Pregnancy, Childbirth and the Newborn by Penny Simkin and April Bolding

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

If disagree with caregiver: in U.S and Canada, a pregnant woman has legal right (in most circumstances) to change caregivers, and caregiver has right to discontinue care if there are other options for pregnant woman

BRAN – Benefits– problem were trying to identify/prevent/fix; how is it done; how likely is it to work, Risks – possible risks/side effects for baby/me. Other tradeoffs/disadvantages such as additional procedures or precautions; cost, Alternatives-other options available; other procedures that may work; delay treatment or choose not to; risks and benefits of alternatives and effectiveness (low risk options sometimes less effective), Next Steps– if it solves problem, what can we do after; if it doesn’t, what after?

Health Care Coverage – licensed midwife may charge as little as $2,500 for uncomplicated home birth. Midwife for prenatal/birth center – $4000-$4500. OB uncomplicated birth $7,500. Cesarean complicated can cost more than $20,000.

Contact insurance company representative to understand coverage. See work sheet on

Some insurance plans cover but don’t pay directly for midwifery care, childbirth prep, birth or postpartum doulas, home birth and breastfeeding assistance, but you pay and they reimburse you. Can also use a FSA (flexible spending account).

~25% of people in U.S. can’t afford health insurance or don’t work for employers who offer it as a benefit. Medicaid coverage can help cover costs although only a limited number of caregivers and birth places. – new mothers to share info about their birth experiences.

Choosing a Birthplace

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

Choosing Caregiver

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

Models of Care – Midwifery vs Medical

A caregiver’s philosophy of care typically follows one or the other.

Midwifery Model of Care – designed to maintain and enhance a woman’s physiological and psychological resources for giving birth

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

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

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

Interviewing a Potential Caregiver – when scheduling, make it clear it’s only to learn more about the caregiver and his or her practice

Questions to Ask a Potential Caregiver

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

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

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

Choosing Childbirth Prep Classes – hospitals, colleges and universities, nonprofit community organizations, groups of caregivers, and independent childbirth educators offer

Hospitals usually have provider oriented about hospital which avoid discussion of reasonable alternatives or controversial topics.

Birth Doulas – Cochrane Library issued a report about dehumanization of women’s birth experiences. Review found that support was most effective when provided by women who weren’t hospital staff.

Most studies show that continuous support benefits laboring women, especially when the support begins in early labor and is given by someone whose only role is to provide it. Benefits include:

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

A few hospitals provide doula services at low cost or no cost to the patient, and some charitable agencies or public health departments cover doula’s fees for women who can’t afford; health insurance plans rarely cover. for lists of questions to ask

Baby’s Health Care – make decisions about baby’s health care before birth. Ex: circumcision and vaccinations

Choose a caregiver before birth

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

Health Care Coverage for baby – cost depends on plan. Children’s health clinics usually cost less than private practices, but they may have longer waiting times. If clinic is associated with a medical school, its staff may change frequently. Community health clinics or well-child clinics associated with a public health department offer free or low-cost checkups and vaccinations, but they usually don’t provide care for sick children.

Questions to Ask Potential Caregiver – do you support breastfeeding, formula feeding, work with lactation consultants, thoughts on circumcision, vaccinations, comfortable with home remedies, use of antibiotics, available for phone consultation, do you have hospital privileges, examine baby after birth.;

Schedule an interview w 1 or more caregivers before birth – check with insurance to see if it covers such appointments; if it doesn’t, see if caregiver will charge a fee.

Finding Help After Baby’s Birth – family members and friends help by cooking meals, running errands, doing laundry, housecleaning and watching baby so parents can sleep/relax. Babys nurses or nannies can take care of baby while you do other activities and mother’s helpers cook and clean but don’t help with baby care or give advice.

Postpartum doula – someone (typically a woman) who’s trained and experienced with helping a woman and her family adjust to postpartum life by teaching them about newborns’ needs and abilities, and about infant feeding, sleep and cues, while providing assistant with household tasks; potential costs may seem daunting but help and care are well worth the price. Health insurance plans rarely cover. Put aside money during pregnancy.

Questions to Ask Potential Postpartum Doula (try to hire before birth)–

Training/education/experience; criminal background check; TB test, DTap vacc, CPR cert, philosophy, meet before birth, additional services, call with questions before birth; when do services begin after birth; experience with breastfeeding, fee, refund policy

Returning to Work – see if possible for family to delay returning to work (you or partner), if one can work part-time/job share, work from home, costs of returning to work – child care, more visits to baby’s caregiver (daycare), income exceed total costs making it worthwhile, how will person who works feel about other staying at home? See PCNguide

Finding Child Care for Baby – arrange well before birth; try to wait 3-4 months after birth before returning to work. Allow at least a month to find child care that best suits your needs. Ask coworkers/other working parents about child care. Consider sharing nanny/babysitter. Ask family members/friends. Stagger you and partners work schedule or work part time. Some works have day cares. If outside your home – see and for advice on evaluating. Give appropriate holiday gifts to caregivers.

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

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

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

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

First Trimester Changes for You and Your Baby – first trimester is “formation” period because by end of it baby’s organ systems are formed and functioning.

First 4 Weeks

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

Weeks 5-14

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

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

15th-27th Week

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

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

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

39th/40th Weeks of Pregnancy

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

41st Week of Pregnancy and Beyond – Post-Dates

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

Common Concerns and Considerations in Pregnancy

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

Note to Expectant Fathers – may never felt so important yet so ignored, so committed yet so abandoned and so deeply in love and sexual yet afraid of sex. Share with other expectant fathers casually or in group.

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

Nontraditional Families

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

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

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

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

Chapter 4 Having a Healthy Pregnancy – making positive lifestyle choices, ideally begin avoiding hazards before pregnant

Caring for Yourself and Your Baby during Pregnancy

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

Note to Fathers/Partners: support mom’s efforts by making changes to your lifestyle as well. If you smoke, you can quit so partner and baby avoids harmful effects of secondhand smoke. Exercise regularly and avoid consuming unsafe foods and substances. Get involved in partners pregnancy – attend some or all prenatal appointments, show interest in prenatal tests and results. Do laborious household chores.

Prenatal Care – schedule once you know you’re pregnant; the wait tog et an appointment with some caregivers can be several weeks. At 1st/2nd visit, will get complete physical exam and numerous tests. Ask questions about current life situation and family medical history. Appointment every month; at end of pregnancy, every 2 weeks; every week as due date approaches. If you want a longer appointment, request in advance. At end of pregnancy, schedule long visit to talk about birth plan. If there’s a group, try to meet others.

Info to include in medical history: prior surgeries/illnesses, hereditary conditions, including birth defects (heart defects) mental retardation, blindness, deafness, stillbirth, miscarriages, mental health conditions – depression/eating disorders, ethnic or cultural traditions, current prescription medications, drug allergies and drug reactions, prior negative experience with a hospitalization, prior sexual abuse, domestic violence or any other significant mistreatment, heavy use of alcohol, tobacco, recreational drugs or other harmful substances.

Prenatal Tests – screening test is a quick, easy and inexpensive way to rule out a particular condition. If results are positive, may need further testing to confirm you have condition. If additional testing determines you don’t have the condition, your screening test gave a “false positive” reading. Diagnostic test is more specific and more reliable; more invasive, expensive and usually have more side effects, so caregivers usually only give if indicated by screening. PCNGuide

Benefits, Risks, Alternatives to test/how test is done/ how reliable/accurate/ how will results influence prenatal care/ cost/insurance cover cost/ consequences of not having.

Routine Exams and Screening Tests

Every visit

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

Specific Visits

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

See PCN Guide

Other Exams/Screening

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

Understanding Ultrasound – 2 forms: Doppler and diagnostic scan. Doppler monitors baby’s heart rate, uses continuous transmission of sound waves to detect motion of baby’s heart as it beats. Done via hand-held device. Scan helps “see” inside uterus, using intermittent transmission of sound waves for less than 1% of the time during the test. For the rest of the test, the equipment receives the echoes of the sound waves, which indicate differences in tissue density. See PCN guide

Studies found no evidence that they harm mother or baby and that benefits outweigh risks. Estimating baby’s age and weight more reliable in early pregnancy. First sight of babies inspires many parents to make an effort to heave a healthy pregnancy and birth.

Warning Signs of Pregnancy Complications:

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

Fetal Movement Counting – some caregivers ask only those women with high-risk pregnancies to count their babies’ movements. Baby doing well in uterus have several active, wakeful periods during the day. Healthy babies move slightly less often toward end of pregnancy due to space restrictions within uterus but don’t markedly reduce activity unless there is a problem. If baby becomes noticeable less active, call caregiver.

The Count to Ten Method – after 28th week, count baby’s movements each day at roughly same time. PCNguide has template. Length of time it takes to complete 10 movements varies among babies. Focus not on how baby’s movements compare with other babies’ but on whether his activity has slowed down compared to his usual pattern. Try waking baby up with a loud noise or wait until you feel baby move. Call caregiver if it takes a longer time than usual to make 10 movements or if baby doesn’t move at least 10x or have an active period within the next 12 hours.

Reducing Stress – see pgs 71-73 above

Treating Illness and Discomforts during Pregnancy

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

Medications – what are benefits, risks and alternatives; if benefits clearly outweigh risks ask about dose, max dose in 24 hr period and other foods/drugs to avoid while taking. How long to take.

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

Substances and Hazards to Avoid during Pregnancy – everything affects baby from caffeinated coffee and herbal teas to dangerous situations such as abuse and domestic violence. Depends on amount and frequency of exposure as well as what trimester you’re in when exposed.

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

Potentially Harmful Substances and Herbs in Food

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

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

Environmental Hazards and Harmful Situations – abusive relationships, workplace stress

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

Traveling During Pregnancy – in last month, caregiver may suggest staying within an hour’s travel time from home. Get copy of medical history to take while traveling. Some airlines limit in week before a due date. Avoid flying at altitudes >7000 feet in small planes without pressurized cabins; the oxygen available to baby may be reduces. If traveling internationally see about vaccines – only a few considered safe in pregnancy.

Long trips by car, bus, plane or train may limit movement, which can affect circulation, increase swelling in legs, and increase risk of developing a blood clot in leg vein. Walk every hour or so. Wear seat belt. Fasten low on hip and below belly. Constant motion may aggravate morning sickness/nausea. Air travel, hot climates and places with forced air ventilation may increase dehydration. Drink lots of fluids, eat well, walk around and get plenty of rest

Common Concerns

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

Food Safety –

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

Nutrition for Special Circumstances

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

Feeling Good and Staying Fit – maintaining good posture helps prevent back pain

Maintaining Good Posture and Moving with Care – maintaining good posture is essential for keeping your balance, preventing back pain and reducing fatigue

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

Exercise in Pregnancy – protects against back pain, reduces intensity of common pregnancy discomforts and boosts energy level, mood and self image. During last trimester, regular exercise increases body’s production of endorphins (natural pain relievers), which can help you cope with labor.

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

Finding Motivation to Exercise – motivation may ebb and flow as energy level rises and falls. Find what time of day works best and schedule for that time. Hearing/reading encouraging words or listening to favorite music can motivate you. If have trouble making time on 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

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

Guidelines for Safe Effective Exercise

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

Core Exercises to Prepare You for Labor – core muscles include abdominal muscles, pelvic floor muscles, and back and hip muscles

Conditioning Pelvic Floor Muscles – pelvic floor muscles form a figure 8 around your urethra, vagina and anus. During pregnancy, increased weight of uterus and relaxing effect of hormones may make these muscles sag. Hemorrhoids may emerge. Exercising pelvic floor muscles can reduce heavy, throbbing feeling you may experience in the area. Can make sex more enjoyable

Pelvic Floor Contraction (Kegel or Super Kegel) – improve blood circulation in pelvic floor muscles. Try not to tighten muscles in buttocks, thighs or abdomen. Hold tightly for 10 seconds. Relax and rest for 10 sec before tightening for another 10 seconds. Super Kegel – hold for 20 seconds, tightening again when contraction begins to fade. Several sets of 10 per day.

Pelvic Floor Bulging – to prepare for pushing baby out. H old breath and bear down gently. Hold for 3-5 seconds, then stop bearing down. Inhale, contract pelvic floor muscles then exhale and rest. 1-2x per week

Conditioning Abdominal Muscles – late pregnancy, avoid double leg lifts or abdominal crunches

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

Mobilizing Pelvic Joints by Squat – during late pregnancy, helps condition your pelvic joints. To birth vaginally, joints need to be flexible enough to allow baby to move from uterus through vagina. When push baby out, squatting can help baby descend into vagina. If you problems with hips, knees, ankles pelvis or have hemorrhoids, avoid. If having trouble getting back up, tighten thighs and buttocks or try wall sitting. Increase amount of time in squat to 90 sec, which is roughly length of long labor contraction. If can’t maintain balance, use piece of furniture or use partner. If difficult to keep heels of floor, calf muscles are tight. Try \ with feet further apart, put book under each heel or rolled up map. Many birthing beds in hospitals have bars to grip while squatting. After 35th week, squat 10x each day.

Postural Exercises to Align Your Body – strengthening and stretching these muscles helps relieve lower back pain and other discomforts that can arise when your body is out of alignment

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

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

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

Comfort Measures for Common Discomforts in Pregnancy

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

Work out 3-7 days per week!

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

To analyze daily diet, visit – how much of each nutrient you’ve consumed

Grains – wheat, rice, oats, cornmeal, barley or rye. Contains iron, b vitamins, minerals and fiber and some are fortified with folic acid. Try to make half of grains whole. Try to limit refined grains. Whole grains – brown rice, oatmeal, popcorn, barley millet, quinoa, spelt, buckwheat, bulgur and wile rice. Or if ingredients list whole-wheat flour, whole oats.

Veggies – try to vary. Dark green (Broccoli, kale, lettuce, spinach), orange (Carrots, sweet potato), dried beans and peas (legumes – black beans, chickpeas, pinto beans, lentils), starchy veggies (corn, potatoes), other veggies (Artichokes, asparagus, brussel sprouts, cauliflower, cucumber, eggplant, onions, peppers, tomatoes, zucchini)

Fruits – eat a variety. Rich in fiber, potassium, Vit C and folate

Milk and Milk Products – calcium for you and baby for strong bones. Protein, potassium, vit A, B, D.

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

Meats and Beans – contain protein, which builds muscles, skin, enzymes, hormones, and antibodies. Also contain B vitamins, Vit E, iron, zinc and magnesium. Choose lean cuts of meat, drain grease after cooking, choose meats that don’t include excess salt/fat. Eat fish 2x a week – choose seafood low in mercury and high in omega3

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

Choose organic fruits and veggies when possible. Some have more pesticide residue – apples, peppers, potatoes, spinach, strawberries. Choose fresh local produce in season. More recently picked, more nutrients. Raw fruits and veggies have higher nutrition than cooked. Best to worst for preserving nutrients: steam microwave, stir fry, roast, bake, boil.

Get nutrition from food vs supplements – books: In Defense of Food; Food Rules Michael Pollan


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

Weight Gain during Pregnancy – depends on prepregnancy weight and height, quality of diet before and during pregnancy, ethnic background and number of previous pregnancies.

Figure out prepregnancy BMI to gauge total body fat. BMI equals weight multiplied by 703 and divided by height in inches squared. Many women gain more or less and their babies are 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

  • Cardiovascular disease (high blood pressure, heart disease or sickle cell anemia)
  • Gastrointestinal illness or nutrition problems (inflammatory bowel disease, phenylketonuria or PKU, Crohn’s disease, eating disorders or gastric bypass surgery)
  • Respiratory or lung disease (asthma)
  • Hormonal imbalance or disease (diabetes, thyroid disease, polycystic ovarian syndrome or PCOS or pituitary disorders)
  • Autoimmune disorder, in which the immune system harms instead of protects body (rheumatoid arthritis, lupus erythematous, and antiphospholipid antibody syndrome or APS)
  • Other conditions of illness (kidney disease, epilepsy, or physical disability)

Complications that arise in pregnancy

  • Vaginal bleeding in early pregnancy – spotting/light vaginal bleeding in first trimester occurs in 20% of all pregnancies. In many cases, bleeding doesn’t harm mom or baby. sometimes, implantation of fertilized egg into uterine wall causes slight vaginal bleeding, usually shortly before the time a woman expects a menstrual period. Other times, cervical tenderness and an increased blood supply to pelvis can cause spotting after a woman has intercourse. Frequent strenuous exercise or a cervical infection causes vaginal bleeding. In rare cases, a condition called molar pregnancy causes brownish vaginal discharge in early pregnancy. In a molar pregnancy, abnormal placental tissue grows into a grape-like cluster; there isn’t a baby, even though a pregnancy test is positive.
    • For about half of women who experience bleeding in early pregnancy, bleeding stops on its own and many women have no further complications. In other cases, it’s serious and sometimes indicates an ectopic pregnancy or possible miscarriage. Women who have continuous moderate or heavy bleeding are more likely to miscarry than those who experience light bleeding only once. Call caregiver. Rest and avoid strenuous exercise and sex. Caregiver may order ultrasound or blood tests.

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

  • Wash hands several times a day, especially before eating and after using toilet. Germs live on doorknobs, handrails, phones, hands and other surfaces.
  • Stay away from sick people, especially if vaccinations aren’t up to date
  • Update vaccinations or have immune status checked before pregnancy. Chicken pox (Varicella zoster), measles, mumps and rubella or German measles (MMR) not recommended in pregnancy or months before conception. If received MMR as a child, may be still immune but effectiveness of some vaccines such as rubella, diminish
  • Eat safe foods. Wash fruits and veggies. Adequately cook meats and other foods. Thoroughly clean food prep surfaces

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)

  • Bacterial vaginosis (BV) – preterm labor; problems result from prematurity
  • Chicken pox (Varicella zoster) – birth defects, illness in baby – slight risk of infection affecting one or all of baby’s organs
  • Chlamydia trachomatis – birth defects, illness in baby; baby not affected before birth, but may have eye infection or pneumonia after birth
  • Cytomegalovirus (CMV)– birth defects, illness in baby; risk of brain damage or hearing loss. About 10% of babies affected when mother is first infected in 1st trimester
  • Fifth disease (parovirus B19) – illness in baby; may cause sever anemia and related problems for baby
  • Gonorrhea (Neisseria gonorrhea) – illness in baby; if baby is infected during birth, infection might cause severe eye infection that may cause blindness
  • Group b streptococcus (GBS) – preterm labor, illness in baby; if baby infected at birth, infection may cause severe disease or death
  • Hep B (HBV) or Hep C (HCV) – illness in baby; if baby is infected at birth and untreated, shes at hish risk of becoming a HBV carrier, but at low risk of becoming a HCV carrier
  • Herpes simplex virus (HSV) – illness in baby; risk of infection is highest when mom has her first outbreat of genital herpes in pregnancy. Any recurrent infection at birth may affect baby. treatment of outbreaks reduces chances of infection
  • Human immondeficiency virus (HIV) – illness in baby; treatment of mother can greatly reduce risk of baby’s acquiring HIV during pregnancy or at birth
  • Human papillomavirus (HPV) – low risk of babys acquiring HPV during pregnancy or at birth. May cause genital warts or cervical cancer later in child’s life
  • Listeriosis (listeria monocytogenes) – preterm labor, illness in baby; may cause miscarriage or infection in baby after birth
  • Lyme disease – bacteria from a tick bite can cross placenta. Risks are unknown, but may cause miscarriage or stillbirth.
  • Mumps (paramyxovirus) – illness in baby; although connection is unconfirmed, infection may cause miscarriage. May cause infection in baby after birth
  • Measles – illness in baby; may cause infection in baby after birth
  • Periodontal disease (gum disease) – preterm labor; severe gingivitis greatly increases risk of preterm birth
  • Rubella (german measles) – birth defects, preterm labor, illness in baby; when baby is infected in 1st half of pregnancy, infection increases risk of problems with hearing, vision, heart function or brain development
  • Syphilis (treponema pallidum) – birth defects, illness in baby; possible problems with baby’s eyes, skin, heart, bones, and nervous system. May cause death.
  • Toxoplasmosis (toxoplasma gondii) – birth defects, illness in baby – possible effects on all of baby’s organs; may cause death. Problems are more severe if mother is first infected in first half of pregnancy
  • Trichomoniasis – problems result from prematurity. Infected mothers often have other infections
  • Yeast (candidaiasis) – illness in baby; exposure may occur with vaginal birth, but infection is rare. Chances of infection on mother’s nipples or in baby’s mouth (thrush) increase if mother had antibiotics near time of birth


  1. Sexually transmitted infections
  2. Group B streptococcus
  3. Bladder and vaginal infections
  4. Listeriosis
  5. Toxoplasmosis
  6. Diabetes mellitus

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

  • Uterine contractions that occur every 10 min or 6 contractions in 1 hr
  • Continuous or intermittent menstrual-like cramps or pressure in lower abdomen and thighs (pelvic heaviness)
  • Dull ache in lower back that doesn’t go away when change position
  • Intestinal cramping with or without diarrhea or loose stools
  • Sudden increase or change in vaginal discharge (watery, blood tinged, or with more thin mucus)
  • General feeling that something isn’t right

Having persistent, fairly regular contractions for 2 hours (along with other signs) indicates labor

Predicting Preterm Labor – results of several tests can increase likelihood:

  • Fetal fibronectin (fFN) is a protein that increases in last weeks of pregnancy and during labor. When test detects it between 22nd and 35th weeks, risk preterm labor increased
  • Transvaginal ultrasound scan or vaginal exam can determine cervical length. If woman’s cervix shortens months or weeks before term with labor contractions
  • Blood tests for specific biochemical markers and saliva test that looks for increase of hormone estriol

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:

  • Placenta Previa – less than 1% of pregnancies; placenta lies completely or partially over cervix. Cant deliver baby vaginally; planned cesarean, after 36th week before labor begins. In early pregnancy, may learn placenta is attached to lower part of uterus (low-lying placenta); in most cases, as uterus grows, site where placenta attached rises away from cervix (if don’t have low-lying placenta in early pregnancy, you won’t develop placenta previa later). Caregiver will diagnose you with placenta previa only if tranvaginal ultrasound scan confirms that placenta continues to cover cervix later in pregnancy. Risk factors: prior cesarean, uterine surgery or abortion; uterine abnormalities; >34 yrs old; many previous pregnancies and heavy smoking. Most common symptoms is painless vaginal bleeding as cervical changes occur in last trimester. Treatment depends on symptoms and includes measures to prevent heavy bleeding and decrease risk of preterm birth. If haven’t had bleeding, caregiver will avoid doing vaginal exams and will advise you to avoid sex and heavy exertion. May be put on bed rest. If had vaginal bleeding, may be hospitalized for close observation and if blood tests show severe blood loss, have a blood transfusion.
  • Placental Abruption – 1 % of pregnancies; placenta partially or almost completely separates from uterine wall during 3rd trimester or during labor. Can cause significant blood loss in mother and can deprive baby of adequate oxygen. Risk increases if have 1 of following factors: extremely high blood pressure, more than 5 previous pregnancies; history of 2nd trimester bleeding; prior abruption; habit of heavy smoking or cocaine use; severe abdominal trauma. Abruption may cause any or all of the following symptoms: vaginal bleeding, continuous severe abdominal pain, lower back pain, tender abdomen and constant tightening of the uterus. Sometimes, vaginal bleeding is absent if blood collects high in the uterus. Ultrasound scan may help determine degree of separation and its effect on blood flow to placenta. Assessing mother’s blood pressure and baby’s heart rate helps estimate severity of abruption and along with testes to check how well mother’s blood clots, help determine appropriate treatment. When abruption is small and baby remains healthy, bed rest and close observation may be the only treatment. If bleeding is severe and baby’s heart rate shows distress (and if baby’s chances of surviving preterm birth are high), woman has an immediate cesarean birth and blood transfusion if necessary.

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:

  • First pregnancy
  • Preeclampsia in previous pregnancy (or close family member with it)
  • Personal history of chronic hypertension, diabetes, kidney disease, polycystic ovarian syndrome (PCOS), or vascular disease
  • Obesity
  • Age older than 35 or younger than 18
  • Pregnant with multiples
  • African descent
  • History of certain autoimmune disorders, such as lupus or rheumatoid arthritis
  • Infections during this pregnancy, such as periodontal disease or UTI

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:

  • Sudden puffiness (edema) in hands/face
  • Rapid weight gain (more than 2 pounds in 1 week)
  • Headache
  • Visual changes or problems (Flashes or spots before eyes or blurred vision)
  • Pain in stomach (epigastric pain) or right side under ribs, or possible pain in shoulder or lower back

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.

  • Amniocentesis – between 15th and 20th week of pregnancy, lab test can sample amniotic fluid to detect Down syndrome, sickle cell anemia, neural tube defects and other disorders. Results available in 2 weeks. May use amniocentesis in late pregnancy to assess baby’s lung maturity before a preterm birth
  • Chorionic villus sampling (CVS) – examines small piece from chorionic villi (early placenta) to provide info about chromosomal abnormalities in baby between 10th and 12th week

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

  • Ultrasound – helps estimate baby’s gestational age and maturity, locates her organs and structures and detects her presentation and position in the uterus. Can determine preterm cervical changes and assess amniotic fluid volume. Often used in conjunction with external version of breech baby, CVS and amniocentesis.
  • Magnetic resonance imaging (MRI) – visual images of internal structure of baby can help confirm malformations. Assess internal organs for potential complications. May use when results of ultrasound unclear.
  • Doppler arterial blood flow studies (velocimetry) – circulation of blood within and among uterus, placenta and your baby. can see if baby is at risk for blood flow complications such as intrauterine growth restriction (IUGR), anemia and prematurity form severe preeclampsia.
  • X-ray – rarely used but can help diagnose pneumonia, dental disease and broken bones

Tests for Baby’s Well-being in late pregnancy

  • Non-stress test (NST) – monitor baby’s heart rate when he’s actively moving, can determine well being and whether a high risk pregnancy can continue
  • Biophysical profile (BPP)- considers info from NST and uses ultrasound to evaluate amniotic fluid volume and baby’s functions. Can assess if high risk or post date pregnancy can safely continue or if induction should be considered. Because test monitors 5 factors (But not baby’s size), it’s a fairly good indicator of condition
  • Contraction stress test (CST) or oxytocin challenge test (OCT) – caregiver induces contractions and monitors baby’s heart rate to predict when he can withstand stress of labor contractions. If not, cesarean may be necessary. Not usually done unless NST indicates problem

PCN Pg 144-145 Tests to Detect Potential Pregnancy Problems

  • Glucose tolerance test (GTT) – first have blood drawn, then drink sugary drink and have blood drawn again every hour in 3 hour period
  • Vaginal or cervical smear – obtains secretions from vagina or cervical area to defect infectious organisms, premature rupture of membranes or substances that indicate an increased risk of preterm labor

Ch 7 Key Points

  • Most pregnancies don’t develop complications and both mother and baby are healthy at birth and afterward
  • Can decrease chances of developing serious problems form chronic condition or from complication that arises with appropriate prenatal care
  • Promptly contact caregiver if see warning signs of complications; early treatment helps minimize severity of complications

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

  • Reduced oxygen to uterine muscles during contraction, which creates a buildup of waste products such as lactic acid, that in turn causes pain
  • Stretching of the cervix as it dilates
  • Pressure of the baby on nerves in and near the cervix and vagina
  • Tension and stretching of ligaments of uterus and pelvic joints during contractions and baby’s descent
  • Pressure of baby on urethra, bladder and rectum
  • Stretching of pelvic floor muscles and vaginal tissues during birth

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:

  • Physical: hunger/thirst, fatigue, muscle tension, full bladder, discomfort from staying in same position
  • Emotional/Mental: fear, anxiety, loneliness, or feeling watched or judged (all can release stress hormones); lack of confidence and preparation; ignorance or misinformation about labor/birth; unsupportive staff or relatives; feeling powerless to make decisions or feeling that your decisions aren’t being respected
  • Variations during labor: frequent long contractions or coupling contractions; baby that’s malpositioned; prolonged, tiring labor; exhaustion; rapid intense labor, with little breaks in between contractions; expectations for labor and birth that don’t match actual experience; hospital policies/procedures/interventions that limit mobility or ability to use coping techniques

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 :

  • Coping skills you’ve used throughout life to comfort yourself when sick, tired, worried, in pain or physically exerting yourself;
  • Self help skills you practice during pregnancy such as breathing techniques, relaxation, visualization and attention focus
  • Comfort items to bring to birthplace such as own pillow or clothes, snacks and beverages, heating pads, cold packs, birth ball, shower/bathtub
  • Hands on support from doula/partner – massage, gentle stroking, acupressure
  • Changes to environment to make it more comfortable such as dimming lights, playing music, aromatherapy, asking for minimal disruptions

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

  • Epidural 76%, 81%
  • Bathtub 6%, 48%
  • Massage 20%, 40%
  • Iv narcotics 22%, 40%
  • Birth ball 7%, 34%
  • Heat/cold 6%, 31%
  • Relaxation 25%, 28%
  • Position changes 42%, 23%
  • Changes to environment 4%, 21%
  • Breathing techniques 49%, 21%

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

  • Confirm partner agrees with goal and helping you achieve it
  • Choose birthplace that supports non-medicated birth and has non-medical tools such as birth balls and large bathtubs. Choose caregiver experienced in supporting women without pain medications. Ask what percentage of clients use pain meds
  • Learn comfort techniques
  • Take childbirth prep classes
  • Consider hiring a doula
  • State wishes in birth plan
  • Avoid/minimize interventions that can increase labor pain (induction and augmentation) or ones that limit mobility (EFM)
  • Consider having code word
  • As move from early labor to active (305 cm), contractions will become painful. Try to adapt breathing, movements or activities to help cope. When cervix dilates 6-7 cm, contraction may become intense. if you can relax between contractions and maintain a rhythm, you’ll be coping well. As move from active labor to transition (7-8 cm), may need to rely on support. Partner can remind you contractions are as painful as they’ll become. If have gone this far, can probably manage rest of labor without pain meds
  • Note to Partners – stay hydrated and keep up energy by eating nutritious snacks.   Conserve strength when physically supporting partner. Use good body mechanics.


  • The Invaluable Birth Doula – don’t overlook services a birth doula can provide. Unlike nursing staff who must concentrate on completing clinical tasks while providing care, a doula can focus solely on you and your partner. She’ll know your birth plan, likes and dislikes, hopes for birth and pain medication preferences. One woman without a partner hired a doula. Another woman whose mother had died wanted feminine energy of someone who had given birth. Another wanted someone to help her and her partner with comfort measures.
  • Some couples hire a doula just as much for the partner as for laboring woman, especially if partner isn’t completely comfortable with demands of labor support and needs a guide or helper, or wants someone to take over the role of primary support person. Doula can provide backup support if partner has medical condition such as hypoglycemia (which necessitates getting regular food and rest), becomes queasy at sight of blood, has physical limitations or simply wants to avoid pressure of having to learn and remember all comfort measures.
  • Can also do necessary taks for partner so they can focus on primary support such as run errands, fetch food, beverages and comfort items such as ice packs. Can take photos, report progress and developments to couple’s friends and family. Can massage woman’s back while partner helps her maintain rhythm or can continue support so partner can eat, get some air or take much needed nap.
  • If doula isn’t available or allowed in birthplace (or don’t want one), trusted relatives or friends can do many of the things a doula can do, especially if they attend childbirth prep classes with you and partner.
  • Contingency Plan – if struggling to cope but still don’t want to receive drugs, ideas to try:
  • Change environment. Take a walk, shower, dim lights or put on relaxing music
  • Change ritual or breathing techniques
  • Eat something or drink a sugary beverage. Sometimes all you need is quick energy boost
  • Find out how far cervix has dilated. Labor may be difficult because you’re making rapid progress
  • Don’t base decision on pain medication on one hard contraction. Find new comfort technique for 4-5 contractions. Endorphins may kick in and may make it manageable.
  • Preparing to Labor with Pain Medications
  • Learn about pain medications during pregnancy whether or not you plan to use them. That way, if need arises, you have knowledge about them and can make an informed decision. Both you and baby are affected if you take pain medications so know all possible risks and benefits.
  • Weighing Risks/Benefits of Pain Medications – benefits include increased ability to relax and sleep, reduction or elimination of pain. Side effects are often mild, manageable and familiar to hospital staff. All interventions have potential risks – decreased blood pressure in mom, prolonged labor, forceps delivery or vacuum extraction, fever in mom or baby and variations in baby’s heart rate. While risks are moderate, may require additional interventions that have their own potential side effects.
  • While medications can minimize or eliminate pain, they generally can’t prevent you from experiencing any.
  • Any medication you receive affects baby. since baby’s liver and kidneys are immature, effects of some drugs last longer than for you. Medication effect depends on drug, amount received, how and when it’s given and other factors. Pcnguide
  • Pain medications affect labor progress. They slow contractions and may increase need for other medical interventions. If labor progress is abnormally slow, drugs may speed up progress by letting you relax
  • Some require restrictions: to bed, of eating and drinking, IV fluids, Pitocin augmentation, administration of oxygen, frequent monitoring of blood pressure and blood oxygen levels, bladder catheterization, EFM, vacuum extraction and cesarean.
  • Key Vocabulary of Pain Medications
  • Route of administration – oral is a pill or liquid you swallow; inhalation is a gas you breathe; intramuscular is a shot given into muscle; intravenous is an injection into a vein – often through IV catheter; neuraxial are drugs injected into space surrounding spinal cord such as epidurals and spinal blocks. How quickly it takes effect depends on route
  • Areas of effect – systemic (Affecting entire body), regional (large area) or local (specific, relatively small part of body). Need more medication to get desired results with systemic than regional or local
  • Type of effect – analgesia reduces perception of pain while anesthesia indicates loss of sensation including pain sensation; anesthetics block nerve endings from sending pain impulses to brain
  • Systemic Medications
  • Pills, injections, gases. They are carried in bloodstream and may affect baby as well because placenta can’t screen them out. Magnitude depends on type and amount used and time between last dose and birth. Other factors include baby’s maturity, health and response during labor.
  • Medication or its byproducts might not disappear from baby’s bloodstream for hours or days and neurobehavioral changes may be present during first few days. Changes may be obvious or only noticeable to professionals who use highly sensitive tests.
  • General anesthesia is systemic medication that causes total loss of sensation and consciousness. Its used only for a small % of cesarean births. IV narcotics are systemic medications used most commonly in labor, although IM narcotics are sometimes given.
  • IV Narcotics or Narcotic-like Medications – reduce transmission of pain messages to pain receptors in brain.
  • Benefits – takes the edge off pain. May take you longer to notice a contraction has started and may seem to fade away sooner. Peak may still be intense enough to feel pain. May work well if you can handle peak but want to have longer break between contractions so you can rest; may even be able to doze between contractions and wake up to manage peak.
  • Tradeoffs – IV fluids, EFM and restriction to bed. May cause sleepiness or lethargy and may cause hazy feeling, disorientation or euphoria. Some find feeling relaxing/pleasant while others feel out on control.
  • Possible side effects – itching, nausea, vomiting. May slow labor and cause variations in baby’s heart rate. Can receive narcotic antagonist to reduce side effects, but it’ll reduce pain relief. After birth, narcotics in baby’s bloodstream may cause her to breathe slowly and have poor muscle tone. She can receive a narcotic antagonist if needed.
  • Timing – effects last 60-90 min. used in early labor when its believed birth is at least 2 hours away. Timing allows effects on baby to fade before birth.
  • Local and Regional Anesthetics – often called blocks reduce feeling or numbness in particular area of body. When injected near specific nerves, it blocks transmission of sensations along them. Affects muscle control, blood flow and temperature in affected area. Most drug names end with suffix –caine such as lidocaine and bupivacaine.
  • Local Anesthetics (Perineal Block) – block sensation in small area near nerve endings. Injected into skin, mucous membranes or muscles. During labor, typically injected in perineum (perineal block). Can be injected in cervix (paracervical block) or vagina (pudendal block) but they aren’t often used.
  • Benefits: perineal block numbs perineum and is necessary for repair of episiotomy or lacerations. May numb perineum before episiotomy or forceps delivery.
  • Tradeoff: injections may be painful
  • Possible side effects: if perineal block given during repair of episiotomy or lacerations, side effects minimal. If given early in 2nd stage (rare), medication may affect baby’s heart rate during labor or his reflexes at birth
  • Timing – given during 2nd stage or episiotomy or forceps delivery is necessary. Given in 3rd stage for repair of episiotomy or lacerations.

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.

  • Benefits – ACOG stated among all options for medicated pain relief, the epidural is the most effective for reducing pain, while allowing the woman to stay alert and actively participate in her labor. 98.8% have significant pain relief. Typically provides relief for rest of labor. Because of locations of injection sites, much smaller amounts of neuraxial can be used than needed for local or systemic analgesia. Fewer mental and respiratory side effects and higher level of satisfaction. Babies are more alert, breathe better and better muscle tone than babies born with higher doses of systemic narcotic like medications.
  • Tradeoffs – accompanied by IV fluids, bladder catheter, continuous monitoring of blood pressure, contractions and baby’s heart rate. Eating/drinking restriction and confined to bed. Reduces mobility. Feeling birth has become a medical event.
  • Possible side effects: most common include decreased blood pressure, longer labor, longer pushing stage and fever. Effects may lead to further interventions (Pitocin augmentation, vacuum extraction or forceps) and secondary side effects on both you and baby (uterine hyperstimulation or variations in baby’s heart rate). Itching/nausea. Some women worry about risk of paralysis or even death but this is so rare its nearly nonexistent. Experience wont depend solely on skills of anesthesiologist; many factors including your and your baby’s physical state and well-being as well as how your body reacts to medications. Postpartum side effect may be shortened duration of breastfeeding. Woman is likely to stop breastfeeding sooner, partly because she might have taken longer after birth to begin holding and nursing her baby and partly because of a mistaken perception that she might not make enough milk. Problems can be overcome by early and frequent skin to skin and by starting breastfeeding within first hour. The earlier a woman initiates breastfeeding and the more often she nurses, the more milk she makes and the more likely she is to have breastfeeding success.
  • Timing – some caregivers require a woman be in active labor (4-5 cm dilated and strong, regular contractions). Epidurals given in early labor likely to slow or stall labor. Others give at any point in labor based on conflicting research that says it doesn’t prolong labor. Others give combined spinal-epidural (CSE), spinal narcotics early in labor and an epidural later on.

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:

  • Spinal Block – inserted through dura (tough membrane that surrounds spinal cord) into the intrathecal space, which is filled with cerebrospinal fluid. Drugs given this way called intrathecal medications. Takes affect within minutes and lasts a few hours
  • Epidural catheter – inserted into epidural space, just outside dura. Thin plastic tube (Catheter) threaded through needle, needle is removed, catheter is taped to back, and test dose of medications is given through catheter to ensure you don’t react poorly to the drugs. Catheter is attached to a pump devise that steadily releases small amounts of anesthetic or analgesia. Within a few min, tingling and numbness are noticeable; within 15 min, likely to be completely numb from top of uterus to pelvis or even from chest to toes. Catheter remains in place and pain relief continues throughout labor. May receive doses by continuous drip, series of doses or from when you need them.
  • Combined spinalepidural (CSE)- epidural needle is inserted, then smaller spinal needle is inserted thought it and into intrathecal space for admin of spinal narcotic. Spinal needle is removed and epidural catheter is inserted. No medication is added to epidural at this time. Effects of spinal narcotic last a few hours or until cervix has dilated to 4-6 cm and intensifying contractions cause you to feel pain. When you need more relief, epidural medication is given through catheter.

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 :

  • Patient controlled epidural analgesia (PCEA) – allows you to press a button to give yourself more medication when you need it. Women tend to use less and are more satisfied than when dosage is controlled for them. Although you have some control, device has a timer that limits number of doses which are carefully measured so you cant overdose
  • Combined spinal-epidural (CSE) – uses spinal narcotic in early labor then an epidural in later labor, when you need more pain relief
  • Light or late epidural – reduce side effects by delaying epidural until in active labor and requesting low concentration
  • Policies vary among hospitals
    • Movement – ask whether you’re able to move and whether movement in bed is encouraged
    • Food and drink – some allow only ice chips but may be allowed clear fluids
    • Delayed pushing – may wait to push until baby’s head is visible at vaginal outlet. Has been proven to reduce vaginal tears, forceps delivery, vacuum extraction and need for cesarean.
    • Lowering dosage or discontinuing – by slowing/stopping at beginning of 2nd stage, may be able to bear down more effectively.

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. 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.

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

Recognizing Muscle Tension: in order to release muscle tension, must be able to recognize. Make right tight fist, feel muscles in forearm with left hand. Relax, feel muscles. Shrug shoulders towards ear. Lower and feel.

Practice with Partner: Observation (how do you look when anxious, uncomfortable, calm, content, asleep). Touch (muscles feel hard or soft). Floating a limb (heaviness that signals relaxation – like lifting sleeping baby’s arm).

Tighten body part and have partner find. Have him find different ways to relax it: warm compress, massage, reminding you to release. Discover which body parts tense most: shoulders, forehead, mouth, jaw, fists.

Relaxation Techniques: By focusing on different parts of the body and consciously releasing the tension in them, you can relax both your body and mind. Lie on side with plenty of pillows or sit in a comfortable chair; then try standing, walking. Begin in quiet calm area then try in more active surroundings. When done, stretch arms and legs.

Passive Relaxation: Try with a partner or relaxation CD – you’ll get used to the sounds and will find it familiar and relaxing during labor. Practicing: Lie on side or sit in semi-reclined position with floor or bed supporting head and limbs. Breathe slowly, easily and fully (how you breathe as you fall asleep). Body and mind release tension and thought, breathing slows and pausing slightly at the end of each inhalation an exhalation (watch someone as they fall asleep).

Lie on side or sit in semi-reclined position with floor or bed supporting head/limbs. Can put pillows under/between knees, beneath head or under belly. Begin breathing slowly, easily and fully – this is how you breathe as you fall asleep. Your body and mind release tension and thought, your breathing slows and you pause slightly at the end of each inhalation and exhalation (observe someone as they fall asleep). Have partner read script in a calm, slow, relaxed voice. Take a couple breaths after you release each area.


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

Relaxation Countdown: After mastering passive relaxation, use following to release tension quickly. Helpful when you want to fall back to sleep, stressed, or when trying to relax after a contraction

Inhale through nose and exhale out mouth, releasing muscle tension in the following order: Head, neck, shoulders; arms, hands, fingers; chest and abdomen, back, buttocks and perineum; legs, feet and toes. Use 5 slow breaths at first (1 for each of the 5 areas). Then try slowly exhaling one deep breath for all 5 areas (rapid relaxation countdown). During labor, first or last breath of each contraction can be rapid relaxation countdown.

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.

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

Rehearsing Slow Breathing for Labor: rehearse until your confident in using for 60-90 seconds a time (typical length of contraction). Practice with different positions. With each exhalation, focus on relaxing different part of your body (See pg 219 for Roving body check) so you can relax every muscle that’s not required to maintain your position. If uncomfortable to inhale through nose and out mouth, can breathe through only which is comfortable. May want to let belly expand first, then chest as you inhale deeply (belly breathing). Or may let chest expand as you inhale (deep chest breathing). Make sure its rhythmic, calming and relaxing.

Light Breathing: helps manage labor pain when you can no longer relax during contractions, when contractions are too painful with slow breathing, or when you instinctively begin speeding up your breathing. Many women switch when contractions are close together and intense. When in active labor, let responses to contractions help you decide when to use. If partner notices you losing rhythm, tensing, grimacing, clenching your fists, or crying at peak of a contraction, he may suggest switching to light breathing.

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

Rehearsing Light Breathing for Labor – you may not feel this is right for you when you practice – may make you tense or that you’re not getting enough air. With practice, it will become 2nd nature and you’ll be able to work with body easier during labor. Will come more naturally as labor becomes more intense. Just as running makes you breathe faster to meet oxygen needs. Take 1 breath every second or 2, for 10 seconds. If you take between 5 and 10 breaths in that time, you are doing it correctly. Continue for 30 sec – 2 minutes. When you can do effortlessly for 2 minutes, try adaptation is following seconds.

If you become lightheaded/dizzy, try to focus on exhalations, perhaps by making small sounds while exhaling such as “hee hee hee” or “puh puh puh” – by doing so, body will naturally inhale as much air as it needs. Breathing lightly through open mouth may cause dryness. Try touching tip of tongue to roof of mouth just behind teeth or hold moist washcloth near your mouth. During labor, may also sip water or other fluids between contractions or suck on ice or popsicle. Brushing teeth, rinsing mouth can also relieve dry mouth.

Partners: Interject encouraging works. Ex: 1, okay, 2 good, 3 let go, 4, just like that, 5 great. During labor, the # of breaths per contraction won’t vary significantly from one to the next, so you’ll be able to figure out peak and half over. Point out when she’s passed half way.

Adaptations to Breathing Techniques: ways to adapt rhythmic breathing by combining slow and light breathing patterns. During labor, try switching to one of these techniques to cope if you become overwhelmed or exhausted, can’t relax or begin to despair. May even discover a spontaneous rhythmic pattern of your own in labor.

Vocal Breathing: combines slow or light breathing with vocalization. As you exhale with each rhythmic breath, you moan, sigh, count, sing, recite poems, recite affirmations, chant or make or say other sounds or words. Low-pitched moans. Loud high pitches sounds, especially if lost rhythm, may indicate suffering or fear – partner can ask “Are the sounds you’re making helping you?” if they aren’t, partner can help lower pitch by moaning with you and maintaining your rhythm with the Take Charge Routine (pg 256). If it helps you cope, no one should change. Support team should keep doors closed so you can make sounds as you please.

Contraction – Tailored Breathing: use intensity of contraction to guide rate and depth of breathing. If contractions peaking slowly, breathe slowly when each contraction begins. As contraction intensifies, quicken and lighten breathing past the peak. As contraction subsides, gradually slow and deepen breathing. Think of each exhalation as a way to relax completely. If contractions are peaking quickly, slow breathing 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

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

Asymmetrical Movement and Positions: Lunge, Side-lying and Semi-Prone- one side of body is doing something different than other side. Try on both sides. Use the side that’s more comfortable or alternate sides.

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

A Note to Fathers and Partners About Relieving Back Pain – the following can help reduce back pain and make her move more comfortable. If one doesn’t work, try another.

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

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

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


4 stimulating pads are placed on back, then connected to small hand held battery operated generated. Between contractions, set intensity to level that feels comfortable and set stimulation to burst mode. When contraction begins. Change stimulation to continuous mode. As back pain increases, increase intensity. Specially designed maternity TENS available – Check with caregiver.

MISSING 232-236

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

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

Chapter 12 – What Childbirth is Really Like

  • PCN Pg 264 
Protecting Your Perineum form a Large tear or an Episiotomy: choose a caregiver who prefers to avoid episiotomies and has a low rate (less than 20%); good nutrition promotes healthy tissues, so eat well during pregnancy; perform perineal massage regularly for a few weeks before birth; when you push, bear down for only 5-7 seconds each time; use positions that put minimal strain on perineum – side lying, kneeling, hands and knees; pant lightly and listen to caregivers directions to avoid pushing while baby’s head and shoulders are being born.


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:

  • Need/wish to start labor
  • Prolonged active labor
  • Concerns about baby’s well being
  • Prolonged 2nd stage of labor
  • Preterm labor and premature birth
  • Gestational hypertension
  • Multiples
  • Breech and other difficult presentations
  • Complications in 3rd stage
  • Rapid unattended birth
  • Prolapsed cord
  • Seriously ill newborn or infant death
  • The Need or Wish to Start Labor
  • Common Medical Reasons for Induction – if caregiver knows/suspects any of following has occurred, baby and mom will be closely monitored for signs of distress
  • Post-date pregnancy – >42 weeks (many caregivers shorten to 40.5 or 41.5 weeks). After 42 weeks, baby has 5-10% risk of postmaturity, condition in which placenta stops functioning well, baby’s growth slows or stops, and risk of stillbirth gradually increases.
  • Rupture of membranes – after woman’s bag of water breaks, risk of infection increases. If labor doesn’t start on its own within 24 hours (or sooner if tested positive for Group B strep), caregiver may recommend induction
  • Lack of growth in baby – if baby is no longer growing or thriving in uterus
  • Genital herpes – woman is having frequent outbreaks in late pregnancy may induce labor between outbreaks to avoid cesarean
  • Illness in mother – gestational hypertension or diabetes; if illness intensifies over time. Induction recommended if birth will alleviate/cure illness
  • Fear of macrosomia (big baby) – ultrasound scan suggests baby is large for mother’s size and build or is growing rapidly
    • studies on accuracy of scan estimates show margin of error of at least 10%; often overestimates baby’s size. In cases of shoulder dystocia, only 30% occur in babies that weigh more than 8.5 lbs. inducing baby because of suspected large baby more often causes labor to stop (arrest of labor), increasing need for cesarean. So don’t recommended on list of medical reasons

Elective Induction (Social)

  • Convenience for caregiver’s schedule – when caregiver is on call
  • Convenience for family’s schedule, support needs or circumstances – for those who can help out after the birth or if woman lives far from hospital or those who need to arrange care of other children during the birth. Or those who had a previous rapid birth and want to better control timing
  • Discomfort in late pregnancy
  • Pregnancy reaches term – 37 weeks, but babies benefit from pregnancies that last closer to 40 weeks. Elective induction shouldn’t be done before 39 weeks to allow babies lungs to fully mature

Reasons to think carefully before consenting to induction – today, elective inductions far outnumber medical inductions in many hospitals. Induce labors outnumber spontaneous labors.

  • Induction leads to a more medicalized birth, with more interventions, such as IV fluids and EFM and fewer options for natural coping and less freedom to move around or use bath/shower.
  • Intervention may make contractions more painful, which may increase need for pain medications
  • It bypasses baby’s ability to start labor at optimal time; babies continue to mature and develop in last weeks of pregnancy. Can cause a premature birth if done too early. It has contributed to rising rate of prematurity in U.S.
  • All methods of inductions carry possible risks, esp uterine hyperstimulation (contractions too strong/frequent) and higher likelihood baby won’t tolerate labor (Ad indicated by EFM)
  • No guarantee that induction will get labor started; if it fails, cesarean is typically performed. Those who had it were 2-4x more likely to have a cesarean.

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.

Self-help Techniques

  • Walking – long walks can help start labor however its more effective at keeping active labor going than it is at starting labor, when extensive walking may just exhaust you
  • Intercourse/orgasm – orgasm causes release of oxytocin and prostaglandins, 2 hormones that cause uterine contractions and may start labor. Semen also contains prostaglandins. Frequent sex more effective than single act
  • Nipple stimulation – release of oxytocin, lightly stroke or have partner gently caress or suck on them or use pump.   Occasionally, it causes contractions that last too long or are too frequent or painful, so discontinue
  • Castor oil – bowels stimulated to empty. It is a strong laxative thought to increase prostaglandin production. Enemas are also used to stimulate bowel movements, but current studies found them ineffective at starting labor.
  • Acupressure

Complementary Medicine Methods – require supervision of trained professional

  • Herbal tea and tinctures – blue cohosh tea causes uterine contractions but can cause blood pressure to rise to unsafe levels
  • Homeopathic remedies
  • Acupuncture – no known risks. Needles placed at strategic points along meridians, or energy flow lines. Little scientific evidence on effectiveness, but few studies show its beneficial. Moxibustion – burning herbs placed close to acupuncture point

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

  • Balloon dilators – have been found to speed up onset of labor by ripening cervix and causing some dilation. Foley balloon catheter (originally designed to empty bladder) or cervical ripening balloon is placed within cervix, where it remains until it falls out when cervix begins to open or until up to 12 hours have passed and its removed.
  • Stripping (or sweeping) membranes – usually quick and relatively noninvasive. Caregiver inserts a finger into cervix to loosen bag of waters from uterine wall in order to prompt the release of hormones that start contractions. May be painful (similar to vigorous vaginal exam) and may cause slight bleeding and cramping, but studies have found it to reduce time until labor begins.
  • Artificial rupture of membranes (AROM) – also called amniotomy; caregiver breaks bag of waters with an amniohook, a long plastic device that resembles a crochet needle. It is rarely successful if cervix is unfavorable, in which case caregiver uses cervical ripening technique prior.
    • Risks and Benefits:
      • AROM for Induction – increases chance of starting labor, especially when used with Pitocin; however, if labor doesn’t start after AROM, chance of cesarean increases. Bacteria can enter uterus after membranes are ruptures, which increases chances of infection to you or baby over time. If need induction for medical reasons, chance of success increases if use it with Pitocin. If want to avoid cesarean, consider trying Pitocin without AROM. If Pitocin doesn’t start labor, it can be discontinued and tried again in a day or 2.
      • AROM to speed up active labor – bag of waters may bulge through cervix during contractions. Performing AROM at this time may cause baby’s head to press more firmly on cervix, likely making contractions suddenly more painful and speeding up labor progress. Without AROM, membranes often remain intact until 2nd stage of labor, and then break spontaneously.
        • If labor is progressing well, might not need AROM. If labor is progressing slowly because baby is an unfavorable position such as OP or her head is tilted back or to the side, may prefer to try other options first to correct baby’s position and speed up labor.
        • Advantage of not rupturing membranes is bag of waters provides baby some cushioning and room for moving into a favorable position. Rupturing membranes may cause baby’s head to stay in an unfavorable position, potentially causing a longer or more painful labor.

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)-

  • Serial Induction – Pitocin discontinued at night to allow you to eat and sleep. May improve chances of vaginal birth. May take several days for labor to start, which can be emotionally and physically draining for you and partner. Done less than in past because family occupying birthing room for days is costly.
  • AROM – membranes are ruptured and dose of Pitocin may be increased quickly. May start labor, but must do so within a certain time frame (12 -24 hrs). if don’t have steady dilation, induction considered a failure and cesarean becomes necessary.

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

  • Call hospital before leaving home for schedule apptmt. They can’t predict women in labor at one time so fi it’s especially busy, you may be told to call back in a few hours when they have room for you
  • Be prepared to wait. may start in 6-8 hours or may take 3 days or longer. Pitocin most commonly used drug and sometimes takes several hours. Induction that begins with an unripe cervix often takes a very long time to work, or it may fail. If cervix is unripe, induction is postponed so you can have prostaglandins or cervical dilators inserted to ripen cervix. Cervical ripening may require several trips to the hospital
  • Expect continuous EFM, which restricts ability to use self-help comfort measures. Ask if wireless or telemetry monitoring is available
  • Expect to become hungry if they restrict eating while receiving Pitocin. Pitocin increases risk of cesarean section and surgery is safest with empty stomach
  • Be prepared for contractions more intense. Labor is often more painful when induced rather than spontaneous
  • Prolonged Active Labor – in 1st stage, early phase is prolonged if it takes longer than usual for cervix to dilate to 4-5 cm and enter active phase. Usually resolves with time, self care and changes to environment that reduce stress and increase body’s release of oxytocin.
  • In active labor, cervical dilation speeds up, contractions become more painful and labor progresses with each contraction. If labor slows or stops in this phase, it may indicate problems with mom or baby.
  • Prolonged active labor can result from a number of things affecting mother: full bladder, medications, immobility, ineffective contractions, baby in unfavorable position, dehydration and lack of nourishment, exhaustion or stress caused by environment, discouragement, anxiety of fear
  • Self-Help Measures to Speed Up Active Labor – way to speed it up depends on cause
  • Full bladder – empty every hour or so
  • Medications – allow time to let them wear off, if it’s safe to do so
  • Immobility – walk or stand to let gravity help baby descend. Shift from lying on one site to sitting or hands and knees
  • Ineffective contractions – Acupressure, nipple stimulation, walking, standing
  • Unfavorable position – try to improve
  • Dehydration – drink plenty of fluids and eat food that gives you energy, if allowed
  • Exhaustion/stress – reassurance, encouragement, safe and nurturing environment, comfort measures and relaxation techniques
  • Medical Care for Prolonged Active Labor – if both tolerating delay, there may be time to let problem resolve itself or determine cause and intervene as necessary.   Additional vaginal exams likely to check for progress in cervical dilation and in baby’s descent or rotation. May receive IV fluids to prevent or treat dehydration. Caregiver may rupture membranes or administer Pitocin.
  • If at birth center or home, transfer to hospital becomes necessary if you need Pitocin or if baby isn’t tolerating labor well. It’s the most common reason for transfer to hospital.
  • If monitoring shows baby is not tolerating well, or if labor continues to lag after Pitocin, cesarean may be necessary.
  • Slow Active Labor Caused by Baby’s Position – one of most common reasons (malposition). 25% of women begin labor with baby in OP – baby’s head towards back. Can prolong labor because baby’s head must rotate further than usual to face mom’s front or OA, favorable position for birth. When baby is OP, cervical dilation and baby’s descent might not progress efficiently.
  • By transition stage, most OP babies have turned to OA position on their own, although some turn after. When low in birth canal, some OP babies are turned by caregiver, who reaches inside vagina and rotates baby’s head to OA; this has a significant success rate. Other babies are born in OP (sunny side up) or by cesarean.
  • If baby is OP or malpositioned (Such as brow/face presentation), may have considerable back pain because baby’s head is pressing unevenly on sacrum, straining sacroiliac joints. May also occur if baby is transverse.
  • Back pain or prolonged active labor is sometimes caused by a subtle malposition called asynclitism, in which baby’s head is tilted and the top of it isn’t centered on the cervix. The head doesn’t press evenly on cervix, which makes dilation less efficient and it doesn’t fit through pelvis as well. When baby’s head is tilted, part of head that emerges first is larger than normal. Its difficult to diagnose in labor because it’s not as clearly associated with back pain as OP. clues include delayed dilation or uneven dilation – cervical lip. Another clue is a swollen cervix that seems to have closed a few cm. after birth of head, its shape is also a clue (off center elongation)
  • What You Can Do If Baby is Malpositioned – can be difficult to identify position. Assume baby is malpositioned if labor progress has slowed, you have back pain or if have irregular or coupling contractions. Try different positions. Once baby’s head fits into pelvis, back pain often subsides and labor progress improves.
  • Medical Approaches to Relieve Back Pain
  • Sterile water block – if have severe back pain but want to minimize use of pain medications, this is a promising option. Caregiver injects tiny amounts of sterile water into 4 places on lower back. Provides almost immediate pain relief by rapidly increasing endorphin production in area around injection sites. Effects last hour or two. First injections may feel like bee stings for up to 30 sec but additional are less noticeable. Doesn’t relieve abdominal pain
  • Medications for pain relief – if have severe pain during prolonged active labor, can ask for epidural or spinal narcotics.
  • Concerns about Baby’s Well-being
  • Most healthy full-term babies get a better start in life if they undergo labor. Contractions jump-start many process that improves a baby’s transition to life outside the womb, such as breathing, temperature regulation, alertness and suckling.
  • During a contraction, the amount of oxygen that’s available ot the baby varies. Although most compensate well, a few can’t and show signs of distress. EFM of heart rate patterns indicate they’re not getting optimal amount of oxygen during contractions. Described as having nonreassuring fetal heart rate, fetal intolerance of labor or fetal distress.
  • Presence of meconium may indicate a baby isn’t compensating well for varying amount of available oxygen during contractions. When a baby’s oxygen supply is low, her intestines cramp to send oxygen-rich blood to other areas that need oxygen the most (such as her brain). This cramping causes meconium to pass. When a woman’s bag of water breaks, the caregiver notes the presence of meconium.
  • Although EFM and presence of meconium don’t always identify oxygen-deprived babies, caregivers won’t hesitate to take measures to improve baby’s well-being if either assessment indicates distress.
  • What you can do if baby has nonreassuring heart rate pattern – need professional help. Follow caregivers request to change positions, breathe deeply; these measures are often enough to restore baby’s heart rate to normal
  • Medical Care for Babies in Distress During Labor – sometimes the problem resolves itself without intervention. If baby is pressing on umbilical cord and constricting flow of oxygen-rich blood, he may shift his position so he moves off the cord, thereby restoring normal blood flow.
  • If intervention is necessary, there are several options to restore a baby’s heart rate to normal. May breathe oxygen by mask and change position to increase baby’s heart rate. If Pitocin is causing contractions too intense, dose can be reduced to slow or stop contractions, increasing amount of available oxygen to baby. if not receiving Pitocin, can receive a tocolytic (anti-contraction) medication to slow or stop contractions and allow oxygen levels (and thus baby’s heart rate) to improve.
  • If volume of amniotic fluid is too low to cushion the umbilical cord, caregiver may use amnioinfusion, a procedure that replaces enough water in your uterus to remove the pressure on the cord caused by your baby’s head or trunk. If these don’t resolve problem or conditions worsen, cesarean may be necessary.

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

  • Episiotomy – surgical incision of perineum that enlarges vaginal outlet. Performed before baby’s head is born as perineum is stretching. Has been found to short time to birth by 5-15 min, which may be necessary if baby is in distress. May recommend if using forceps to deliver or if shoulder dystocia suspected. After birth, repaired with sutures and mom may have moderate to severe pain during first few days.
    • Routine Episiotomy – studies in 90s found no benefit and some risks to this. Caregivers who continue (some have rates as high as 80%) hold on to 2 outdated beliefs: spontaneous tear is worse and that stretched perineum is more damaged. Most spontaneous tears (half of vaginal births) are smaller than average episiotomy and serious large tears are more likely to occur with one. If baby is in distress in late 2nd stage, it may be necessary.
  • Vacuum Extraction and Forceps Delivery – silicone suction cup vs long steel tongs. Vacuum used more often. Both used more often on those with epidurals. Caregiver pulls on it as woman pushes during contractions.   Both instruments are generally safe although bruising; swelling and scraping of baby’s head often occur. Caregiver discontinues use if its obviously baby isn’t descending. At that point, cesarean becomes necessary.
  • Vacuum Extraction and Forceps Delivery

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:

  • may be asked to drink 1-2 large glasses of water and lie down for an hour, then call again if contractions contraction. Mild dehydration sometimes causes contractions
  • if go to hospital, contractions are evaluated with EFM and may receive vagina exam or ultrasound to discover whether cervix is changing. If it isn’t changing, you aren’t in preterm labor. May have an active or irritable uterus and may be told to rest
  • if cervix is changing, caregiver checks whether baby’s lungs are mature enough so he can breathe on his own after birth. Withdraws small amount of amniotic fluid from uterus (amniocentesis) and analyzes surfactant levels
  • If baby is immature and birth seems unavoidable, focus of care shifts to prevention of respiratory distress syndrome (RDS)- the most common complication of premature birth. Caregiver may tri to delay birth for a day or 2 in order to allow time for corticosteroids to speed up maturing of baby’s lungs. This reduces incidence of RDS by 40-60%; they may also help decrease intracranial bleeding (Brain hemorrhage) in newborn
  • Drugs used to stop/slow preterm labor are powerful and have strong side effects. Highest doses used only for a day or two then lower doses combined with bed rest for longer period to keep preterm contractions from increasing in frequency and intensity
    • beta mimetic agents (terbutaline and ritodrine)
    • calcium channel blockers (nifedipine)
    • prostaglandin inhibitors (naproxen and indomethacin)
    • oxytocin receptor antagonists (atosiban)
    • magnesium sulfate (used to treat gestational hypertension has also been used to stop preterm labor but has proved unsuccessful and produces uncomfortable side effects and is dangerous to baby
  • Giving mom systemic pain mediations (narcotics) isn’t recommended since can affect baby’s heart rate and sometimes breathing after birth. Plan to use relaxation and breathing patterns for pain relief in early labor and can request regional anesthesia (epidural) in active labor, which has less effect on newborn

Care of the Premature Baby:

  • If baby is born before corticosteroids have had enough time to mature her lungs, treatment for RDS becomes necessary, which includes administering oxygen and mechanical assistance with breathing. Baby may need to have surfactant instilled into her lungs, which allows lungs to expand during an inhalation and remain partially inflated during an exhalation
  • If baby is very premature, may need to transfer to hospital with intensive care nursery. Because baby is at high-risk, heart rate may require continuous monitoring
  • Might not be allowed to hold baby right away. Most premature infants taken to special care nursery or NICU, where they stay until they can breathe on their own, stay warm at room temperature and breastfeed or take a bottle
  • Baby may require prolonged hospitalization. Participating in baby’s care benefits both child and adults.

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.

  • Multiples (Twins, Triplets or More) – Higher risk of complications such as preterm rupture of membranes, preterm labor, preeclampsia, prolonged labor, prolapsed cord and babies who are malpositioned or who are premature or small in size for their gestational age. Labor/birth usually more complicated than birth of a single baby; for example a woman’s overstretched uterus sometimes can’t contract efficiently, which slows labor progress and increases risk of postpartum hemorrhage.
  • Risk of these difficulties increase as number of babies increase. Expect more medical supervision and more interventions..
  • Timing is a controversial topic; some believe that waiting until labor starts on its own can affect babies well being – that multiples are born healthier if labor is induced or cesarean is scheduled between 37 and 39 weeks. Studies have found inconsistent results. Others believe physiological process of labor is best for mom and baby.
  • May recommend epidural in case an intervention that may be painful for mom is needed to deliver 1 or more babies (such as forceps). Although twins often born vaginally at term, rate of cesarean birth for twins is higher than for single babies and rate increases with number of babies. Its rare for triplets or more to be born vaginally at term.
  • Vaginal birth of twins – ultrasound during labor to identify babies’ presentations. Results determine whether vaginal birth or cesarean birth is best for babies’ well being and your own. If vaginal birth is attempted, it likely occurs in an operating room in case a cesarean becomes necessary.
  • Most favorable presentation is vertex and in most cases both babies are vertex at time of birth. If both babies are breach, cesarean is performed. If 1st baby vertex and 2nd is breech, caregiver may attempt to turn 2nd baby after vaginal birth of first or 2nd baby may be born breech. Birth of 2nd baby usually occurs within 5-30 min after the first.
  • Breech and Other Difficult Presentations – typically at birth, baby positions herself so her head is over the cervix; this vertex presentation is most favorable for vaginal birth. In 5% of births, baby is in less than favorable presentation. Face and brow occur in less than half of 1% of births; they usually prolong labor. Very rare shoulder presentation (transverse lie) 1/500 birth; cesearean usually necessary.
  • Breech presentation occurs in 3-4% of births, although incidence rises with multiples or premature births. 3 types:
  • Frank: baby’s buttocks are over cervix and legs are straight up toward her face (most common breech)
  • Complete – sitting cross legged over cervix
  • Footling: one or both of baby’s feet are over cervix

In U.S. breech babies are typically born by cesarean. Many women try to turn breech babies before birth by using self help techniques.

  • Self-Techniques to Turn a Breech Baby– By 34-36 weeks, baby should assume his birth position. Effectiveness hasn’t been formally studies; others have been studied and found ot be mostly ineffective. But pose few if any risks. Even in success is low, try may decrease risk of cesarean
  • Breech Tilt Position –hips 10-15 inches higher than head. Exaggerated open knee chest or hands and knees with buttocks high in air. 10 min 3x a day, when baby is active. To ease discomfort, make sure your stomach and bladder are empty. Try to relax abdominal muscles and visualize baby somersaulting so her head is in position over your cervix. May feel baby squirm as her head presses into the top of your uterus (fundus)
  • Use of sound– during active phases, babies can hear well and often respond to sounds. By playing pleasing or familiar sounds low in uterus, baby may move head down to hear. Can play through headphones placed just above pubic bone. Partner can talk to baby.
  • Use of cold on fundus – if area becomes uncomfortable cold, baby may move head. Makes sure to have a layer of cloth between ice pack and skin. No longer than 20 min at a time

Complementary Medicine Methods

  • Acupuncture – Urinary Bladder 67, located on outside tip of each little toe. Can also use moxibustion; some reports show success rate for turning breech by onset labor 50%
  • Webster technique – analysis of mom’s pelvis, adjustment of her sacrum and relief of abdominal muscle tension. Goal is to relieve any uterine constraint that may be preventing baby from moving into a favorable birth position. Hasn’t been formally studies but popularity is growing.
  • External Version – 37-38 weeks but some consent earlier on an experimental basis. Studies show it’s a safe procedure with a ~65% success rate.
  • Baby receives stress test before and after
  • Using ultrasound, confirms breech, estimates volume of amniotic fluid, visualizes uterus, cord and site of placenta and plans direction in which to move baby. it isn’t done if volume if low or you have uterine abnormalities. Procedure may be avoided if placenta is implanted in front wall of uterus
  • Receive an injection of a tocolytic drug (such as terbutaline), which relaxes uterus. Make may you feel a little nervous or shaky
  • Caregiver presses and pushes on baby through abdominal wall, encouraging him to turn to a vertex presentation

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.

  • Birth Options for a Breech Baby– although vaginal breech births usually result in healthy babies, it carries risks. May increase risk of prolapsed cord or even spinal cord injury, a rare problem that can occur if baby’s head is tilted back (hyperextended) when passing through birth canal. Another potential risk is compressed cord. During vaginal breech birth, baby’s feet and body are born before head. As baby’s head comes through, it can compress cord and reduce amount of oxygen in blood coming from placenta. Because baby’s feet and buttocks are smaller than her head, they may be born before cervix dilates enough for her head to pass through, in this event, birth of her head may be delayed, causing distress.
  • Because of potential of complications, cesareans have become routine in U.S. since 70s. fewer caregivers learned skills to conduct them. In 2000, influential study found that breech babies born by cesarean had better outcomes. Recent criticisms of story.
  • In other parts of world, vaginal breech births are common. In Europe and Australia, they are routine.

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.

  • Complications in 3rd stage of labor 3rd stage begins with birth of baby and ends with delivery of placenta

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.

  • Uterine Atony – poor uterine muscle tone and its most frequent cause of postpartum hemorrhage. If uterus doesn’t contract after birth, caregiver will massage it to encourage contractions. Nursing baby or lightly stroking nipples also helps contract uterus by stimulating release of oxytocin. If these measures don’t control bleeding, caregiver may give you Pitocin to promote contractions.
  • Lacerations – tears of cervix, vagina or perineum may occur, regardless of whether you had an episiotomy. If have lacerations, they’ll be sutured to control bleeding. Vagina may be packed with sterile gauze to further stop blood flow.
  • Retained Placenta or Placental Fragments- if placenta or fragments of it aren’t expelled form uterus, they interfere with postpartum contractions and allow blood to flow freely through vessels at the site where the placenta attached to your uterine wall. Placenta or fragments are removed, receive Pitocin or another medication to contract your uterus and uterus is massaged to promote further contractions. Can continue treatment by massaging uterus yourself and by breastfeeding baby. in rare cases, placenta cant be separated from the uterine wall (placenta accrete). The only safe treatment for this serious complication may be a hysterectomy (removal of uterus).

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

  • Get help, if possible. Even a child can assist you
  • Gather clean sheets, towels, paper towels, tissues and extra clothing
  • Wash hands
  • Remove all clothing from bottom/vaginal area
  • Lie on side or sit leaning back – make sure in clean place with enough room for baby to rest as she slips out
  • Put sheet, towel or some clothing under bottom
  • Try not to hold breath if body is pushing. Pant through each contraction until baby is born
  • After baby is born, wipe away any mucus from nose/mouth. Remove any membranes covering her face. Wipe her head and body to dry her. Place her on your bare abdomen or chest to keep her warm. Cover with cloth, towels, clothing
  • Don’t cut cord!
  • Put baby to breast and let her breastfeed
  • If at home, await birth of placenta (if hasn’t expelled in 15-20 min, try kneeling to see if gravity can help it come out. If unsuccessful, go to hospital)
  • Place placenta in nearby bowl, newspaper or cloth
  • Place towels or pad between legs to absorb blood flow
  • Go to hospital or get medical help a.s.a.p. to check both you and baby. medical professional will cut cord.

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.

  • If baby doesn’t breathe spontaneously – have someone call 911 if possible. Place baby on stomach with his head lower than his trunk, then rub his back briskly but gently. If he doesn’t respond within 30 sec, hold his ankles together and smack the soles of his feet sharply. If still doesn’t breathe, check for mucus in mouth with finger. If know how to give infant CPR, do so. If you don’t, call 911 for help.
  • If you have excessive bleeding from vagina – more than 500 milliliters or 2 cups may indicate postpartum hemorrhage, esp if you begin to have symptoms of shock such as rapid pulse, pale skin, trembling, faintness, feeling cold and sweating. Firmly massage fundus (top of uterus( ina circle until uterus contracts and encourage baby to nurse (or you or partner can stroke nipples to stimulate release of oxytocin)) to stimulate contractions. To avoid shock, like down and elevate hips so they’re higher than head.

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:

  • Get into open knee chest position so gravity can help move baby away from cervix and possibly off cord.   Might or might not be able to feel cord in vagina
  • Arrange for immediate transportation to hospital
  • Remain in knee chest position in vehicle/ambulance
  • When arrive, tell staff you may have prolapsed cord. Nurse will insert hand into vagina to keep baby off cord. Expect cesarean asap

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):

  • Chance of rupture lowest for woman who has had only 1 prior cesarean with a low transverse scar and who hasn’t been induced
  • Chance or rupture higher if woman has had more than 1 prior cesarean, had an infection after prior cesarean, had cesarean less than 18 months ago or has had labor induced
  • Chance highest (and too risky) for woman who has had vertical incision or inverted T or J shaped incision for prior cesarean, had a rupture from previous labor that caused problems, or had ultrasound scan that found uterine scar to be less than 2.5 millimeters thick

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:

  • Mother has had multiple prior cesareans, has complicating medical conditions, or obese
  • Gestation >40 weeks and baby estimated to weigh >9 lbs
  • Labor induced/augmented

Improving Chances of Having Successful VBAC:

  • Choose caregiver who has high VBAC attempt rate and success rate of 70%+
  • Consider hiring doula who has had VBAC herself or has worked with women VBACs
  • Take childbirth refresher class or VBAC class
  • If cesarean was traumatic, contact local branch of ICAN – International Cesarean Awareness Network; mission is to prevent unnecessary cesareans through education, provide support for recovery and promote VBAC. see paper “Your Right To Refuse: What do to if your hospital has banned VBAC”
  • Try to minimize medications for pain relief and use interventions only if necessary
  • Review “10 steps to improve chances of having a safe and satisfying birth” and “Reducing chances of having a cesarean”

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

  • Fear – may fear labor pain, long labor, uterin rupture, complications, another cesarean, failure to deliver normally or simply the unknown. Discuss fears with caregiver, childbirth educator, doula, or cesarean support group. They can help you identify the most distressing parts of your previous birth and help you plan nhow to avoid or address them. You may plan not to wait for hours before having cesarean if have another long labor that doesn’t progress
  • Shame/guilt – talk with others who understand your feelings so you can approach this birth with fresh perspective
  • Lack of confidence – remember each pregnancy and birth is different. Get to know women who’ve had successful VBACs. Perhaps they visualized the birth experience they hoped for
  • Feeling pressured – may feel pressured to make one decision or another. You have the right to make an informed decision. Only you can make the decision that’s best for you and your family
  • Stress in labor – specific events in VBAC may increase stress:
    • When early labor is underway, you may suddenly second guess whether it’s a good idea. Think of ways to deal with this beforehand
    • Particular events in labor may trigger flashbacks. Don’t suppress them, even in unpleasant. Acknowledge and note how things are different this time
    • Big hurdle may be reaching point in labor that led to previous cesarean. Until you pass that point, may question ability to birth vaginally. After you’ve passed it, breathe a sign a relief and enjoy a boost of optimism

Having the Best Possible Cesarean Birth:

  • Educate yourself – learn about procedure from books, classes and discussions with caregiver. Learn birthplace policies and regulations
  • If planned cesarean is necessary, prepare in advance – eat well and exercise regularly. The more physically fit before surgery, the quicker recovery
    • Tour hospital, including special care nursery. Ask to have an lab work, tests and paperwork done before day of surgery. Meet with anesthesiologist to discuss options and learn what medications he wil use
    • If hospital allows for 2 support people, ask for a friend/family member to join. Or consider doula. Her calm, familiar presence and knowledge of cesareans can reassure you. After baby is born, she can remain by your side while partner is with baby
    • Take breastfeeding class with partner so you both know ways to help make nursing after cesarean easier
  • Wait for labor to begin (or at least wait until 39th week) – if caregiver recommends cesarean before labor, be certain there are clear medical reasons. There are advantages to waiting until labor begins on its own. Ask caregiver to schedule surgery as close as possible to due date and ask about amniocentesis to verify baby’s lung maturity
    • Labor benefits babies – babies born by scheduled cesarean without experiencing labor are 4sx more likely to develop persistent pulmonary hypertension, a potentially life threatening situation
    • Severe complications, including breathing difficulties, infection and other problems that require admission to NICU 2x as likely for babies born at 37 weeks than babies born at 39 weeks
    • Not waiting for labor to begin for planned cesarean can lead to accidental prematurity of estimated gestational age is wrong. Knowing exact date of conception, having ultrasound scan early in pregnancy that documents gestational age or having baby’s lung maturity verified are ways to better estimate

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

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

Systemic Medications

IV Narcotics or Narcotic-like Analgesics

  • How/When Given: IV by direct injection or injection into an IV line. Sometimes, patient controlled analgesia (PCA) used. Can also be given by IM injection. Given in early to active labor, when it’s believed birth is at least 2 hours away. Also give after cesarean
  • Drugs Used: morphine, fentanyl (sublimize), meperidine (Demerol), butorphanol (Stadol), nalburphine (Nubain); stadol and nubain are combination drugs which contain a narcotic antagonist to lessen side effects
  • Benefits: during active labor, drugs reduce awareness of pain and promote relaxation between contractions. Large doses of narcotics (esp morphine) may be used in a prolonged prelabor in hopes of slowing or stopping contractions and allowing you to rest.
  • Possible Risks:
    • You: itching, nausea, vomiting, drowsiness, hallucinations, dizziness or feeling of being high; may lower heart rate, respiratory rate and BP; may affect ability to use self-help comfort measures; may temporarily slow labor progress
    • Baby: may make heart rate readings appear normal; after birth may slow breathing or alter behavioral responses (poor suckling) for several days
  • Additional Precautions/Interventions: possible restriction to bed/IV fluids; frequent monitoring of BP and baby’s heart rate; frequent reminders for you to breathe deeply and help to keep you oriented; narcotic antagonists, if needed to reduce side effects; changes in your position or admin of oxygen to improve baby’s heart rate pattern; discontinuation of medications at least 2 hours before birth to reduce side effects on baby; oxygen and resuscitation equipment on hand if baby is born within 4 hours after narcotics given
  • Additional Systemic Medications Less Commonly Used in Labor
    • Sedatives and barbiturates such as Nembutal or Phenobarbital, which are given by pill/injection; used for anxiety or in larger doses to help you sleep during a slow, painful prelabor. May be used before 4 cm dilation but should be discontinued before active labor to reduce effects on baby. rarely used in U.S. and Canada
    • Tranquilizers such as Phenergan, Versed or Valium given by pill or injection. Used for anxiety in early labor or following a cesarean. Not used in active labor because effect on newborns
    • Inhalation analgesia (nitrous oxide), inhaled through mask. Doesn’t eliminate pain but effects on mental state mean you’re less troubled by pain. Drug is rapidly metabolized, which means few or no side effects on baby. rarely used in U.S. but common in Canada
    • Narcotic antagonists such as Narcan, which are given by injection in labor if narcotic medication is causing adverse side effects of by injection into newborn with breathing problems caused by narcotics given shortly before birth
    • General anesthesia, in which induction agent given by IV, then inhalation agent inhaled through mask. Causes unconsciousness as well as complete numbness. Used in less than 10% cesarean births.

Local Anesthetics

Local Perineal Block

  • How/When Given – by injection around vaginal opening; in 2nd stage, before episiotomy or in 3rd stage for repair of episiotomy or tear
  • Drug Used– Lidocaine (most often)
  • Benefits – numbness in perineum; relief of pain during crowning, episiotomy or stitching after the birth
  • Possible Risks – injections may sting; if given during 2nd stage, may increase swelling in perineum and increase likelihood of vaginal tears. Minimal to no risks to baby
  • Additional Precautions and Interventions– postpose until after birth and use only if stitches necessary
  • Additional Local Anesthetics Less Commonly Used
    • Pudendal block, given by injection deep into vagina. Numbs vagina and perineum during birth. Rarely used except with forceps delivery
    • Paracervical block, given by injection into cervix. Numbs cervical pain and pressure in lower uterus. Given between 5-9 cm. rarely used, because of effects on baby.

Neuraxial Medications (Epidural or Spinal)

Epidural Analgesia with Combination of Narcotics and Anesthetics

  • How/When Given– epidural catheter; given in active labor until birth
  • Drugs Used – combination of narcotic and a “-caine” anesthetic
  • Benefits – decreased pain and numbness (or reduced sensation) in abdomen, back and perineum; increased ability to relax/sleep; mental clarity
  • Possible Risks– reduced mobility, drop in BP, fever, discomforts such as itching, nausea and vomiting, slowed labor progress, decreased urge to push, which may lead to forceps or vacuum delivery; spinal headache caused by epidural needle that has been inserted too far (2% chance), secondary side effects from precautions
    • Baby: same as for IV narcotics although milder; worrisome changes to heart rate pattern, fever
  • Additional Precautions and Interventions– restriction of food/drink, IV fluids, bladder catheter, restriction to bed, various devices to closely monitor you and baby.
    • As needed: oxygen by mask, Pitocin to speed labor, episiotomy, vacuum, forceps, cesarean, blood patch for spinal headache (amall amount of blood injected in epidural space near dural puncture), additional medications to control itching/nausea
      • If baby showing effects – same as IV narcotics
      • If baby born with fever – admittance to special care nursery for 48 hours for observation and antibiotics; septic workup to check for infection (blood test and spinal tap)

Spinal (Intrathecal) Narcotic Analgesia

  • How/When Given– spinal injection, early to active labor
  • Drugs Used – narcotic only
  • Benefits – decreases perception of pain; allows for ability to move freely in bed. May be able to stand with assistance; still feel sensations other than pain (touch, pressure, temp), when compared to iv narcotics, receive more pain relief with less medication. Effects last up to 2 hours
  • Possible Risks– itching, nausea, vomiting; weakness in legs or loss of balance while walking; possible altered mental state, but less so that with IV narcotics and narcotic-like analgesics; spinal headache (less than 1% chance)
    • Baby: same as for IV narcotics, though effects milder
  • Additional Precautions and Interventions– if have spinal headache, blood patch; lying flat for hours/days
    • If baby showing effects of narcotics, same as for IV narcotics

Combined Spinal- Epidural (CSE)

  • How/When Given– spinal injection as early as 2cm with addition of anesthetic at 5-8cm
  • Drugs Used – spinal narcotics given first; epidural analgesia given when needed
  • Benefits – same as for spinal narcotics and epidural analgesia
  • Possible Risks– same as for spinal narcotics and epidural analgesia
  • Additional Precautions and Interventions– same as for spinal narcotics and epidural analgesia

Spinal Block

  • How/When Given– spinal injection; used for planned cesarean
  • Drugs Used – -“caine” drugs
  • Benefits – total numbness from chest to toes, although you may still feel some pressure or pulling during the delivery of your baby. provides excellent pain relief without impairing your mental awareness. Can be administered quickly and takes effect almost immediately. Effects last a few hours.
  • Possible Risks– drop in BP, occasional feeling of being unable to breathe (because chest becomes anesthetized); spinal headache (1% chance)
    • Baby: fetal distress, subtle neurobehavioral effects for day
  • Additional Precautions and Interventions– same as for spinal narcotics and epidural analgesia plus assisted ventilation if breathing difficulties arise

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)


  • Physical Changes: cervix begins to ripen, efface and move forward. Have nonprogressing contractions and may have restless back pain, soft bowel movements and menstrual like cramps; may last for days
  • How you may feel/respond: tired, discouraged, anxious. May be unable to sleep through contractions. May overestimate labor progress, start rituals and go to birthplace. May focus more than necessary on contractions.
  • Ways To Cope: engage in distracting activities and projects; alternate distracting activities with restful ones such as taking a bath, listening to music, lying down, having a massage etc; use labor-stimulating measures (only if you feel pressured to get into labor); eat if hungry (carbs), drink to thirst
  • Ways Partner/Doula Can Help: review route to birthplace; encourage you to eat/drink; pack vehicle and make sure there’s fuel; time contractions (5-6 at a time) every few hours or when labor seems to have changed; ensure you aren’t left alone; help make the time pleasant for you; alert your doula to be ready to come when you need her if she’s not already with you; enhance emotional security and reduce stress by creating a soothing, safe, private and loving atmosphere

First Stage of Labor: Early Labor

  • Physical Changes: denotes time from onset of labor until cervix is dilated 4-5 cm; contractions are progressing, usually mild at first, then becoming longer, stronger and closer together; cervix continues ripening, effacing and begins to dilate; may have bloody show; membranes may rupture (10% chance) but this usually happens later in labor; may have back pain with contractions
  • How you may feel/respond: same as in prelabor plus have mixed feelings – excitement, confidence, and optimism or anxiety and distress – often at same time; as contractions intensify, you can no longer be distracted by them
  • Ways To Cope: begin using planned rituals (relax, breathe, and focus through each contraction) when intensity of contractions stops you from doing distracting activities; use slow breathing, releasing tension with each exhalation; ask doula for help; contact caregiver or birthplace as instructed when contractions have reached 4-1-1 or 5-1-1 pattern; comfort measures for back pain
  • Ways Partner/Doula Can Help: continue timing contractions periodically; call caregiver or birthplace when contractions reach designated intensity, frequency and length or if membranes ruptured; focus on your contractions as soon as you begin doing a planned ritual; give you constructive feedback, not false praise; help you release tension in a selected area of your body with each exhalation; remind you of positions and comfort techniques

First Stage of Labor: Getting into Active Labor

  • Physical Changes: cervix dilated 4-5 cm; contractions intensify and occur every 3-4 min, lasting 1 min or longer; labor progress should begin to speed up at 5 cm
  • How you may feel/respond: head for birthplace or call midwife; may struggle to remain in control and worry that labor is too hard and long; may become serious, withdrawn, and focused on your labor; may recognize that labor isn’t within your control, leaving you feeling trapped – you may weep; you can no longer be distracted during contractions, you need partner or doula’s undivided attention during them; find unnecessary conversation annoying; may want pain meds; can release control and accept your labor if you can move freely, feel safe and uninhibited and have good support
  • Ways To Cope: try to release your need to be in control; let labor happen as you discover what helps you cope (finding your spontaneous ritual); maintain a rhythm with your breathing and movements, letting your partner or doula help as necessary; try to continue slow breathing if you find it restful; remember that labor progress should speed up soon; if planned for early epidural, can probably receive it during this phase
  • Ways Partner/Doula Can Help: drive to birthplace carefully!; use massage (hand or foot), double hip squeeze, counterpressure, slow dancing etc; rhythmically murmur soothing, encouraging words to you; guide you with visualizations, imagery, rhythmic talk or breath-counting – whatever helps you respond well; help you keep a rhythm in your breathing, moaning, swaying, tapping or whatever action you choose; refrain from asking questions during contractions and ask only simple yes or no questions between contractions; help with your ritual (stroking you, holding you, talking to you through contractions) or simply stay by you if that’s all you require; help you follow preferences on pain meds

First Stage of Labor: Active Labor

  • Physical Changes: cervix dilates from 5-8cm; lasts on average 3-5 hours; if baby is OP or her head is tilted to 1 side, dilation of cervix may pause as baby corrects position; may have back pain (30% chance)
  • How you may feel/respond: calmer than before, now that you’ve discovered how to get through contractions; may enter birth zone and become aware or little other than labor
  • Ways To Cope: same as for early labor and getting into active labor plus – take a bath for relaxation and pain relief; stay hydrated by taking frequent sips of water/juice
  • Ways Partner/Doula Can Help: same as for getting into active labor plus stay by you side, offer you liquids, remind you to empty your bladder

First Stage of Labor: Transition

  • Physical Changes: cervix dilates from 8-10 cm; baby begins to descend toward vaginal opening; contractions are long and close together; pain and intensity of labor at its max; lasts less than 2 hours or less than 1 if given birth before; as cervix completes dilation, may have a lip that remains
  • How you may feel/respond: scared/lost; angry/frustrated; may want more help from others; may feel you’ve reached your limit; may lose rhythm and ritual; may cry out, tense, weep or protest; may feel hot, then cold; may tremble; may feel nauseated; may vomit
  • Ways To Cope: Keep a rhythm; follow partner/doula’s lead with Take Charge Routine; Hang in there! ; if want an epidural, can do it at this time as long as labor isn’t moving too fast
  • Ways Partner/Doula Can Help: maintain a confident, calm, optimistic manner; keep eye contact with you; Take Charge Routine; remind you that transition means you’re almost ready to push out baby; hold you tightly if that’s what you want; keep encouraging you and never give up; let you weep while acknowledging your pain

Second Stage of Labor: Resting Phase

  • Physical Changes: time from complete dilation to when begin to push; for up to 20 min, may have few noticeable contractions or have no urge to push; after baby’s head has slipped through cervix, uterus may need time to tighten around rest of baby’s body before you can begin to push
  • How you may feel/respond: feel relief, optimism, confidence and pain-free; have renewed energy, enthusiasm, hope even if you don’t experience a pause in contractions; no longer in the birth zone – your clearheaded, talkative and more aware of your surroundings
  • Ways To Cope: rest or doze, if you can; if want to push spontaneously, remind caregiver of preference, review positions, if resting phase lasts more than 20 min, change to upright positions to encourage an urge to push
  • Ways Partner/Doula Can Help: should match your enthusiasm, use the lull to renew energy (drink beverage, close eyes and rest for a moment, use restroom), help you change positions

Second Stage of Labor: Descent Phase

  • Physical Changes: baby rotates and descends into birth canal; oxytocin surges cause an urge to push, which may be mild at first, but becomes compelling an irresistible. You begin to push reflexively with contractions; contractions aren’t as close together as they were in transition, and they may be shorter; may last for a few min or up to 2 hours; at first, baby’s head can’t be seen then it appears at your vaginal opening when you push and retreats between pushes; your caregiver supports your perineum, applies warm compresses and may direct your pushing
  • How you may feel/respond: may feel inadequate in pushing until you get the hang of it; may find this phase reward, but you may find it painful and tedious. Either way, you’re working hard; may find the pressure in your vagina alarming and fear it will worsen, making you hold back from pushing; may feel less pain as baby’s head repositions
  • Ways To Cope: hold breath and strain when contractions make you feel that you can’t avoid pushing. You may bellow or cry out with effort; try to bulge your pelvic floor; consider touching baby’s head or watching her progress in mirror; if you’re holding back, or if pushing is painful, try to push into the pain and through it. Doing so will feel better than stopping when it hurts. Change your position every 30 min for comfort or to speed up labor progress. Consider directed or prolonged pushing if labor isn’t adequately progressing with spontaneous bearing down; if using directed pushing, follow directions for when and how long to hold your breath and strain
  • Ways Partner/Doula Can Help: encourage and praise your efforts (not yell push); apply cool, damp cloths to forehead, cheeks, neck and chest; report on progress (as soon as baby’s head is visible); remind you to release tension in perineum; remind caregiver of feelings about episiotomy if appropriate; support your position and help you change positions; if pushing is ineffective, remind you to open your eyes and look toward where your baby is emerging (may use a mirror)

Second Stage of Labor: Crowning and Birth

  • Physical Changes: baby’s head emerges; it no longer retracts into your vaginal opening between contractions; perineum and area around urethra are most vulnerable to tearing in this stage; caregiver either supports your perineum (warm compresses) or does episiotomy (unlikely)
  • How you may feel/respond: feel excited because your baby’s birth will be very soon; may feel a burning sensation from vaginal stretching; may have mixed feelings: may be tempted to push hard to get the birth over with or despite the burning. Or you may fear the burning feeling and become reluctant to push.
  • Ways To Cope: recognize the burning as a sign that labor is almost over. Use your partner’s help with positions. To slow the birth of your baby’s head and protect your perineum, stop pushing and pant/blow when your caregiver says; rejoice in baby’s birth!
  • Ways Partner/Doula Can Help: support you as you change positions; refrain from rushing you, help you keep from pushing as needed; say little or nothing when your caregiver is directing you to slow the birth of your baby’s head; rejoice in your baby’s birth!

Third Stage of Labor

  • Physical Changes: lasts up to 30 min; baby’s umbilical cord is clamped and cut; baby’s condition is evaluated using Apgar; if baby is fine and hospital policy allows, baby is placed on bare abdomen or chest; uterus contracts and shrinks, placenta separates from uterine wall. You expel placenta with a few pushes; may briefly tremble uncontrollable (normal); caregiver checks uterus to confirm it’s contraction and checks birth canal for tears
  • How you may feel/respond: feel relief that labor is over; become engrossed with baby; feel concern over trembling; feel alarm if contractions are still painful; feel surprise at discomfort when caregiver examines birth canal or massages your uterus after placenta is expelled
  • Ways To Cope: move away clothing so baby can be skin to skin; don’t rush breastfeeding – baby needs time to acclimate before she’s ready to feed. Let her show you that she’s ready to start suckling; ask for warm blanket to stop trembling; use light breathing and focus on partner or doula during uterine massage and examination or stitching of perineum; try to be patient during postpartum procedures. You’ll have time to focus on baby soon.
  • Ways Partner/Doula Can Help: help you get baby onto bare abdomen; help you breathe and focus through any painful procedures; get you a warm blanket if you’re trembling; open shirt and snuggle skin to skin with baby, if you can’t hold her right away; request that routine newborn procedures be delayed for at least an hour so you can bond with baby; enjoy the time with your new family!


Appendix C – Recommended Resources



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