy baby by controlling symptoms before becoming pregnant; create plan with caregiver
Complications that arise in pregnancy
PCN Pgs 129-130
Uterine Fibroids – up to 75% of women develop fibroids (aka leiomyomas or myomas) at some time during their lives, 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 or remove them.
Venous thrombosis – blood clot that typically occurs in a vein in leg or pelvis. Pressure from enlarged uterus slows flow of blood returning from legs and blood changes how it clots to help reduce postpartum bleeding so have slightly increased risk of developing blood clots in legs during pregnancy or soon after birth.
Clot that develops in a vein close to skin is called thrombophlebitis and it causes swelling, tenderness and redness. Treatment includes bed rest with leg elevated, hot packs to affected area, special support stockings and a mild pain reliever if needed.
Deep vein thrombosis (DVT) develops in a big vein that’s deeper in yoru body and is much more serious than thrombophlebitis. DVT causes leg or pelvic pain and redness, warmth or swelling near the affected area. If you have dVT in calf, may have increased calf pain when you flex toes toward knee.
If notice symptoms, notify caregiver immediately. Risk of developing venous thromboembolism (VTE) and possibly pulmonary embolism, a potentially fatal condition in which portion of blood clot breaks loose and travels to a lung. Symptoms include sudden shortness of breath, chest pain and rapid heart rate. Chances of developing VTE increase if you’re older than 30, you or family have history of blood clots or you’ve recently been on bed rest or been sitting for a long time.
Treating DVT may require pain medication (if leg pain is severe) as well as hospitalization and IV doses of anticoagulant (blood thinner) Heparin to prevent further clot formation. Heparin doses continue at home until birth and are administered by self-injection, pump or IV; then another anticoagulant, Coumadin, is taken orally for 6 weeks.
PCN Pg 130
Infections – risk of acquiring a serious infection during pregnancy is low, but sometimes infectious disease can affect pregnancy/harm baby. potential risks depend on organism (virus, bacterium or spore), whether you have antibodies to organism from prior exposure, whether disease is treatable, when during pregnancy you acquired infection. Even if you get infection during pregnancy, baby might not become infected and even if he does, he may not be harmed.
PCN Pgs 130-134
Ways to Avoid Getting Sick – best way to prevent complications is to avoid getting sick
Sexually Transmitted Infections (STI) – previously called STDs; can cause problems during pregnancy, but if treated early, risks to baby are minimal. If had multiple partners, at greater risk for chlamydia, gonorrhea, genital herpes, hep B, HIV, HPV, syphilis and trichomoniasis. If had symptoms – genital sores, abnormal discharge or discomfort/difficulty with urination, see caregiver.
Group B Streptococcus (GBS) – 10-30% of pregnant women are carriers which means GBS bacteria is present ni body but don’t have signs of infection. Without treatment, 1/200 newborns will develop a GBS infection, which can be life threatening. If moms receive antibiotic treatment during labor, babies risk of infection drops to 1/4000.
Guidelines for screening women between 35-37 weeks by swabbing vagina and anus and having secretions cultured in a lab. If she is a GBS carrier, caregiver treats her with antibiotics during labor and watches her baby closely for signs of infection.
Women with following circumstances may receive antibiotics during labor without prior screening: UTI caused by GBS during pregnancy (even if received antibiotics), previous pregnancy with baby who had severe GBS. If a woman hasn’t been tested or results of culture aren’t known when labor begins, a woman receives antibiotics if she has any of following risk factors: preterm labor (before 37th week), rupture membranes for more than 18 hours before labor begins, fever of 100.4F (38C) or higher
Antibiotic treatment of all pregnancy GBS carriers is controversial. Although only a few develop an infection, all babies are exposes to possible side effects of antibiotics such as allergic reaction, creation of drug-resistant bacteria and yeast infection after birth. Even so, most GBS carriers choose antibiotic treatment during labor to reduce risk of GBS in baby.
Bladder and Vaginal Infections – increase risk of preterm labor. Symptoms of bladder infection or UTI include frequent urination, urgency to urinate, blood in urine, and pain, especially at end of urination. Symptoms of vaginal infection include vaginal discomfort or itching and foul-smelling discharge. Normal to have thin, milk smelling and whitish vaginal discharge.
Listeriosis – form of food poisoning that can harm baby. While rare, affects pregnant woman 20x more than others. Bacteria is in unpasteurized dairy products, raw or undercooked meats and fish, and in contaminated soil and water. Avoid eating unpasteurized milk and soft cheeses during pregnancy. Don’t eat meat, poultry, eggs or seafood that isn’t cooked thoroughly. Wash produce before eating and carefully wash food prep surfaces and utensils.
Toxoplasmosis – cats are the most common carriers, especially outdoor cats that eat rats, mice and other raw meet. Passes in its feces and can transmit from hands to mouth if you don’t wash hands after handling cats or gardening. Can also ingest from eating raw/undercooked meat/unwashed root veggies. May be immune if been around cats for years, but tests for immunity unreliable and not recommended. If get it for first time during 1st trimester, may cause congenital defects or miscarriage. If infected 3rd trimester, baby may be born with infection. Can treat with antibiotics, but prevention is best treatment. Wash hands after touching cat, have someone else change litter and wear gardening gloves. Cook meat well and wash veggies thoroughly.
Infections during pregnancy chart (birth defects/preterm labor/illness in baby)
PCN Pgs 134-135
Diabetes Mellitus and Gestation Diabetes Mellitus – aka DM or simply diabetes occurs when someone has trouble making or using insulin, a hormone that helps glucose (sugar) pass into cells for the body to use as an energy source. 2 types: type 1 – body stops making insulin. Type 2 – body uses insulin ineffectively. Without insulin, blood glucose levels rise dramatically and glucose passes into urine. Can cause serious problems in pregnancy.
Woman with DM needs to balance her medications with her activity level and diet. May need to adjust insulin dose or begin taking injections to control blood glucose levels. Improves chances of carrying healthy baby to term if she controls blood glucose levels before and during pregnancy.
Gestational diabetes mellitus (GDM) develops or is first recognized in pregnancy and affects 3-5% of women. Human placental lactogen (HPL) diminishes the effect of insulin and allows more glucose for baby’s growth. In some women, their response to this pregnancy hormone is out of balance, leading to excessively high blood glucose levels.
Early detection and appropriate treatment of GDM can help prevent problems such as increased chances of UTI, overly large baby, preterm birth, stillbirth and newborn with hypoglycemia (low blood sugar), jaundice or breathing difficulties.
Some caregivers use urine tests to screen for glucose in early pregnancy. Most use blood teste to screen for GDM between 24th and 28th week. Risk factors include women who have family members with DM, obese women, and those of Hispanic or African descent.
If blood test is positive for high glucose levels, caregiver will order a glucose tolerance test (GTT) to confirm diagnosis, a process that requires blood testes every hour for 3 hours.
Treatment includes a special diet, exercise, and in some cases oral medications or insulin injections. If caregiver suspects baby is overly large or that placenta circulation is affected, her or she may induce your labor near term. After birth, blood glucose levels will probably return to normal levels; however about half of women develop type 2 DM later in life.
PCN Pg 135
RH (Rhesus) or RHD Blood Incompatibility – presence or absence of antigen called RH or RhD factor. If blood type includes a plus sign, Rh is present. More than 85% of population is Rh positive. If includes a minus sign, Rh factor is absent. 15% of Caucasians, f3-5% of people of African descent and few people of Asian descent are Rh negative.
If blood is Rh negative, baby’s father needs to have blood tested as well. Although you and baby don’t share blood systems, if you and baby are Rh incompatible, his blood may enter your bloodstream when you give birth or if you experience a miscarriage or have invasive tests such as amniocentesis or chorionic villus sampling (CVS). You may start producing antibodies that may cause mild to severe anemia in your baby. body produces antibodies slowly, so first pregnancy might not be affected.
Injecting an Rh negative mom with Rh immune globulin (Rhogam) at 28th week can prevent Rh sensitization. Also given after a miscarriage or abortion, with any invasive procedure or if necessary after uterine bleeding or trauma. If blood test finds baby Rh positive, mom will receive another dose within 72 hours of birth.
If you are Rh negative your caregiver will test blood for antibodies throughout pregnancy. If level of antibodies increase, amniocentesis helps assess how seriously the antibodies have affected your baby. in severe cases of anemia in baby, treatment may include early birth and a blood transfusion to replace blood cells. Only in extreme cases does a baby need a blood transfusion in the womb.
PCN Pg 137
Signs of Preterm Labor – some women without any risk factors deliver babies early; only 12% of women have. If have 2 or more symptoms, call caregiver
Having persistent, fairly regular contractions for 2 hours (along with other signs) indicates labor
Predicting Preterm Labor – results of several tests can increase likelihood:
Diagnosing Preterm Labor – if ultrasound or vaginal exam detects shortening and opening of cervix. Women pregnant with multiples – babies expand uterus to size that may naturally cause these changes so caregivers will use additional tests
PCN Pgs 139-140
Complications with Placenta – a few women develop problems with how and where placenta attaches to uterus. 2 most common:
PCN Pgs 141-142 (should be 140-142)
High Blood Pressure and Gestational Hypertension – your activity level, emotional state and body position can affect blood pressure. Lower when at rest, lying down, or free of emotional stress. Higher when active, upright or stressed. Short term changes are normal; however pressure that stays too high can cause health risks at any age.
Someone with high blood pressure (hypertension) has had at least 2 consecutive readings over 140/90. Affects 10% of pregnancy women in U.S.; can be chronic or develop during pregnancy. When it first appears after 20th week of pregnancy and remains high for several readings, it’s called gestational hypertension or pregnancy-induced hypertension (PIH).
Pregnant woman with high blood pressure is at risk for serious problems with uterine and placental blood flow and possible damage to other internal organs. Reduced blood flow to placenta can result in less ovygen and fewer nutrients for baby and may cause growth problems. Gestational hypertension can also develop into a more dangerous condition called preeclampsia.
Preeclampsia – previously called “toxemia” is a multi organ condition with mild to severe symptoms that affects ~5-8% of pregnancies. Typically occurs after 20th week of pregnancy and first signs are gestational hypertension and proteinuria (protein in urine). Mild preeclampsia developed near term may cause fewer health problems than severe preeclampsia which begins before 30th week of pregnancy. With early diagnosis and aggressive treatment, complications are generally minimal and mom and baby are typically healthy at birth and afterward.
Risk Factors for Preeclampsia – causes aren’t well understood; combination of factors appears to trigger the condition. Some women at higher risk. Most significant risk factors:
Complete risk assessment may include a combination of tests, such as blood and urine tests and uterine blood flow studies.
Other signs of preeclampsia – 2 screening tests can detect early signs of preeclampsia. Urine test will show proteinuria and routine blood pressure checks will discover high blood pressure. If have any of following signs, call caregiver immediately:
It’s possible – but rare – that woman with preeclampsia will have high blood pressure and proteinuria and have none of they other symptoms. Particular sign usually indicates the specific organ system affected. The more systems affected, the more severe the condition. Severe preeclampsia can cause: placenta abruption; HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) which indicate blood and liver complications; eclampsia, which indicates neurological irritability and imminent convulsions; seizures, stroke, coma or even death of mother and baby (in most severe cases)
Treating Preeclampsia – only cure is birth of baby (normal blood pressure usually returns within days or weeks). Treatment to avoid further complications is available based on severity of disease and baby’s gestational age and health.
If symptoms are mild (bp over 140/90, proteinuria, fluid retention), treatment usually includes decreased activity or bed rest, blood pressure checks and close observation. May receive medications to lower blood pressure or to reduce risk hypertension will slow bay’s growth.
If have severe preeclampsia (bp over 160/110, proteinuria accompanied by liver, blood or neurological complications), you’ll be hospitalized and given drugs such as antihypertensive and magnesium sulfate to reduce risk of seizures. PCNguide has more info. Continue to receive magnesium sulfate for at least 24 hours after birth to prevent seizures.
If severe symptoms worsen or don’t sufficiently improve with treatment, caregiver may suggest inducing labor or performing planned cesarean. If concerned how a preterm birth will affect baby, may want to postpone induction. If health of baby’s life isn’t in jeopardy, caregiver may suggest delaying birth for a day or 2 so you can receive corticosteroids to promote baby’s lung development before birth.
Reducing Risk of Developing Preeclampsia – for women at risk, taking a low dose aspirin (50-150 milligrams) each day helps reduce risk and may decrease rate of perinatal death and increase babies birth weight. Studies on folic acid supplementation in 2nd trimester show reduced risk. Early detection helps decrease risk of developing severe preeclampsia and other complications. Attend all prenatal appointments, have appropriate screening tests and work with caregiver to control high blood pressure and treat early signs. If contract any infection, consult caregiver for early treatment. Infection may increase risk.
PCN Pg 143 Diagnostic Tests
Results from 1 test might not be completely accurate, so caregiver may order several to confirm diagnosis; some have more risks than others.
Tests to detect genetic defects and diseases – you may choose not to have these invasive tests because they require penetrating uterus. Although rare, potential risks include miscarriage, infection, bleeding or leaking of amniotic fluid.
Cordocentesis or percutaneous umbilical blood sampling (PUBS) – sample of baby’s blood from umbilical cord to detect chromosomal defects, blood disorders, and conditions such as infection, anemia and lack of oxygen. Done after 18th week of pregnancy. Because test carries more risks than amniocentesis, only used when need confirmation of diagnosis more quickly.
PCN Pg 143-144
Imaging Tests for Your Health and Baby’s Well Being – noninvasive look at baby and uterine structures, except for x-ray, they pose no significant risks
Tests for Baby’s Well-being in late pregnancy
PCN Pg 144-145 Tests to Detect Potential Pregnancy Problems –
Ch 7 Key Points
Chapter 8 – Planning for Birth and Post Partum
Chapter 9 – When and How Labor Begins
Chapter 10 – Labor Pain and Options for Pain Relief
Why Labor is Painful –
Your Perception of Pain – simply understanding they physical reasons helps many women cope. Labor pain is normal and temporary. By changing the way you think of pain, you can alter perception of it and reduce its severity.
Gate Control Theory of Pain – helps explain why people feel more pain in some cases and les sin others and why some people feel it more than others. Think of following experiences: stubbed toe that hurts less when you dance, a bruise that goes unnoticed until after game, pain of physical exertion eased when you focus on a rhythm (counting, chanting or singing a song in your head)
Although pain never goes away, your awareness of it decreases when brain receives other stimuli that are non-painful or pleasant (pain modifiers). Helps explain why distractions help relieve pain. Can make pain more manageable during labor by increasing pleasant stimuli (massage, music, cold packs, heating pad or other distractions and focusing on them).
Neuromatrix Theory of Pain – expansion of Gate Control Theory and takes into account all possible factors that can influence how pain is felt and interpreted. Helps explain why women differ in reactions to labor pain and why some women find comfort measures more helpful that others. Past experiences of pain or trauma are factors, as are preexisting factors such as chronic pain or painful medical conditions, anxiety, personality or temperament, physiological factors such as central nervous system’s and endocrine system’s reactions to stress and cultural or familiar attitudes toward pain. Some of these are genetically determined; others are formed earlier in life.
Factors That Increase Labor Pain:
Measures that make labor pain more manageable – to minimize factors that increase labor pain, be aware of them in advance, make plans to manage them and ensure that your support people are aware of them and work to minimize their impact on you: eat and drink enough to stave off hunger and thirst; dim lights and arrange for minimal interruptions; if have past trauma, get counseling before
Think of what comforts you: what comforts you when sick, what did parents do to make you feel better, what do you do during physical exertion to keep going, what soothes pain of headache/sore muscles, what helps you feel safe in unfamiliar situations, what calms you when stressed/scared, what kind of support from others best helps you. Download worksheet from PCNguide.
Pain vs Suffering in Labor: pain is a mild to unpleasant physical sensation that might or might not be associated with physical damage; suffering is a debilitating emotional state that might be associated with pain or with another cause, such as grief, humiliation or defeat. Can have pain without suffering (strenuous workout). Suffering includes: perceived threat to body/psyche, helplessness and loss of control; distress; inability to cope with distressing situation; fear of dying or death of baby
If don’t have enough stimuli that help reduce perceptions of pain (massage, movement, baths, encouraging words) or if have too many factors increasing it (fear, loneliness, ignorance of what’s happening, immobility, unkind/insensitive treatment, anxiety/depression), more likely to be overwhelmed by pain and feel as if suffering.
Rating Intensity of Pain and Ability to Cope – Pain intensity scale vs pain coping scale
Releasing Control in Labor vs Losing Control – although you can’t consciously control your contractions , you can control how you respond to them. To help avoid feeling discounted, passive, powerless, learn about options for childbirth well before they begin. Read about interventions you are considering and make sure decisions are reflected in birth plan
Options for Pain Relief – essential to have a “toolbox” of coping options :
Availability of Pain-Relief Options – options depend on where you give birth. If birth at birth center, won’t have access to epidural. Hospital policies, care practice and available equipment might/might not support various comfort techniques such as eating, mobility, baths/showers, birth balls, acupuncture and aromatherapy. Anesthesiologist may not be available at all times
Effectiveness of Various Pain Relief Options % used, % helpful
Although pain medications – especially epidural – can effectively minimize or eliminate pain, they’re also expensive and carry risks and disadvantages that may complicate labor. Consider trying various nun drug methods first to see if they can help you manage effectively. Even if planning to receive epidural or pain meds, still wise to know comfort techniques to cope on way to hospital or while waiting for pain medication.
Determining Your Preferences for Pain Relief – do you prefer to give birth without drugs or do you prefer to use medications? How strongly do you feel about this? May be influenced by past experiences or expectations about labor. Better able to cope if have info on all available options. More likely to avoid, postpone or minimize if you have a partner or doula who encourages you and helps with self-help comfort measures, supportive staff, caregiver who’s patient/encouraging. The more uncomplicated your labor, the better your chances for non medicated labor. If labor is prolonged, complicated or includes painful interventions, you’re more likely to need medications.
Pain Medication Preference Scale – PMPS
Being Flexible with Plan for Pain Relief – labor may progress faster than expected, leaving no time for medications or you may be one of unlucky few for whom medications don’t provide adequate pain relief. Partner should remember pain medication preference. If plan to delay, he/she should suggest trying another coping technique for 4-5 contractions before helping you get drugs. Can also use a code word
Preparing to Labor without Pain Medications – if having drug free labor is your goal
Regional (Neuraxial) Analgesia and Anesthesia: Epidural and Spinal Blocks – neuraxial medications are injected in your lower back near nerve roots in spinal column. They affect the region of your body to which these nerves and their branches go. The region can be as small as your abdomen and lower back, or as large as the area from your chest to your toes. Medications are often a combination of of an anesthetic fentanyl, which enhances the overall numbing effect. A spinal block is an injection that takes effect quickly and lasts for an hour or two. An epidural catheter is a tube through which medication is given for as long as it’s needed.
Procedure for Epidural and Spinal Blocks – as wait for anesthesiologist, contractions may be intense so may need to cope. Receive IV fluids to reduce risk of drop in blood pressure and to allow for administration of additional medications if needed. Procedures can take 10-20 min. if you have IV in already, nurse can increase flow to give you ¼ to 1 liter of fluid quickly. When anesthesiologist arrives, asked to lie curled on side or sit up and lean forward to curve back. Cleans lower back with antiseptic and numbs skin with local anesthetic. Prep can take 10 min or longer. May need support to help you sit or lie still during contractions. Where and how he places needed or catheter in back depends on type of block:
Temp, blood pressure, pulse and blood oxygen levels are checked frequently. May also have electrocardiogram (EKG). Many women receive excellent pain relief and don’t experience any side effects. If monitoring indicates that you or your baby are reacting poorly to neuraxial medications, then more interventions may be necessary.
If blood pressures drops significantly, baby’s heart rate will also decrease. Caregiver may turn you onto your side, place an oxygen mask on your face and ask you to breathe deeply. May be given medications or additional IV fluids to raise BP. Managing side effects often causes a cascade of interventions. If epidural causes contractions to slow down, may receive Pitocin to stimulate them – which may overstimulate your uterus, which can lead to variations in baby’s heart rate, which may increase need for cesarean.
Chances of fever increase since medication alters ability to regulate your temp. the longer it’s in place, the higher your risk. When you have a fever, baby’s heart rate may increase to a worrisome level and cesarean may be necessary. Epidural wont cause an infection in baby, but may increase chance shell be treated for one. If you have a fever during labor, baby may have one at birth but it can’t be assumed its because of epidural since it’s associated with infection so baby will be checked for infection with blood tests and possibly a spinal tap. She may be kept in special care nursery and given antibiotics for 2 days until test results are known. It will separate you from baby and can be worrisome.
Options for Epidurals :
Note to Partners: stay with mom and relax together when she has an epidural. It may leave her feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events. Help her change positions as much as possible; if she has a light epidural, she may be able to get on hands and knees.
Occasional challenges with epidurals – partner might not initially receive sufficient pain relief; she might experience windows of pain or pain might return after initial relief.
Might have discomforts such as itching, nausea and feeling overheated or chilled. Give her a massage, help her change positions, cover her with a warm blanket, place a cool cloth on her forehead or giver her ice chips or sips of water if allowed. Do not place heating pads or ice packs on any part of her body that’s affected by epidural.
Partner still may experience intense pressure or burning during pushing stage. Reassure her that these sensations are normal and signal that baby will be born soon. If holding one of her legs as she pushes, be careful not to pull back too far – think about her hips normal range of motion and don’t force beyond that point to avoid straining hips, thighs or lower back.
Help partner get lots of skin-to-skin contact with baby so breastfeeding can begin in first hour.
Failed Epidurals – 12% don’t provide complete pain relief when first inserted, while 7% may provide good pain relief initially but fade over time. Some only provide minimal pain relief, others allow for windows of pain. Staff may be able to fix it by changing your position, increasing medication or repositioning epidural catheter – these measures have resulted in good pain relief for nearly all women with epidurals (98.8%).
Key Points Ch 10 – no one should suffer in labor; see PCN guide for pain medications
Chapter 11- Comfort Techniques for Pain Relief and Labor Progress
Finding Your Own Way to Cope with Labor Pain: The Three R’s: Your response will depend on nature of your labor, your coping style, your goals/expectations and how prepared you feel for labor. Those who cope well have 3 behaviors in common: 3 R’s: Relaxation, Rhythm and Ritual.
Relaxation: May move about between contractions and let their muscles relax during contractions. May become active during contractions (swaying, rocking, stroking bellies) and relax only between contractions. Or may remain quiet and unresponsive to their surroundings during and between contractions.
Rhythm: Rhythmic activity calms the mind and lets a woman work well with her body. May rhythmically breathe, moan or chant during contractions. May rhythmically tap or stroke something or someone. May rock, way or dance in rhythm. May curl her toes in rhythm. Partner or doula’s role is to enhance the rhythm and reinforce it through contractions. Can breathe/sway in rhythm/dance/direct.
Ritual: Repetition of meaningful rhythmic activity during contractions. Relaxation, breathing (223) and attention-focusing (208) common rituals that childbirth educators teach. Help women in early labor establish effective coping style. Most spontaneously adapt their planned rituals or find a new one to increase ability to cope as labor progresses. Partner’s behavior and actions can influence the effectiveness of a ritual. He must not do anything to change your ritual. Having someone act in same way during each contraction will be reassuring to you. May be: maintaining eye contact with you, repeating the same words or phrases, counting your breaths through each contraction. If focus is inward, partner may be close by and protect you from interruption. Can switch ritual at anytime – look to doula, partner or caregiver for suggestions. Hospital policies, options or interventions may limit your options so make sure to practice one you can do during disturbances, such as self-talk (silent or vocal), tapping or stroking. Ex: rock in rocking chair, partner stroking leg, partner points out when halfway through contraction; swaying through contractions
Comfort Techniques for Labor: Remembering labor pain is part of process helps keep pain manageable. Think about what helps your relax: listening to music, massage, soothing voices, warm bath, meditation, praying, chanting, humming, recalling pleasant places, visualization, empowering images. Think about what makes you feel safe. PCNguide.com download comfort techniques.
Tune in to pain or tune out the pain.
Attention Focusing: Visualization: picture uterine muscle contracting and pulling our cervix open. Visualize baby pressing cervix open. Imagine calm, pleasant places. Recall happy, peaceful events. Visualize each contraction as a steep hill to climb, wave to ride…Cognitive Attention focusing: thinking/saying words of song/poem/verse/prayer – direct attention away from pain: counting with rocking/swaying/walking/ dancing /tapping/stroking. Visual Focus: partner’s face, picture, reminder of baby, flower, view, focus on a line. Sound: favorite music, partner’s soothing voice, repeated rhythms, recording of rhythmic environmental sounds by moaning, sighing, counting breaths, singing, reciting poems/prayers, chanting. Low-pitched sounds better.
Baths/Showers: can help body relax – try to stay in for at least 20 min. Bath pillows/lean against folded towels. Can kneel over side of tub. Temp close to body temperature so don’t overheat. Studies show no infection after membranes ruptured. Can also lower blood pressure. Can slow labor in early labor so take shower instead. Active labor, bath speeds up labor while delaying intensity of pain.
Foods and Fluids: high carb (fruit, pasta, toast, rice and waffles). Easy to digest food/beverages (soup, broth, herbal tea). May become less interested, but hunger (or low blood sugar levels) may decrease tolerance for pain. If not hungry, to keep hydrated: can sip clear broths, popsicles, water, tea, juice, sports drink. Empty bladder often as it may slow labor/increase pain. Recent studies women eating/drinking during labor no disadvantage for low risk. IV if vomiting, prolonged labor to prevent dehydration. Rolling IV moves around. If dry mouth – ice chips, popsicle or sour lollipop. Brush teeth/rinse mouth with cold water/mouthwash.
Heat and cold: Electric heating pad/hot water bottle on lower abdomen, back, groin or perineum relieves labor pain. Cloth bag/sock filled with rice and heated in microwave. Soak washcloths in hot water; wrapping in plastic retains heat longer.
Cold pack on lower back can relieve back pain. Ice packs for perineum after birth. Cool wet cloth, bag of ice cubes or frozen peas, frozen wet washcloths, cold cans of soda, frozen gel packs w straps. Wear warm robe or use blanket.
Have partner hold in hand for few seconds without pain and have cloth in between source and skin. If have pain medication, avoid using on numb areas.
Comfort Items: Rolling pin/rolling massage devices, gardener’s foam knee pad, shawl/rebozo, warm blanket and socks, fan, iPod, transcutaneous electric nerve stimulation (TENS), birth ball
Birth Ball – Since forces you to have proper posture when you sit, decrease muscle strain. To help relax trunk and perineum, sit on ball and sway hips side to side. Relieve back pain and adjust baby’s position, ball on bed and kneel on bed or stand next to it and lean over ball. Sway hips from side to side or front to back. Practice before labor. See below.
Massage and Touch– two of most effective ways to direct attention away from labor pain. Firmly stroke, rub or knead your neck, shoulders, back, feet or hands. Lightly stroke back or thighs. Press firm on tense areas such as hips, thighs, shoulders, hands, lower back. Tightly embrace partner. Shower head. Lightly rhythmically stroke belly, following lower curve of uterus – imagine stroking baby’s head. Dust hands with baby powder. Match movements with breath.
Crisscross Massage– ease back pain and relax lower back muscles. Kneel forward on hands and knees or over birth ball or lean forward onto counter, chair or birth ball. Flex hips so thighs are about 90 degrees from spine. Partner stands or kneels next to you, facing your side. Places hand on each side of your body at narrowest part of waist. Presses into sides, moves each hand up and over back following waistline
Acupressure for Comfort and Progress in Labor: Hoku (back of hand where thumb and index bones come together) and Spleen 6 (inner side of leg, 4 fingers above anklebone). 10-60 seconds, rest for same amount before repeating 3-6x. Reduce pain/speed up labor. Don’t press before due date – preterm labor.
Partners: practice beginning contraction to end; practice with ice cube with and without comfort measure; remind mama to move around; be aware of facial expressions and tone of voice
Relaxation and Tension Release: Remaining relaxed especially important in early labor. Practice releasing muscle tension then so you get used to it. If you tense up in early labor, you’ll have trouble relaxing later.
Recognizing Muscle Tension: in order to release muscle tension, must be able to recognize. Make right tight fist, feel muscles in forearm with left hand. Relax, feel muscles. Shrug shoulders towards ear. Lower and feel.
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).
Lie on side or sit in semi-reclined position with floor or bed supporting head/limbs. Can put pillows under/between knees, beneath head or under belly. Begin breathing slowly, easily and fully – this is how you breathe as you fall asleep. Your body and mind release tension and thought, your breathing slows and you pause slightly at the end of each inhalation and exhalation (observe someone as they fall asleep). Have partner read script in a calm, slow, relaxed voice. Take a couple breaths after you release each area.
Relaxation Countdown: After mastering passive relaxation, use following to release tension quickly. Helpful when you want to fall back to sleep, stressed, or when trying to relax after a contraction
Inhale through nose and exhale out mouth, releasing muscle tension in the following order: Head, neck, shoulders; arms, hands, fingers; chest and abdomen, back, buttocks and perineum; legs, feet and toes. Use 5 slow breaths at first (1 for each of the 5 areas). Then try slowly exhaling one deep breath for all 5 areas (rapid relaxation countdown). During labor, first or last breath of each contraction can be rapid relaxation countdown.
SUMMARY OF ABOVE 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 laying 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.
Rehearsing Slow Breathing for Labor: rehearse until your confident in using for 60-90 seconds a time (typical length of contraction). Practice with different positions. With each exhalation, focus on relaxing different part of your body (See pg 219 for Roving body check) so you can relax every muscle that’s not required to maintain your position. If uncomfortable to inhale through nose and out mouth, can breathe through only which is comfortable. May want to let belly expand first, then chest as you inhale deeply (belly breathing). Or may let chest expand as you inhale (deep chest breathing). Make sure its rhythmic, calming and relaxing.
Light Breathing: helps manage labor pain when you can no longer relax during contractions, when contractions are too painful with slow breathing, or when you instinctively begin speeding up your breathing. Many women switch when contractions are close together and intense. When in active labor, let responses to contractions help you decide when to use. If partner notices you losing rhythm, tensing, grimacing, clenching your fists, or crying at peak of a contraction, he may suggest switching to light breathing.
Rehearsing Light Breathing for Labor – you may not feel this is right for you when you practice – may make you tense or that you’re not getting enough air. With practice, it will become 2nd nature and you’ll be able to work with body easier during labor. Will come more naturally as labor becomes more intense. Just as running makes you breathe faster to meet oxygen needs. Take 1 breath every second or 2, for 10 seconds. If you take between 5 and 10 breaths in that time, you are doing it correctly. Continue for 30 sec – 2 minutes. When you can do effortlessly for 2 minutes, try adaptation is following seconds.
If you become lightheaded/dizzy, try to focus on exhalations, perhaps by making small sounds while exhaling such as “hee hee hee” or “puh puh puh” – by doing so, body will naturally inhale as much air as it needs. Breathing lightly through open mouth may cause dryness. Try touching tip of tongue to roof of mouth just behind teeth or hold moist washcloth near your mouth. During labor, may also sip water or other fluids between contractions or suck on ice or popsicle. Brushing teeth, rinsing mouth can also relieve dry mouth.
Partners: Interject encouraging works. Ex: 1, okay, 2 good, 3 let go, 4, just like that, 5 great. During labor, the # of breaths per contraction won’t vary significantly from one to the next, so you’ll be able to figure out peak and half over. Point out when she’s passed half way.
Adaptations to Breathing Techniques: ways to adapt rhythmic breathing by combining slow and light breathing patterns. During labor, try switching to one of these techniques to cope if you become overwhelmed or exhausted, can’t relax or begin to despair. May even discover a spontaneous rhythmic pattern of your own in labor.
Vocal Breathing: combines slow or light breathing with vocalization. As you exhale with each rhythmic breath, you moan, sigh, count, sing, recite poems, recite affirmations, chant or make or say other sounds or words. Low-pitched moans. Loud high pitches sounds, especially if lost rhythm, may indicate suffering or fear – partner can ask “Are the sounds you’re making helping you?” if they aren’t, partner can help lower pitch by moaning with you and maintaining your rhythm with the Take Charge Routine (pg 256). If it helps you cope, no one should change. Support team should keep doors closed so you can make sounds as you please.
Contraction – Tailored Breathing: use intensity of contraction to guide rate and depth of breathing. If contractions peaking slowly, breathe slowly when each contraction begins. As contraction intensifies, quicken and lighten breathing past the peak. As contraction subsides, gradually slow and deepen breathing. Think of each exhalation as a way to relax completely. If contractions are peaking quickly, slow breathing wont help you cope. Instead, use light breathing throughout each contraction.
Slide Breathing – some women, especially with respiratory condition such as asthma, find that quicker pace of light breathing makes them uncomfortable and tense, regardless of how often they practice. If you can’t master light breathing after several attempts, slide breathing is a good alternative.
Inhale deeply and slowly, then exhale with 3 or 4 light puffs of air. Pause, then repeat process. To help guide breathing, say “in” to yourself as you inhale, drawing out the word to match the length of your inhalation, then say “out” with each puff of air you exhale. Although deep inhalations make slide breathing similar to slow breathing, the change in rhythm provides a different focus.
Variable Breathing: combines light, shallow breathing with a longer or more pronounced exhalation, sometimes called “pant pant BLOW” or “hee-hee-HOO” breathing. Just with slide breathing, this is an option for women who feel uncomfortable or short of breath when using light breathing. Also helpful for women who need breathing patterns to have structure.
Use light breathing for 2-4 breaths, then take another light inhalation followed by a long, slow, emphasized exhalation (the “blow”). The last exhalation helps you steady your rhythm and release tension. Some women emphasize it by making a drawn out “hoo” or “puh” sounds. Find a comfortable pattern and repeat throughout contraction. Partner can count breaths to keep rhythm. “1, 2, 3, Blow!” or can count breaths to yourself to focus attention.
Rehearsing Breathing Adaptations for Labor: include favorite adaptations and practice in various positions. Relax for only 30 sec or so between practice contractions to prepare for brief rest you’ll experience during late 1st state of labor. In this stage, contractions may last 2 minutes or they may occur in pairs with little break between the 1st and 2nd contractions (Coupling). Be prepared to use light breathing or its adaptations for up to 3 minutes without losing breath.
Using Breathing Techniques to Avoid Pushing – may have early urge to push at peak of a contraction – this urge is considered premature if it occurs before cervix is completely dilated. If you have urge and don’t know if completely dilated, alert nurse or caregiver – they can confirm dilation by vaginal exam. If dilation not complete, you’ll be asked to resist urge to push.
To avoid pushing, lift chin and either breathe deeply, pant, or blow lightly until the urge subsides. Can say/sing “puh, puh, puh” or “hoo, hoo, hoo” with each exhalation. When urge to push passes, resume rhythmic breathing for the rest of the contraction. Changing positions can also help reduce the premature urge to push (try hands and knees, side-lying and open knee-chest positions). These won’t take away body’s urge to push, but will keep you from holding breath and bearing down with urge.
Rehearsing Breathing Techniques to Avoid Pushing: occasionally practice a premature urge to push. Hold your breath or grunt as you breathe to signal to your partner that you have an urge to push. They can remind you how to resist urge until it passes. Rehearsing this can be silly and fun, but its good practice.
Comfort Techniques for Back Pain, Slow Labor or an Extra Challenging Labor – contractions may begin to couple or become irregular. Labor may become prolonged. Baby’s position may give you back pain (pg 285 for positions).
Positions and Movement – to reduce pressure of baby’s head on back or to speed up slow labor, use positions to help baby rotate into a better position or movements that decrease back pain
Asymmetrical Movement and Positions: Lunge, Side-lying and Semi-Prone- one side of body is doing something different than other side. Try on both sides. Use the side that’s more comfortable or alternate sides.
A Note to Fathers and Partners About Relieving Back Pain – the following can help reduce back pain and make her move more comfortable. If one doesn’t work, try another.
Other Comfort Measures to Reduce Back Pain – heat and cold, baths, showers and:
4 stimulating pads are placed on back, then connected to small hand held battery operated generated. Between contractions, set intensity to level that feels comfortable and set stimulation to burst mode. When contraction begins. Change stimulation to continuous mode. As back pain increases, increase intensity. Specially designed maternity TENS available – Bodyclock.net. Check with caregiver.
PCN Pgs 236-237 Practice time as a Rehearsal for Labor – learn how to work with partner to use techniques effectively. Practice enough so you’re comfortable with them and review periodically. Visit. PCNGuide.com for a practice guide. Practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.
Chapter 12 – What Childbirth is Really Like
Chapter 13- When Childbirth Becomes Complicated
Labor Complications and Interventions – compared to normal labor, complicated labor is longer, more painful or more difficult and may require medical help to ensure well0being of mom and baby.
Most labor complications rarely pose immediate problems that require prompt medical attention. If potential problem arises, such as slow cervical dilation, it may be resolved simply with time, patience and self help techniques. Problem becomes complication only if these approaches don’t resolve it. Caregivers may use interventions such as induction, episiotomy, continuous EFM, cesarean and others. For every complication, there are usually several possible interventions. Caregivers consider many factors such as: circumstances of woman’s pregnancy and labor, woman’s preference, current scientific evidence, hospital policies, legal liability issues, caregiver’s training, professional peer pressure, cost of interventions.
Some occur more than others. From most common got least common:
Elective Induction (Social)
Reasons to think carefully before consenting to induction – today, elective inductions far outnumber medical inductions in many hospitals. Induce labors outnumber spontaneous labors.
Medical Conditions that rule out Induction – genital herpes outbreak, placenta previa, previous surgery to remove uterine fibroids, or baby with transverse presentation
Non-Medical Methods for Induction most have had little scientific evaluation but generally simpler and easier than medical induction. Pose milder risks although some have unpleasant side effects. Less likely to start labor than medical methods. PCNguide.
Complementary Medicine Methods – require supervision of trained professional
Medical Methods of Induction – choice of method depends on condition of cervix. Induction more likely to succeed if cervix is favorable – ripe, anterior and partially effaced and dilated. Cervix is unfavorable if its firm, posterior and not effaced
Medical Non-drug methods
Medications to Induce or Augment a Labor – Pitocin aka “Pit” is synthetic version of oxytocin, the hormone your body releases to start labor. (Syntocinon is another synthetic version of hormone). Pitocin is almost always used for medical induction, and it’s sometimes used to help augment a slow labor by increasing the frequency and intensity of contractions. Administered intravenously, allowing dosage to be increased, reduced or stopped, if necessary.
Although Pitocin causes uterus to contract, it doesn’t ripen cervix. If cervix unfavorable for induction, cervical ripening methods are necessary before receiving it.
Medications to Ripen the Cervix– synthetic prostaglandins mimic hormone body releases to ripen cervix. 1 type is prostaglandin E2 or dinoprostone, which comes in a gel (Prepidil) that’s placed next to cervix to speed up ripening. Also available in tampon like device (Cervidil); this may be more desirable choice because medication can be removed entirely if it becomes necessary to stop ripening.
Another type is prostaglandin E1 or misprostol (Cytotec); more likely than the others to cause contractions along with cervical ripening. Comes in a pill that’s taken orally or in a gelatin capsule that’s placed next to the cervix.
2 Options if Induction Leads to Slow Labor Progress (and membranes haven’t ruptured)-
Strange story of Misoprostol (Cytotec)- mid 1990s it was introduced as quick inexpensive way to ripen cervix and induce labor. Use controversial because was approved for stomach ulcers. No research for safe dosages. Using the drug for any purpose other than treatment of stomach ulcers was (and continues to be) “off label”. Helps induce labor quickly, but along with quick labors came severe contractions and distressed babies. Many moms and babies suffered physical harm, and some. Moms found birth traumatic. Research now has recommended low doses (25 micrograms for vaginal use and 50 micrograms for oral use) and dispensed no more frequently than every 4-6 hours. Some believe its as safe as other prostaglandins. After woman’s membranes have ruptured, giving it orally is safer. Women with prior cesarean shouldn’t have it because of increased risk of uterine rupture.
Procedure for Medical Induction –
Prolonged 2nd Stage of Labor: 2nd stage begins when cervix is fully dilated and ends with birth of baby. Labor may slow or stop for reasons that can cause a prolonged active phase (such as exhaustion or a malpositioned baby). Sometimes, receiving an epidural prolongs the 2nd stage.
One problem unique to 2nd stage is baby that doesn’t descend through birth canal, despite hours of pushing by her mother (. In rare circumstances, it’s difficult to resolve – if baby can fit through upper part of pelvis (pelvic inlet) but can’t rotate and descend through lower part (pelvic outlet). 2nd rare problem is short umbilical cord, which can cause baby’s heart rate to slow during contractions or limit her descent because cord can’t stretch enough for her passage through vaginal opening. Sometimes, a cord of sufficient length can pose same problem if its wrapped around baby; in most cases cord remains loose enough to prevent a problem. In both examples, cesarean may be required.
Shoulder dystocia is a rare but potentially serious complication that occurs when baby’s head has been born but birth of her shoulders is delayed because they’re too broad to fit through pelvis. It becomes critical for baby to finish being born quickly because oxygen supply from cord may be reduced. Caregiver may use skilled maneuvers to rotate baby and deliver shoulders. Often episiotomy is necessary and sometimes baby’s collarbone breaks in effort to get her out quickly. Newborns collarbone is flexible and usually heals quickly.
What You Can Do If 2nd Stage is Prolonged: Change positions – squatting, lap squatting, supported squat or dangle. They use gravity and allow for maximum enlargement of the pelvic outlet. Standing, semi sitting and hands and knees. If unable to use because epidural limits movements, try exaggerated lithotomy position flat on back with knees drawn up toward shoulders – may help baby move beneath pubic bone. If tension in perineum seems to interfere with ability to bear down, try sitting on toiled. Caregiver may suggest prolonged pushing.
Medical care for prolonged second stage labor
Vacuum extraction, forceps delivery, episiotomy or cesarean if attempts to change position aren’t helpful. Caregiver may also recommend if you’re exhausted and unable to push effectively, if you’ve received medications that inhibit your efforts and slow your labor, if Pitocin augmentation isn’t helping or if baby isn’t tolerating labor. See PCNGuide
A vacuum extractor is a silicone suction cup and forceps are long steel tongs. Vacuum used more often. Both use more frequently on those that received epidurals.
Caregiver pulls on it as woman pushes during contractions. Both instruments are generally safe for baby although bruising, swelling, and scarping of baby’s head often occur. Caregiver discontinues use of instruments if its obvious baby isn’t descending. At that point, a cesarean section becomes necessary.
291-294 Preterm Labor and Premature Birth – – labor is preterm if begins before 37th week. The younger a premature baby’s gestational age, the more problems likely she’ll have.
Certain indicators can identify women at high risk: previous miscarriage, prior premature birth, cervix that’s short, ripe or dilating early in pregnancy. Caregivers may recommend bed rest, medications and cervical cerclage to stop preterm labor and prevent a premature birth.
Some women have no risk factors. If you see any signs, call caregiver immediately. Methods used to prevent more likely to succeed if it’s detached before cervix has dilated to 2 cm. Because it’s a high risk situation, usually involved OB. If premature birth unavoidable, pediatrician or neonatology is typically present for immediate evaluation and treatment of baby.
What to Expect if You Have Preterm Labor:
Care of the Premature Baby:
Kangaroo Care – newborns kept skin to skin with one of parents as much as possible. Proponents believe it’s the most effective way to promote a baby’s well-being, especially for premature or sick baby. as soon as newborn’s condition is stable, he’s placed nude on mother’s bare chest or abdomen. Blanket covers both of them. Several times a day.
Studies show baby’s growth and development improve with Kangaroo care. Baby spends more time in deep sleep, more time in quiet-alert state and less time crying. He has fewer episodes of apnea (suspension of breathing) and fewer episodes of bradycardia (slow heart rate). His temperature stabilizes, and he gains weight more rapidly which can lead to shorter hospital stay if he’s ill or was born prematurely. Premature baby’s health particularly improves when allowed to smell his parents’ familiar scent, hear their heartbeats, and absorb their body heat. Skin to skin helps easy any anxiety he may have from being connected to various monitors, IV lines, and tubes for oxygen and food. If at risk, contact newborn nursery to learn more about policies and how to arrange.
Gestational Hypertension and Preeclampsia – expect caregiver to monitor your BP and baby’s well being closely throughout pregnancy. If condition is mild and stable and remains that way, pregnancy is allowed to continue to term. Be aware that preeclampsia rarely improves and often worsens as pregnancy continues. In severe cases, or when blood tests indicate HELLP syndrome, most caregivers recommend managing a woman’s labor in order to keep her BP down and prevent seizures from eclampsia.
Caregivers recommend inducing women because ending pregnancy is often 1st step to resolve problem. Some also recommend epidural because of its suspected side effect of lowering BP; however studies haven’t shown this practice to be effective.
In U.S. breech babies are typically born by cesarean. Many women try to turn breech babies before birth by using self help techniques.
Complementary Medicine Methods
Takes 5-10 min. if baby’s heart rate shows distress, procedure is stopped. If placenta begins to separate from uterine wall during procedure (rare) or if baby remains in distress after it’s stopped, may need cesarean.
May only take a nudge or two or may require constant pressure. Try to relax ab muscles and use light breathing. If you need a break, say so. Caregiver can hold baby in place until you’ve caught breath.
Caregiver may offer epidural or spinal block for comfort. Unclear whether anesthesia presents more risks that not using it; it prolongs the procedure and recovery time and its expensive.
Can screen for breech babies then plan vaginal births for them. When practicing this guideline, half born vaginally, the number of complications decrease markedly and both mom and baby fare well.
If attempts to turn breech baby are unsuccessful by 37-38 weeks, time to consider planned cesarean.
Postpartum Hemorrhage- Excessive loss of blood (more than 500 milliliters or 2 cups) during first 24 hours after birth. Occurs in 20% of women, making it the most common problem during 3rd stage. Treatment depends on cause. 3 main causes: uterine atony; vaginal, cervical or perineal lacerations; and retained placenta or placenta fragments. Treatment may require IV fluids or a blood transfusion if bleeding is severe. Excessive loss of blood may lead to symptoms of shock, such as rapid pulse, pale skin, trembling, faintness, feeling cold and sweating.
Rapid Unattended Birth – some women’s labors begin with contractions less than 4 min apart and progress rapidly. If so, head for birthplace immediately or call midwife. Do not drive yourself. If can see baby’s head at vaginal opening or feel him coming down birth canal, stay at home – don’t travel; its better to have shelter and essential supplies. Have driver pull over to side of road and help you deliver baby.
Quick Checklist for Rapid Unattended Birth
Possible Problems after a rapid unattended birth – usually both mother and baby are fine, but complications may develop. Medical help is likely only minutes away.
Prolapsed Cord – during normal vaginal birth, umbilical cord stays high in uterus as baby descends through birth canal and out the vaginal opening. With prolapsed cord, cord slips below baby so it’s either in vagina or lying between baby and cervix. Although rare (1/400), its potentially serious because baby’s body can compress cord, especially during contractions and reduce amount of oxygen available to her.
Can occur when membranes rupture with a gush of amniotic fluid and cord is allowed to slip toward vaginal opening because baby’s body doesn’t block its passage. Can happen if baby is premature or in a breech or transverse presentation or if her head isn’t yet engaged in pelvis and is still “floating high”. If pregnant with multiples, risk of prematurity and malposition increases, which increase risk of prolapsed cord.
At prenatal visits in late pregnancy, ask caregiver to check baby’s position via ultrasound or hand. If membranes rupture with gush and you know baby is breech or transverse, take following steps:
if baby’s head is still unengaged but low in pelvis, can follow caregivers advice for managing rupture membranes. If you don’t know whether baby’s head is low or high, risk of prolapsed cord is less if position is unknown than if head is known to be high. May take above steps as precaution.
Seriously Ill Newborn or Infant Death
Most babies are born healthy and normal. Some born with health problems (congenital problems) or birth defects. Other babies are born dead (stillbirth) or die around the time of birth from genetic abnormalities, birth trauma or infection.
Seriously Ill Newborn – likely that you or partner can spend time with baby, even if he’s in a special care nursery. If baby is transferred, may be able to arrange for an early discharge from your hospital so you can visit your baby. because of special nutritive qualities of colostrum and breastmilk, may want to nourish baby by breastfeeding or bottle feeding expressed milk. Consider keeping a notebook so you can jot down questions as they arise and record the answers as you receive them. Can also keep track of baby’s treatment and progress.
Infant death – if have still birth or baby dies soon after birth, will have to make several tough decisions. If baby dies before labor begins, do you want labor induced? If so, when? Do you want to be awake and participate in the birth? Do you want the support of a doula or someone other than your partner? After birth, do you want to recover in an area that’s separate from other mothers and babies on the postpartum floor or somewhere else in hospital? Do you want an early discharge from hospital? Do you want an autopsy done to help find cause of death? What may make memories more meaningful? May want religious ceremony such as baptism. May want to photograph, have footprints taken, obtain lock of hair etc.
Coping with a seriously ill newborn or infant death – appendix c has list of resources. Write a record of birth experience. Consider talking to counselor, therapist, hospital chaplain or spiritual leader.
Chapter 14 – All About Cesarean Birth
Need pages 308-323;
PCN Pgs 323-329 Vaginal Birth after Cesarean (VBAC) – if had a cesarean and are pregnant again, need to decide between planning another cesarean or planning a trial of labor after cesarean (TOLAC), in which labor is allowed to begin and progress with the hopes of having a vaginal birth after cesarean (VBAC).
Making the Choice Between VBAC and Repeat Cesarean – discuss with caregiver; medial benefits and risk specifics to your situation. Because caregivers views on VBAC vary widely, may want to consult with multiple providers.
Medical Benefits and Risks of VBAC vs Repeat Cesarean – benefits of TOLAC to mother might be balanced by increased risks to baby; benefits of cesarean to baby might be balanced by increased risks to mother. When they are medically equivalent options, woman’s preference should be respected. ACOG agreed VBAC is a safe and appropriate choice for most option.
Need to examine relative rare but real risk of uterine rupture, the separation or opening of the scar from the uterine incision. If rupture occurs, it often results in a hysterectomy for mother (14-33% risk) and can lead to death of baby (6% risk).
With TOLAC, risk of rupture is 325/100,000 or 1/3 of 1%; planned repeat cesarean risk of rupture drops to 26/100,000. Overall risk of baby’s death is 130/100,000 for TOLAC and 50/1000,000 for repeat cesarean. It’s similar to risk of baby’s death for first time mother laboring with unscarred uterus (100/100,000).
Even with increased chance of rupture, vaginal birth carries fewer overall risks that surgical birth. TOLAC carries a lower risk of hysterectomy, blood transfusion, and deep vein thrombosis; it also a shorter hospital stay. Overall risk of maternal death is less than 4/100,000 for TOLAC and more than 13/100,000 for repeat cesarean.
If risk of uterine rupture high or chances of having other complications in labor are high, planned cesarean may be best. It has fewer risks than an unplanned cesarean that occurs after a failed TOLAC. If risk of uterine rupture is low and chances of VBAC success are favorable, best option may be to attempt VBAC.
What Influences My Chance of Uterine Rupture – chance relatively small (1/3 of 1% for TOLAC):
Monitoring for and Managing Uterine Rupture – during VBAC labor, caregiver closely monitors both mom and baby for uterine rupture, which she can diagnose by observing baby’s heart rate, shape of mother’s abdomen and moms BP. If caregiver suspects rupture, mom has emergency cesarean to prevent excessive bleeding and distress to baby. majority of babies are fine after rupture.
Likelihood of VBAC Success– most woman who plan TOLAC achieve a vaginal birth (60-94%). More likely if woman is <40 and has had prior vaginal birth and reason for previous cesarean hasn’t recurred and labor is progressing well. Less likely if:
Improving Chances of Having Successful VBAC:
Availability of VBAC – before 1980, common though was “once a cesarean, always a cesarean”. From 80s-90s, experts recommended VBAC because they believed it was safer than repeat cesarean. In 99 and 08, experts recommended hospitals permit VBAC only when physician, staff, anesthesia were immediately available to provide emergency cesarean. Due to staffing, many hospital policies turned against it. By early 2010, 1/3 of hospitals no longer permitted VBAC and ½ of physicians stopped offering it as an option. In July 2010, ACOG changed their stance, stating if laboring woman arrived at hospital that didn’t support TOLAC, she shouldn’t be forced to have a repeat cesarean against her will. However, physician uncomfortable with it may refer her to another physician. Search for caregiver that supports decision or consider relocation to friend/relative home near hospital that supports it.
Emotional Reactions when deciding between repeat cesarean and VBAC – because fear/anxiety can slow/complicate labor, its best to address during pregnancy
Having the Best Possible Cesarean Birth:
Natural Cesareans/Slow cesareans – cesareans used to be used in emergencies; doctors have begun doing it more slowly and encouraging immediate skin to skin after delivery. Learn more http://tinyurl.com/la83t2
Prepare cesarean birth plan – even if planning vaginal birth, consider writing. Ask if you can have 2 support people in OR, what will atmosphere be in OR, if you can choose music, staff narrate what’s happening; if they will chat with you to keep you relaxed; will they stop chatting if you request; will staff lower screen or use mirror to see baby’s birth; restrictions on photographing and video recording; partner announce baby’s sex; minimal suctioning of baby’s nose and mouth; skin to skin; newborn exams done where you can see; can baby stay in OR during repair; breastfeeding after birth; internal repair/double layer suturing; non drug options if experience anxiety, trembling or nausea; when can eat after surgery. If answers don’t satisfy you, consider switching to different caregiver or birthplace.
Understand reasons for cesarean – fully understand benefits, risks, alternatives before consenting. If having emergency one, ask why its needed. Can help you accept events of birth
Insist on early, frequent contact with baby – cesarean, narcotics, and high level sof stress may delay breastfeeding and affect breast milk production. More time you spend nestling baby and more frequently you nurse, sooner milk supply increases. Skin to skin also enhances emotional bond.
Develop postpartum plan – plan for extra support you’ll need
Key Points – more than 30% have cesareans in U.S. vaginal birth has fewer overall risks. Consider cesarean only when potential medical benefits outweigh risks. Steps to take to increase chances of vaginal birth. VBAC viable option for many women with prior cesareans; however local hospital may limit access. Preparing a birth plan for cesarean will help you have a positive birth experience
Chapter 15 – What Life is Like For A New Mother
Chapter 16 – When Post Partum Becomes Complicated
Chapter 17 – Caring for Your Baby
Chapter 18 – Feeding Your Baby
Study guide 10
Chapter 19 – When You’re Pregnant Again
Appendix A – Common Medications Used for Pain Relief During Labor
PCN Common medications used for pain relief during labor Pgs 450-458 Effects and side effects vary for all, depending on drug, total dosage, timing, baby’s condition and your reaction. See PCNGuide
IV Narcotics or Narcotic-like Analgesics
Local Perineal Block
Neuraxial Medications (Epidural or Spinal)
Epidural Analgesia with Combination of Narcotics and Anesthetics
Spinal (Intrathecal) Narcotic Analgesia
Combined Spinal- Epidural (CSE)
Appendix B – Summary of Normal Labor without Pain Medications
Summary of Normal Labor without Pain Medications (if plan to have epidural, use this until receive epidural)
First Stage of Labor: Early Labor
First Stage of Labor: Getting into Active Labor
First Stage of Labor: Active Labor
First Stage of Labor: Transition
Second Stage of Labor: Resting Phase
Second Stage of Labor: Descent Phase
Second Stage of Labor: Crowning and Birth
Third Stage of Labor
Appendix C – Recommended Resources