Pregnancy Childbirth and The Newborn (The Complete Guide)

by Penny Simkin


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Chapter 1

BECOMING PARENTS

The Birth Plan

A birth plan is essentially a list of the options you and your partner prefer for your birth experience. There are several advantages to having such a list:

Advantages to you. Preparing a birth plan requires that you find out, think about, and discuss the available options. It helps you clarify your preferences. The birth plan is a concrete vehicle for discussion with your caregiver. By enhancing communication and clarifying your expectations of each other, a birth plan can build trust and understanding among all members of the childbirth team. Throughout labor and birth, the birth plan frees you from having to explain and re-explain your wishes and expectations, especially when there is a change of nursing staff.

Advantages to your doctor or midwife. A birth plan helps your doctor or midwife understand your goals and expectations. Your caregiver can assist you in preparing a realistic plan that all of you find satisfactory. Prior discussion allows your caregiver to note and discuss any areas of misunderstanding or disagreement, allowing you to talk them over and work out a suitable compromise. Of course, the birth plan is not a binding legal agreement, and even if signed or initialed by your caregiver, it is neither a promise nor a guarantee that circumstances will not require a change in the plan.

Advantages to the nursing staff. The birth plan acts as a guide for the nurses in individualizing your care. When you enter the hospital in labor, you will probably be a stranger to the nurses. A birth plan helps the nurses to quickly become better acquainted with you. It tells them what you really want, as decided by you when you were calm and able to think clearly. Studies show that women have a greater sense of satisfaction with their birth experiences if the desires and expectations they had before birth are met. If not met, they may feel disappointment, anger, or depression. If the nurses know what is important to you, they are more able to fulfill your wishes and expectations.
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Gettng Started with a Birth Plan

If you decide to prepare a birth plan, tell your caregiver beforehand. This may be a new idea for your doctor or midwife, who may be uncomfortable about it at first, especially if he or she is accustomed to making most of the decisions. You will want to explain why you are preparing a birth plan, emphasizing that you want ii to enhance cooperation and trust between you and your caregiver and the nurses. Explain that it will help you to know what to expect under both normal and abnormal circumstances.

Reactions of doctors and midwives vary. Some caregivers believe birth plans are unnecessary, because neither they nor the nurses will make decisions during labor without your consent. Some feel birth plans are a waste of time. They do not realize how helpful it is for you to know in advance whether your desires for care are realistic and acceptable. They may also not realize that without a birth plan you might have to verbally explain your wishes to each doctor, midwife, or nurse involved in your care. This might be more stressful than letting, them read what is important to you and discussing your care in the context of your expectations. If your caregiver is opposed to a birth plan, then you have gained valuable insight and can act on it. You can either give in and give up your birth plan, negotiate, or find another caregiver. At the very least, you have clarified your relationship and will not be confused or surprised in labor. When your doctor or midwife is supportive of the idea of a birth plan, it is an excellent opportunity to discuss and plan together how your labor and birth will be managed. Cooperation and trust are built between you. These carry through the birth experience and add much to the satisfaction felt by all concerned. If problems arise during labor, the underlying understanding and trust are most reassuring if you have to adjust to changes in the plan.
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Language of a Birth Plan

The wording you choose can have a substantial impact on how your caregivers receive your birth plan. Language that clearly expresses your preferences and reflects a spirit of flexibility and cooperation on your part will be greeted by your caregivers in the same spirit. If your list of preferences reads more like a list of demands, it will be received defensively. Be polite and respectful. Phrases such as "would prefer," "if possible," and "unless medically necessary" indicate that you understand that it may be necessary to modify your plan.

Components of the Birth Plan

Your birth plan should contain an introduction and sections on normal labor and birth, care of the newborn, and unexpected events (a prolonged labor, cesarean birth, a premature or sick baby, the death of the baby).

This book discusses most of the routine practices you may encounter. Use it as back ground for your birth plan and for discussion with your caregivers. In addition, because routine practices vary from area to area, your childbirth educator can be a helpful resource as you prepare your birth plan, especially if she or he is familiar with the options available in your community. Use your childbirth educator as a consultant on local practices, choices available, wording to use, or any aspect of the birth plan with which you need help.

The Introduction

The introduction is a paragraph that tells the staff a little about you and explains why your birth plan is important to you. For example, you might want to tell the staff if your pregnancy has been pleasant and healthy; if you have had difficulties with infertility, previous miscarriage, or other problems during pregnancy; if you have a fear of childbirth or of hospitals; if you have religious preferences or special needs; or if a natural or home birth is extremely important to you. Also, you might give any helpful information about your partner or others who will be present. Do they have physical or emotional conditions that may influence their participation in your care? Will there be a unique combination of family members present (for example, adoptive parents, lesbian coparents), children present, or stressful family dynamics? win you be accompanied by an experienced or professional labor support person, in addition to your partner? The nurses can help you more effectively if they have this kind of information. You might also state that you win appreciate the expertise, help, and support of the staff in carrying out your birth plan.

Normal Labor and Birth

When labor and birth are proceeding normany, few interventions are necessary for medical safety. They may be used routinely, however, for reasons other than demonstrated safety. Some, such as intravenous fluids or continuous electronic monitoring, are used in the belief that it is better to use them before rather than after a problem arises. Others, such as the back-lying position for birth, the use of stirrups, and changes of shifts of nurses and other staff, exist for the convenience of the staff or caregiver. Still others, such as the use of silver nitrate or antibiotics for the baby's eyes, are required by law. Some practices, such as enemas, shaving the perineum, the requirement that surgical masks be worn by everyone except the mother, holding the baby upside down by the heels, and so on, became routine at a time when they were believed to be beneficial, but now are known to be of little or no benefit or even harmful. They are rarely done today in most areas of North America. Some routines, such as anesthesia and circumcision, may present an element of risk to mother or baby that may not be worth taking, depending on the circumstances and the benefits to be gained. Others, such as feeding sugar water to the baby, are simply habits, and no one seems to know exactly why they began. Some require your informed consent-that is, your caregiver explains the procedure, its benefits and risks, and the alternatives (including not doing it) and their benefits and risks; your consent is recorded on your chart.

Part of your preparation will be to find out which routines you are likely to encounter, along with the reasoning behind them. Childbirth classes, the hospital tour, and your caregiver can help you find out which routines are used. As you prepare this part of your birth plan, list only the preferences that matter to you. You do not have to hold an opinion on everything.

Care of the Newborn

This section describes how you want your baby cared for during the first few days. There are as many differences in the way healthy newborns are cared for as there are differences in every other aspect of maternity care. Generally, the healthy newborn needs little more than a warm environment, diapers, clothing, and access to her parents' arms and her mother's breast. Certain observations, tests, and procedures are done routinely to discover serious congenital disorders or prevent potentially serious illnesses. In considering the options listed in the chart on pages 242-44, balance concerns for your baby's comfort and wellbeing with the potential benefits and risks of each procedure.

Unexpected Events

The section on the unexpected may not be needed, but will be most helpful if something unforeseen does arise. A birth plan for a cesarean birth can help you retain some of the priorities of your original birth plan. Though an unexpected cesarean can be a disappointment, you will feel better about the experience if you have thought about this possibility and your choices are considered. Information in chapter 10 will help you with a cesarean birth plan.

Although almost all babies are born healthy and beautiful, there is a slim chance that something could go wrong or that the baby might have a problem. This possibility concerns most expectant parents. You know that prematurity, illness, birth defects, or even death sometimes happen. It is helpful to consider in advance how you would want such misfortunes handled, because if they occur, many decisions have to be made when you are upset and unable to think clearly. Your birth plan can i,nclude such possibilities, so that the staff can care for you and your baby according to your preferences, See the chart on page 18 and page 181 for further discussion about the choices to consider in preparing your birth plan.

Once you have made your birth plan about the unexpected, put it aside. You will probably not need it, but if you do, you will have your own plans to follow at this extremely difficult time.

As you can see, preparing a birth plan requires time, thought, and information gathering. By the time you have finished, you should have a fairly complete picture of what you can expect in your birth experience and immediately afterward. Not only will you and your caregivers have decided how your uncomplicated, normal labor and birth will be managed, but you will also know how unexpected variations and complications will be handled. The decisions you make in advance when you are calm, not stressed, and able to concentrate will help carry you through and guide you and your caregivers at a time when you and your partner need to devote all your mental and physical energies to coping with childbirth.

Options to Consider for your Birth

The following is a list of common practices labor, birth, and post partum, along with options for handling each. Use this book and others, discuss the options with your childbirth educator and caregiver, and take tours of local hospitals to discover what you want. Then make up a rough draft of your birth plan. Go over it with your caregiver and make a final draft. Make several copies-one to keep, one for your chart, an extra to give the staff, if in necessary, and one for your baby's chart. Remember that the following procedures are not all routine everywhere and that some of the options may not be available to you. Find out which are by asking questions on the hospital tour, in childbirth class, or during prenatal care appointments. Most of the following options are discussed in other parts of this book. Check the index for specific pages.
During labor: Procedure or practice Options
Enema
  • No enema
  • Self-administered or given by nurse
  • If constipated at onset of labor
  • To start or stimulate labor
Shaving of pubic hair
  • No removal of pubic hair
  • Clip hair around vagina
  • Shave hair around vagina
  • Shave for cesarean
Presence of partner /others
  • At mother's discretion
  • One or more partners present throughout labor andbirth
  • Limit on number of support people
  • Other children at birth
  • At doctor's, nurse's, or anesthesiologist's discretion
Position for labor.
  • Freedom to change position and walk around
  • Confined to bed in various positions
  • Confined to one position in bed
Onset of labor.
  • Spontaneous (begins on its own)
  • Selё-induced: nipple stimulation, enema, castor oil, sex, acupressure
  • Medical or surgical induction: artificial rupture of membranes, prostaglandin gel, intravenous Pitocin
  • Induced with or without tests for fetal maturity and well-being
  • Induced for medical reasons or for convenience
Food/fluids
  • Eat and drink as desired
  • Water,juice
  • Popsicles
  • Ice chips only
  • IV fluids
  • Heparin lock in case IV fluids needed
  • No liquids
Rupture of membranes
  • Spontaneous
  • Artificial, before or during early or late labor
  • Replace lost fluid via amnioinfusion, if needed
Vaginal exams
  • At mother's request
  • Only when labor changes
  • Occasionally
  • Frequently
Monitoring fetal heart rate.
  • Auscultation with stethoscope
  • Auscultation with Doppler (ultrasound stethoscope)
  • Intermittent external electronic fetal monitoring
  • Internal electronic fetal monitoring for medical reasons
  • Routine continuous electronic monitoring-internal or external
  • Fetal scalp stimulation ( or acoustic stimulation) to confirm fetal distress
Pain relief
  • Help from partner(s) and nurses or midwife
  • Relaxation, breathing, comfort measures
  • Tub bath or shower
  • Medications, anesthesia only at mother's request
  • Medications and/or anesthesia encouraged by medical staff
Enhance or speed labor
  • Walk, change position
  • Nipple stimulation
  • Enema
  • Rupture of membranes
  • Pitocin
To empty bladder
  • Walk to toilet
  • Bedside commode
  • Bed pan in bed
  • Catheterization
For birth: Procedure or practice Options
Position
  • Mother's choice of position
  • Caregiver's choice of position
  • Lithotomy and stirrups
Expulsion techniques
  • Spontaneous bearing-down
  • Directed pushing
  • Prolonged breath-holding and straining
Speed up birth
  • Gravity-enhancing positions
  • Prolonged pushing on command
  • Episiotomy
  • Forceps or vacuum extractor
Bed for birth
  • Mother's choice of birth chair, bean bag, tub (water birth), floor, or bed
  • Birthing bed
  • Labor bed
  • Delivery table with or without stirrups
Covering of perineal area
  • Undraped, mother may touch baby during birth
  • Sterile drapes around vagina
Care of perineum
  • Try for intact perineum with massage, support, hot compresses, controlled pushing, and positions to promote perineal stretching
  • Anesthesia, before or after episiotomy, and stitches
  • Ice packs immediately after birth
After birth: Procedure or practice Options
Cord cutting
  • Clamp and cut after it stops pulsating
  • Partner cuts cord
  • Clamp and cut immediately
Delivery of placenta
  • Spontaneous
  • Encouraged with breast stimulation, baby suckling
  • Hastened with massage of the fundus and/or medication (Pitocin)
  • Manual extraction
Maintaining uterine muscle tone
  • Frequent checking for uterine tone
  • Fundal massage by mother, as necessary
  • Fundal massage by nurse
  • Medication-1V or by injection
Contact between modter and partner or loved ones
  • Regulated by mother
  • Restricted to visiting hours only
Discharge of mother and baby
  • When desired
  • Early discharge (within 24 hours after birth)
  • Standard discharge (1 to 3 days after birth)
Baby care: Procedure or practice Options
Airway
  • Baby coughs and expels own mucus; suctioned if necessary
  • Suction with bulb syringe almost immediately
  • Deep suctioning with tube down windpipe
Warmth
  • Baby skin-to-skin with mother with blanket covering both
  • Wrapped in heated blanket
  • Placed in bassinet with radiant heater or in electrically warmed bed
  • Placed in thermostatically controlled, heated isolette
Immediate care
  • Baby held by parents and suckled by mother; in parents' arms for observation
  • Kept near parents in bassinet or isolette
  • Taken to nursery for observation, weighing, and feeding
Eye care
  • None
  • Use of nonirritating agent, such as erythromycin or tetracycline
  • Use of silver nitrate
Vitamin K
  • None
  • Oral doses (after birth and a few days later)
  • By injection soon after birth
First feedings
  • Breastfeeding on demand
  • Scheduled breastfeeding
  • Supplemental reedings (water, glucose water, formula) to breastfed baby given by parents or nurse
  • Supplemental reedings (water, glucose water, formula, breast milk) given by medicine dropper, "finger feeding," or bottle
  • Demand reedings with infant formula
  • Scheduled formula reedings
Contact between baby and mother/parents
  • 24-hour rooming-in
  • Daytime rooming-in
  • For reedings only, in nursery at other times
Circumcision
  • None
  • With one or both parents present to comfort baby
  • With no anesthesia
  • With local anesthesia
  • Out-or-hospital circumcision
Unexpected Events
If problems develop either during labor or afterward, you may have to let go of some of your preferred options, because more interventions may be necessary for safety. Thr following are some options that are usually available under such circumstances.
Cesarean birth: Policy Options
Timing (if cesarean is planned)
  • After labor begins
  • Scheduled before labor begins
Presence of partner/others
  • More than one supportive person present
  • Father or partner only
  • Partner seated at mother's head
  • Partner stands and watches or photographs surgery and birth
  • No partner present
Anesthesia
  • Regional anesthesia with little or no premedication
  • Regional anesthesia with premedication
  • Sleep-inducing medication for sedation for the first few hours after birth
  • General anesthesia
Participation
  • Screen lowered at time baby is delivered
  • Anesthesiologist or obstetrician explains events
  • No explanation to parents
Contact between baby and mother/parents
  • Held by partner soon after birth, where mother can touch and see
  • Breastfeeding as soon as possible
  • Sent immediately to nursery or intensive care
Discharge of mother and baby
  • When desired
  • Within four to five days
Premature or sich infant: Policy Options
Contact between baby and mother /parents
  • Parents visit and care for baby as much as possible
  • If baby is in another hospital from mother, partner goes with baby
  • Baby separated from parents with little or no visiting
Feeding when baby is able to digest food (before this point baby fed intravenously)
  • Mother nurses baby
  • Mother's expresses milk to be given to baby by bottle, dropper, or tube
  • Formula feeding by bottle, dropper, or tube
  • Fed by parents or nurse
Contact with support group
  • Initiated by parents, nurses, or support group
  • No contact
Stillbirth: policy Options
Onset of labor
  • Spontaneous (begins on its own)
  • Induction of labor
Sedation
  • No sedatives
  • Medication that leaves the mother awake and alert
  • Sleep-inQucing medications
Conduct of labor and birth
  • Participation in decision making and use of labor coping techniques
  • Management left to hospital staff
Death of a newborn: Policy Options
Contact with baby after death
  • See and hold baby as often and for as long as desired
  • See and hold baby initially after death
  • No contact with baby
  • Obtain mementos (photograph, lock of hair, foot , prints, naming the baby)
Care of baby after death
  • Autopsy
  • Spiritual services (baptism, memorial service, funeral)
Mother's recovery
  • On postpartum unit
  • In room separate from postpartum unit
  • Early discharge
  • Spiritual and grief counseling
  • Contact with parent support group

Chapter 3

PRENATAL CARE

Routine Pregnancy Tests

This table lists the tests you can expect during pregnancy. If a test indicates a possible problem, further testing and appropriate treatment will be started.
Test Purpose Comments
A pelvic (vaginal) examination First ar second prenatal visit:
  • To confirm pregnancy
  • To correlate size of uterus with date of last menstrual period
  • To estimate size and shape of pelvis
  • To obtain vaginal secretions to detect infection or cervical cancer (Pap smear)
 
Late pregnancy :
  • To assess condition of cervix and station of baby
  • To obtain vaginal secretions to detect infection, if indicated
  • Exam may cause dark brown or reddish vaginal discharge
  • Exam may increase risk of infection or premature rupture of membranes
Urine tests First prenatal visit:
  • To confirm pregnancy
  • Urine tests may be less accurate than blood tests to confirm pregnancy
Each prenatal visit:
  • To detect infection
  • To check for sugar and acetone, which might indicate diabetes
  • To check for protein, which might indicate preeclampsia or infection
  • Urine tests are less accurate than blood tests to confirm diabetes
Blood tests First or second prenatal visit:
  • To confirm pregnancy
  • o determine blood type, Rh type
  • To test for anemia (hematocrit and hemoglobin)
  • To test for German measles immunity
  • To test for syphilis
  • To test for antibodies to human immunodeficiency virus (HIV), the AlDSvirus
  • To test for antibodies to hepatitis B virus
  • Some tests will be repeated
  • Some caregivers do not perform all these tests
  • Anemia may be treated with iron supplements and/or diet changes
  • See page 54 for information about infections during pregnancy
  • See page 57 for a discussion of Rh incompatibility
Blood pressure test Each prenatal visit:
  • To detect pregnancy-induced hypertension (PIH) or preeclampsia
  • See page 56 for a discussion of PIH.
Maternal weight check Each prenatal visit:
  • To detect sudden weight gain that could be due to preeclampsia
  • To help monitor mother's nutritional status
  • See page 56 for information on preeclampsia
  • See page 71 for a discussion of normal weight gain in pregnancy.
Abdominal examination Each prenatal visit:
  • To measure the growth of the uterus (fundal height) which indicates fetal growth and gestational age
  • If a problem is suspected, ultrasound visualization (page 65) is usually recommended.
Last weeks of pregnancy :
  • To estimate size and position of the fetus (Leopold's maneuvers)
  • To estimate amniotic fluid volum
  • To detect breech presentation
  • If breech, mother may use self-help measures to turn fetus (page 178) ; a medical professional may perform external version
Listening to fetal heart rate (FHR). The FHR IS heard through the moth er's abdomen with a fetal stethoscope or a Doppler, which uses ultrasound Each prenatal visit after the FHR can be heard ( about 12 weeks):
  • To assess the well-being of the fetus
  • Hearing the FHR increases the expectant parents' feelings of attachment for their baby and makes the baby seem more real.
Breast exam Once or more during pregnancy:
  • To check for flat or inverted nipples
  • To assess condition of breasts for ability to breastfeed
  • To detect any breast abnormalities including screening for breast cancer
  • If her nipples are flat or inverted, the mother can use methods to draw them out. See page 266 for , a discussion of these measures.
  • Breast self-exams should be performed regularly throughout pregnancy
Alpha-Fetoprotein (AFP). A blood test that measures the level of alpha-phetoprotern, a substance produced by the fetal liver that crosses to the maternal blood stream in predictable amounts. Test results are usually available in one week. 16 to 18 weeks gestation:
  • To screen for a baby with a neural tube defect (spina bifida, anencephaly) , the presence of twins, or fetal death (high level of AFP)
  • To screen for Down's syndrome (low level of AFP)
  • If AFP test results are outside the normal range, then further testing includes a repeat blood test to confirm findings, ultrasound, geneuc counseling, and possible ammniocentesis.
  • The test will not detect all cases of neural tube defects or Down's syndrome.
  • There is a high rate of false positives (the test indicated a problem when there is none).
  • The test's accuracy is questionable if the due date is unclear
  • The risk of neural tube defects is about I to 2 per 1,000 births
  • Insulin-dependent diabetics usually show an AFP level lower than others
  • The test helps parents plan management of pregnancy or birth ( they could terminate the pregnancy, plan a cesarean if spina bifida is detected, or prepare for a child with a disability).
Prenatal risk profille (Tnple Screen). A blood test that measures levels of three substances: human chorionic gonadotrophin (hCG), a hormone produced by the chorionic villi; estriol, a by-product of estrogen metabolism. and maternal serum alpha-fetoprotein (AFP) 15 to 18 weeks gestation:
  • To screen for Down's syndrome (low levels of estriol and AFP combined with high levels of hCG)
  • Initial studies indicate that the Triple Screen is more accurate than AFP screenrng alone in detecting Down's syndrome (2 to 3 times more accurate in women under 35; 50 percent more accurate in women over 35)
  • It is useful for those who do not have amniocentesis, although it does not detect the hundreds of other possible inherited disorders that can be detected by amniocentesis or chorionic villus sampling.
  • It IS a screening procedure only; thIS test may mIss 20 to 30 percent of Down's syndrome pregnancIes in women over 35, and 40 percent in women under 35
Glucose screening A blood sample is taken from the mother one hour after she drinks a sugary(glucose) drink or eats a spesial carbohydrate meal 24 to 30 weeks gestation (commonly 28 weeks):
  • To screen for gestational diabetes, which, if untreated, may cause problems for mother and baby
  • If the mother's blood sugar is elevated, a longer and more sensitive glucose tolerance test (GTT) is planned.
  • ApproXImately 85 percent of those with an elevated blood sugar in the screenIng test WIll be found to have normal blood sugar levels in the GTT.
  • Detection of diabetes enables treatment to avoid problems for the mother or baby.
  • See page 55 for a discussion of gestational diabetes.

Diagnostic Tests

The following tests evaluate either your well being or your baby's, Rarely is anyone test used alone, For example, if there is a question about fetal well-being in early pregnancy, an ultrasound and an amniocentesis might be recommended, If a question arises in later pregnancy, the doctor or midwife might ask you to count fetal movements daily and come in once or twice a week for a nonstress test, particular blood tests, and a biophysical profile. If fetal well-being is still in question, ultrasound exami nations, amniocentesis, contraction stress tests, and others might be performed.
Amniocentesis
A local anesthetic may be given to numb the skin of your abdomen, Then a needle is passed through your abdomen and uterus into tbe amniotic sac, and fluid is withdrawn and sent to a laboratory for the appropriate examinations, Amniocentesis is performed with ultrasound to avoid puncturing the fetus, placenta, or umbilical cord. Amniocentesis can be performed whenever there is an adequate pocket of fluid, usually after 13 to 16 weeks gestation. The amniotic fluid is handled differently, depending on the test being performed, To identify chromosomal abnormalities, fetal cells are isolated from the amniotic fluid and given time (2 to 4 weeks) to multiply, which provides sufficient quantities to allow analysis. For other tests, the fluid can be analyzed immediately for the presence of various substances that reveal specific information about your baby,
Benefits /purposes Risks /disadvantages
Amniocentesis in early pregnancy (done at 13 to 16 weeks gestation):
  • Provides information on certain birth defects, metabolic disorders, or chromosomal abnormalities such as Down's syndrome, sickle cell anemia, neural tube defects, and many others; some of these may be suspected after routine screening tests
  • Helps you make a desision about continuIng or termInating a pregnancy
  • Slightly increases risk of miscarriage; should be weighed against the fact that women aged 35 have a 0.5 percent risk of chromosomal abnormality
  • Requires injection of RhoGam if mother is Rh negative
  • Produces a small amount of discomfort
  • Is invasive and carries a small additional risk of Intrauterine infection
  • Length of time required to obtain results (2 to 4 weeks) may be stressfull
  • Termination of pregnancy (abortion) , if desired, might not be performed until 15 to 20 weeks gestation (later abortions are more risky and may be more stressful than earlier abortions)
  • Is expensive, although health insurance covers costs for women over 35 and those at risk for genetic defects
Benefits /purposes Risks /disadvantages
A mniocentesis in late pregnansy ( often in the last trimester) :
  • Provides vital information on fetal lung maturity when early delivery IS beIng considered for the health of mother or baby.
  • Reveals severity of Rh disease or other suspected blood disorders and helps determine if treatment of baby will be necessary
  • May cause premature labor
  • May Injure fetus, placenta, or cord, but thlS risk IS greatly reduced of ultrasound is used
  • May cause intrauterine infection0
  • Slight risk of hemorrhage or embolism
Chorionic Villus Sampling (CVS)
A slim catheter is inserted into the uterus through the opening in the cervix (transcervical CVS) or through the abdominal wall via a needle (transabdominal CVS)o It is guided by ultrasound and placed on the chorionic membrane, which covers the fetus. Fragments of the chorionic villi are suctioned through the catheter into a syringe and then sent to a laboratory for analysis. The procedure takes about 15 to 20 minutes. Chorionic villus sampling is usually performed between 8 and 11 weeks gestation.
Benefits /purposes Risks /disadvantages
  • Provides information about genetic defects and chromosomal abnormaities (same as that obtained from midtrimester amnIoCentesIs
  • Performed at an earlier gestational age than amnIocentesis; test results are available within 7 to 14 days, allowing for earlier declsion about termInatin Of pregnancy (early abortions are safer and simpler than those done after 16 to 18 weeks)
  • Provides a sample large enough to take advantage of molecular genetics technology such as DNA analysis
  • May risk miscarriage, but not clear that it adds to miscarriage rate, which is normally rather high (as high as 4 percent) at this stage of pregnancy
  • May cause maternal bleedIng and crampIng or amnIobc fluid leakage
  • AVaIlable In only a few pennatal centers
  • Is expensive and may not be covered by insurance
  • Requires InjeCbOn of ProGam if mother is Rh negative
  • Has not been used as long as amniocentesis; extensive long-term studies of full range of risks and benefits are still needed
  • Often requires mother to have a full bladder, which may be uncomfortable
Contraction Stress Test(CST) or Oxytocin Challenge Test (OCT)
This test indicates how the fetal heart rate (FHR) responds to uterine contractions, The woman is either given intravenous Pitocin (a form of oxytocin) or she stimulates her nipples (causing a natural release of oxytocin) by stroking or rolling them until she has three contractions in ten minutes, Then, while the uterus continues contracting at that rate, an external electronic fetal monitor mea- sures the FHR, Test results are "reassuring" if the heart rate remains normal during contractions" The test is "nonreassuring" or "ominous" if the FHR indicates fetal distress" It sometimes takes several hours to complete this test. It is considered reliable only during the last weeks of pregnancy
Benefits /purposes Risks /disadvantages
  • Helps indicate how well fetus can withstand stress of labor contractions
  • Helps determine if a high-risk pregnancy can continue, If labor should be induced, or if a cesarean birth is indicated
  • Reflects placental function and fetal reserves
  • May cause preterm labor
  • Interpretation of results differs
  • Produces occasional false results, which could lead to unnecessary Intervention
  • Is costly, since it is usually performed in a hospital or clinic
Doppler Blood Flow Studies (Velocimetry)
A Doppler ultrasound unit, placed on the woman's abdomen, obtains information about Jhe rate of blood flow (velocity) in the umbilical artery of the fetus and/or the uterine artery of the mother. This information is recorded as velocity wave forms that show the differences in blood flow during and between heartbeats (reported as the "systolic/diastolic ratio"). These studies may be performed during the latter months of pregnancy or during labor
Benefits /purposes Risks /disadvantages
  • Provides insight about condition of utero-placental and/or fetal circulation
  • Helps identify a fetus at risk for an adverse outcome due to fetal placental blood flow problems (intrauterine growth retardation, pregnancy-induced hypertension, and other problems)
  • Helps evaluate effect of labor or obstetric intervention on fetal placental circulation
  • Is noninvasive
  • A relatively new procedure; full range of applications still undetermined
  • Possible Inappropnate Intervention because Its ability to predict maternal and fetal outcome is unclear
Estriol Excretion Studies
Estriol, made jointly by the fetus and placenta, is a form of estrogen. The estriol content of a woman's 24-hour urine collection or a single sample ofher blood is measured in several consecutive studies (usually weekly). If estriol levels drop, it is a possible sign that the fetus is not tolerating the pregnancy well. Estriol studies are performed in late pregnancy
Benefits /purposes Risks /disadvantages
  • May indicate efficiency of placenta and status of fetus; used when deciding whether to induce labor or continue a pregnancy complicated by diabetes, maternal hypertension, or postmaturity
  • Is no longer considered accurate enough to be used in deciding to induce labor or perform a cesarean because many factors other than fetal problems can cause low estriol excretion; other tests are considered to be far more reliable
  • Produces variable results WIth multIple pregnancy, presence of a kidney InfectIon, or use a certain drugs
Fetal Biophysical Profile (FBP or BPP)
This test evaluates fetal physical functions and has five components. It combines a nonstress test to check the fetal heart rate during movement with an ultrasound scan that allows assessment of fetal activity, muscle tone, breathing movements, and amniotic fluid volume, Each component is scored with 0, 1, or 2 points, so the highest possible total is 10 points, Fetal biophysical profiles are usually done in the latter weeks of pregnancy
Benefits /purposes Risks /disadvantages
  • Is rapidly performed in office or clinic
  • Is relatively risk-free
  • Is a fairly good predictor of fetal disadvantages condition when scores are high (6-10) or low (0-2)
  • Experts may disagree on interpretation of results
  • Intermediate score (3-5) are difficultto interpret
  • See Ultrasound and Nonstress Test for other possIble disadvantages
Fetal Movement Counts
During late pregnancy, the woman counts and records her baby's movements during a brief period each day. See pages 58-59 for a description of fetal movement counting, Formal fetal movement counting is a more reliable predictor of outcome than reliance on the mother's informal impressions of fetal activity
Benefits /purposes Risks /disadvantages
  • Helps assess well-being offetus
  • Is free and relatively simple
  • Is noninvasive
  • Can be done by the mother herself, at her convenience, in her own home
  • Helps mother learn about her baby
  • Requires more time and work by expectant mother
  • May raise mother's anxiety over her baby's well-being
Nonstress Test
This test indicates how the fetal heart rate responds when the fetus moves. The fetal heart rate (FHR) is recorded for 20 to 30 minutes with an external electronic fetal monitor, and the woman indicates each time she feels the fetus move, If there is no spontaneous fetal movement, the baby may be asleep. The examiner may push on the woman's abdomen or sound a loud noise near her abdomen to stimulate the baby to move, An increase in heart rate of approximately 15 beats above the baseline during fetal movement (a reactive test) is normal and a sign of fetal well-being, Nonstress tests are considered reliable only during the last weeks of pregnancy"
Benefits /purposes Risks /disadvantages
  • Helps predict fetal well-being
  • Is done in caregIver's office, clinic, or hospital
  • Is noninvasive
  • Helps determine if a high-risk pregnancy can safely continue or if further testing is desirable
  • Interpretation of results somewhat subjective; experts may differ over meaning
  • Occasionally produces false results
Percutaneous Umbilical Blood Samoling (PUBS)
First described in 1983, this relatively new procedure is similar to amniocentesis except that blood from the baby's umbilical cord, rather than amniotic fluid, is withdrawn. During PUBS, also called cordocentesis, the doctor, guided by a high resolution image created by ultrasound, passes a needle through the mother's abdomen and uterus into the umbilical cord, The procedure takes about 10 minutes, Sometimes a similar technique is used to give a blood transfusion or drugs to a fetus with a serious blood disorder, anemia, or an infection. PUBS can be performed after 16 weeks gestation.
Benefits /purposes Risks /disadvantages
  • Provides same information as amniocentesis, but with quicker results (within 48 to 72 hours)
  • Allows evaluation and treatment of a fetus with a blood disorder , like Rh incompatibility or sickle cell desease
  • Enables diagnosis of suspected fetal infection, hemophilia, and other conditions
  • Assesses fetal red blood cell count to detect anemia
  • In future, may be used to monitor effectiveness of drug treatment of fetus
  • Requires greater technical skill than amniocentesis on part of doctor and is only available at large prenatal diagnostic centers
  • Is invasive
  • Potential complications include infection, preterm labor, premature rupture of membranes, bleeding from umbilical cord, placental abruption, blood clot in cord, transient irregular fetal heart rate, and fetal death
Preterm Labor Detection (Tocodynamometry)
An electronic monitor, strapped to the mother's abdomen and connected to a recorder in a shoulder bag, measures uterine contractions and fetal movement. Information from ambulatory tocodynamometry can then be transmitted over the telephone from the mother's home to the doctor's office. The monitor is usually worn twice a day for I to 2 hours during late pregnancy.
Benefits /purposes Risks /disadvantages
  • Used for early detection and treatment of preterm labor
  • Is noninvasive
  • Helps determine effectiveness of medications given to prevent labor contractions
  • Sometimes leads to an incorrect diagnosis of preterm labor and unnecessary treatment
  • Is costly and inconvenient
  • May give false sense of security because it sometimes misses preterm labor
  • ScIentific studIes have not shown thattocodynamometry prevents preterm labor
Ultrasound
High-frequency sound waves are sent through a transmitter, called a transQucer or probe, into the woman ' s uterus via the abdomen or, less commonly, the vagina. These waves echo back from various structures of the fetus, the placenta, and the mother's internal organs and are reproduced as a picture on a video screen. It usually takes 20 to 30 minutes to get an entire image of the fetus and other structures. Ultrasound can be performed at any time during the pregnancy. The timing depends on the reason for testing. Vaginal ultrasound may be better than abdominal ultrasound for detecting some problems, such as placenta previa and ectopic pregnancy.
Benefits /purposes Risks /disadvantages
  • Confirms pregnancy
  • Can determine whether the pregnancy is uterine or ectopic
  • Helps estimate the age of fetus (by providing measurements of various landmarks, such as the skull, femur, and abdomen)
  • Helps locate fetal organs for inspection, measurement, diagnosis, or treatment
  • Helps assess the position and condition of the placenta
  • Detects how fetus is lying in uterus, showing presentation and position
  • Confirms a multiple pregnancy
  • Gives immediate results
  • Helps assess amniotic fluid volume
  • Helps estimate fetal growth or weight
  • Appears safe when used judiciously and medically indicated
  • adds additional expense to prenatal care
  • Accuracy varies, depending on quality of equipment, skill of person interpreting results, and gestational age of fetus
  • Often requires that mother have a full bladder, which may be uncomfortable
Vaginal/Cervical Smear
At any time during pregnancy, secretions from the mother's vagina or cervical area can be removed by a swab or suction bulb and examined under a microscope or cultured.
Benefits /purposes Risks /disadvantages
  • Detects organisms that cause infections (for example, trichomonas or yeast, bacteria, herpes virus)
  • Determines if premature rupture of membranes has occurred by testing the acidity (pH) of fluid or by inspecting it with a microscope; amniotic fluid has a fern-like appearance under the microscope
  • May be used to evaluate the lipid content of amniotic fluid with premature rupture of membranes to determine fetal lung maturity
  • Carries very slight risk of infection
X ray
Ionizing radiation is used to take an internal picture of the mother and the fetus, X rays are rarely used in pregnant women today, Ultrasound is considered a safer, more reliable, and more useful alternative, When used, X ray should be done only after the first trimester.
Benefits /purposes Risks /disadvantages
  • Helps determine size and shape of mother's pelvis (pelvimetry)
  • Helps discover posItion an number of baby or babies
  • Helps determine if baby ia a breech presentation
  • Helps confirm fetal skeletal problems
  • Early prenatal exposure to radiation has been associated with leukemia and genetic mutations in babies
  • Is a poor predictor of course of labor and "fit" of baby when used for pelvimetry

Chapter 4

NUTRITION IN PREGNANCY

Nutrients and Vitamins

Key nutrient & RDA Important functions Important sources Comments
Calories
N-2,200
P-2,200 (lst trimester)
P-2500 (2nd & 3rd trimesters)
L-2,700
  • Provide energy for tissue building and increased metabolic reqUIrements
Carbohydrates, fats, and proteins Calorie requirements vary according to the stage of y?ur preg nancy, your sIZe, actIVIty level, prepregnant weig~t, and how well nourished you are.
Water or liquids
N-4 cups
P-8+ cups
L-8+ cups
  • Carries nutrients to cells
  • Carries waste products away
  • Provides fluid for increased blood, tissue, and amniotic fluid volume
  • Helps regulate body temperature
  • Aids digestion
Water,juices, and milk Liquid is often neglected, but it is an important nutrient.
Protein
N-46 g
P-60 g
L-65 g
  • Builds and repairs Meat tissues
  • Helps build blood, amniotic fluid, and placenta
  • Helps form antibodies
  • Supplies energy
Meat, fish, poultry, eggs, milk, cheese, dried beans and peas, peanut butter, nuts, whole grains, and cereals Fetal requirements increase by about one third in late pregnancy as the baby grows.
Minerals
Calcium
N-800 mg
P-1,200 mg
L-1,200 mg
  • Helps build bones and teeth
  • Important in blood clotting
  • Helps regulate use of of other minerals in your body
Milk, cheese, whole grains, vegetables, egg yolk, whole canned fish, and ice cream Fetal requirements increase in late pregnancy. Caffeine can decrease the amount calcium available to the fetus.
Phosphorus
N-800 mg
P-1,200 mg
L-1,200 mg
  • Helps build bones and teeth
Milk, cheese, and lean meats Calcium and phosphorus exist in a constant ratio in the blood. An excess of either limits, the use of calcium.
Iron
N-15 mg
P-30 mg
L-15 mg
  • Combines with protein to make hemoglobin
  • Provides iron for fetal storage
Liver, red meats, egg, yolk, whole grains, leafy vegetables, nuts, legumes, dried fruits, prunes, and prune and apple juice Fetal requirements increase tenfold in last 6 weeks of pregnancy. Supplement of 30 to 60 mg of iron daily is recommended by the National Research Council.
Zinc
N-12 mg
P-15 mg
L-19 mg
  • Component of insulin
  • Important in growth of skeleton and nervous system
Meat, liver, eggs, and seafood-especially oysters Deficiency can cause malformations of fetal skeleton and nervous system.
Iodine
N-150 mcg
P-175 mcg
L-200 mcg
  • Helps control the rate of body's energy use
  • Important in thyroxine production
Seafoods, iodized salt Deficiency may cause goiter in infant.
Magnesium
N-280 mg
P -320 mg
L-355 mg
  • Helps energy, protein, and cell metabolism
  • Enzyme activator
  • Helps tissue growth and muscle action
Nuts, cocoa, green vegetables, whole grains, and dried beans and peas Most is stored in bones. Deficiency may cause neuromuscular dysfunction.
Fat-soluble vitamins
Vitamin A
N-800 mcg RE
P -800 mcg RE
L-l,300 mcg RE
  • Helps bone and tissue growth and development
  • Essential in development of enamel-forming cells in gum tissue
  • Helps maintain health of skin and mucous membranes
Butter, fortified margarine, green and yellow vegetables, and liver In excessive amounts, it is toxic to the fetus. It loses its potency when exposed to light.
Vitamin D
N-5 mcg
P-10 mcg
L-10 mcg
  • Needed for absorption of calcium and phosphorus and mineralization of bones and teeth
Fortified milk, fortified margarine, fish liver oils, and sunlight on your skin Toxic to the fetus in excessive amounts.
Vitamin E
N-8 mg oc-TE
P-10 mg oc-TE
L-12 mg oc-TE
  • Needed for tissue growth, cell wall integrity, and red blood cell integrity
Vegetable oils, cereals, meat, eggs, milk, nuts, and seeds Enhances absorption of vitamin A
Vitamin K
N-65 mcg
P -65 mcg
L-65 mcg
  • Essential for the synthesis of blood clotting factors
  Produced in the body by the intestinal flora
Water-soluble vitamins
Folic acid
N-180 mcg
P-400 mcg
L-280 mcg
  • Essential in hemoglobin synthesis
  • Involved in DNA and RNA synthesis
  • Needed for synthesis of amino acids
Liver, leafy green vegetables, and yeast Deficiency leads to anemia. Can be destroyed in cooking and storage. Supplement of 400 mcg per day is recommended by the National Research Council. Oral contraceptives may reduce blood level of folic acid.
Niacin
N-15 mg
P-17 mg
L-20 mg
  • Needed for energy and protein metabolism
Pork, organ meats, peanuts, beans, peas, and enriched grains Stable; only small amounts are lost in food preparation.
Riboflavin
N-l.3 mg
P-l.6 mg
L-l.8 mg
  • Essential for energy and protein metabolism
Milk, lean meat, enriched grains, cheese, and leafy greens Oral contraceptives may reduce serum con centration of riboflavin.
Thiamin (B1)
N-l.l mg
P-l.5 mg
L-l.6 mg
  • Important for energy metabolism
Pork, beef, liver, whole grains, and legumes Essential for conversion of the carbohydrates into energy in the muscular and nervous systems.
pyridoxine (B6)
N-l.6 mg
P-2.2 mg
L-2.1 mg
  • Important in amino acid metabolism and protein synthesis
  • Required for fetal growth
Unprocessed cereals, grains, wheat germ, nuts, seeds, legumes, and corn Excessive amounts may reduce milk supply in lactating women. May help reduce nausea in early pregnancy.
Cobalamin (B12)
N-2.0 mcg
P-2 2 mcg
L-2,6 mcg
  • Essential in protein metabolism
  • Important in formation of red blood cells
Milk, eggs, meat, liver, and cheese Deficiency leads to anemia and central nervous system damage. Is manufactured by micro-organisms in the intestinal tract. Oral contraceptives may reduce serum concentration.
Vitamm C
N-60 mg
P-70 mg
L-95 mg
  • Helps tissue formation and integrity
  • Is the "cement" substance in connective and vascular tissue
  • Increases iron absorption
Citrus fruits, berries, melons, tomatoes, chili peppers, green vegetables, and potatoes Large supplemental doses in pregnancy may create a larger-than normal need in infant. Benefits of large doses in preventing colds have not been confirmed.
* N-nonpregnant
P-pregnant
L-lactating (first 6 months)

Chapter 6

EXERCISE, POSTURE, AND COMFORT IN PREGNANCY

Conditioning Exercises

Whether or not you participate in an organized exercise program, you can practice the following conditioning exercises along with an invigorating activity such as walking, stationary cycling, swimming, or modified dancing. The conditioning exercises described here are designed to keep the muscles most affected by pregnancy ( the pelvic floor and abdominal muscles) in good condition during pregnancy, to help you to use your muscles effectively during birth and to speed your postpartum recovery.

Conditioning the Pelvic Floor Muscles

The pelvic floor ( or perineal) muscles are attached to the insides of the pelvic bones and act like a hammock to support your abdominal and pelvic organs. During pregnancy, these muscles may sag in response to the increased weight of your uterus and the relaxing effect of the hormones produced by your body. Regular exercise of the pelvic floor muscles maintains tone and improves circulation, which can reduce the heavy, throbbing feeling that you might experience during pregnancy or post partum. Since the pelvic floor muscles are stretched during birth and their condition is of lifelong importance, regular exercise of the pelvic floor is essential during pregnancy and throughout your lifetime.


The pelvic floor muscles form a figure-8 pattern around the urethra, vagina, and anus. During childbirth, the circle of muscles around the vagina stretches to allow the birth of the baby. When they are in good tone, they are elastic, which means they can stretch but also return to their original length. Birth is quicker, more comfortable, and easier if these muscles are in good tone and you relax them rather than tighten them. Pelvic floor exercises during pregnancy (along with perineal massage, described on page 126) will help you prepare for this process. Regular exercise of these muscles may also enhance sexual enjoyment for you and your partner. Problems such as leaking urine and the relaxation of the rectal wall may be prevented or reduced if the muscle tone of the pelvioC floor is maintained.

To check the strength of your pelvic floor muscles, try to stop the flow of urine in midstream. If you cannot, it is a sign of weakness, but do not despair. These muscles respond quickly to exercise. You may also check by inserting one finger in the vagina and tightening your pelvic floor muscles around it. You should feel the grip of the muscles on your finger. (H you do not feel the gripping sensation, it is probably a sign of weakness.) During intercourse, check by tightening your pelvic floor muscles around your partner's penis; he can help evaluate your progress.

Pelvic Floor Contraction (also called perineal squeeze or Kegel exercise )

Aim: To maintain the tone of the pelvic floor muscles, improve circulation to the perineum, and provide better support for the uterus and other pelvic organs.

Starting position: Assume any position-sitting, standing, or lying down.

Exercise: Contract or tighten the pelvic floor muscles as you would to stop the flow of urine. You will feel tension and a slight lifting of the pelvic floor. Hold as tightly as you can for ten seconds or more. At first you will probably notice the contraction diminishing or fading, even though you have not deliberately let go. Simply tighten the muscles whenever you feel this letting go, again and again, until ten to twenty seconds or more have passed, then relax and rest.

Repetition: Do three to five pelvic floor contractions in a set. Try to do several of these sets each day. Hat first you are unable to maintain the tightening effort for ten seconds, begin with three or five seconds and gradually work up to ten, then twenty.

Pelvic Floor Bulging

Aim: To practice and prepare for the second stage of labor-pushing the baby out. Bulging the pelvic floor (not contracting it) i~ what you should do as the baby is coming out.

Starting position: Get into the tailor-sitting position, squat, or any of the birthing positions (see chapter 8, pages 151-52). Make sure your bladder is empty when practicing this one!

Exercise: Consciously relax the pelvic floor muscles. Hold your breath and bear down or strain gently as you do when you are having a bowel movement, letting the perineal muscles relax further and bulge outward. Putting your hand on your perineum will help you to feel this bulge. Do not bear down hard or strain forcefully; hold for three to five seconds.

Stop bearing down. Breathe in, contract the pelvic floor, then relax and rest. Once you have learned to do this while holding your breath, try doing it while letting air out. You will find that you do not have to hold your breath to bulge your perineum.

Repetition: Repeat once a day.

Mobilizing the Pelvic Joints

Squatting

Aim: To increase the mobility of the pelvic joints, stretch the muscles of the inner thighs and the Achilles tendons or heel cords, and practice a position used to assist the birth of the baby.

Starting position: Stand with your feet comfortablyapart (approximately two feet) and your heels on the floor. Squat with your weight evenly on your heels and toes to allow for greater stability, greater curve of the lower back, and better alignment of the birth canal. To maintain your balance, squat with support: hold onto your partner's hands, astable piece of furniture, or the doorknobs on either side of a door, or you can lean your back against a wall and slide down. Your partner can also support you from behind by sitting on a chair as you squat and lean back between his or her knees with your arms over the knees.

If your feet roll inward or if you cannot squat with your heels flat, it is because of short or tight Achilles tendons. Try spreading your feet farther apart, wearing shoes with moderate heels, elevating each heel with a one- toO two-inch book, or squatting with support. Many hospital birthing beds come equipped with squatting bars, which can be attached to the bed to give you something solid to hold onto while squatting. (See the illustration on page 123.)

Caution: If you have hip, knee, or ankle problems, consult your caregiver before trying this exercise. If the squatting position causes pain anywhere in your legs or pubic area, try squatting and leaning back with support. If support does not help, discontinue this exercise.


Exercise: Slowly squat with your weight on your heels and toes, not just your toes. Do not bounce. Stay down for at least thirty seconds, then rise slowly.

Repetition: Repeat five times daily. Progress to squatting for one and a half minutes at a time.

Conditioning the Abdominal Muscles

The abdominal muscles are .the muscles most obviously stretched during pregnancy. Keeping them in good condition helps you maintain good posture, avoid backache, push the baby out more easily, and hasten the full recovery of your figure after the birth.

There are four layers of abdominal muscles. ~at, like a corset, support the contents of the abdomen. These layers work together to bend the body forward or sideways, rotate the trunk, tilt the pelvis, and help with breathing. Many abdominal exercises done by nonpregnant women are potentially risky for pregnant women, especially in late pregnancy. To avoid back and abdominal muscle strain in late pregnancy, do not do double-leg lifts, straight sit-ups, or sitbacks. An exercise that conditions these muscles without causing excessive strain is described below.

Pelvic Tilt

Aim: To strengthen the abdominal muscles, improve posture, and relieve backaches.

Starting position: Lie on your back with your knees bent and your feet flat on the floor.


Exercise: Flatten the small of your back on to the floor by contracting your abdominal muscles. Hold the abdominal muscle contraction for a count of five as you exhale. Relax.

Note: To check that you are doing the exercise correctly, place your hand beneath the small of your back as you tilt your pelvis. You will press your back onto your hand. If you feellight-headed while lying on your back, perform only the variations of this exercise.

Repetition: Repeat this exercise and each variation five times daily.

Pelvic Tilt Variation A Starting position: Get on your hands and knees. Keep your back straight-not hollowed, swayed, or arched-and your knees comfortably apart.


Exercise: Tighten your abdominal muscles to arch your lower back. (Imagine a frightened dog who tucks her tail between her legs.) Hold for a count of five. Relax and return your back to the starting positiondo not sag.

Pelvic Tilt Variation B

Starting position: Stand leaning against a wall. Have your buttocks and shoulder:s touching the wall, your feet apart and twelve to fifteen inches away from the wall, and your knees slightly bent.

Exercise: Breathe in. As you exhale, press your lower back against the wall by contracting the muscles of your abdomen. Imagine that your abdominal muscles are hugging your baby within your uterus. Hold for a count of five without holding your breath. Relax.

Note: To check yourself, put your hand between the wall and the small of your back.


As you tilt your pelvis, you should feel your back press against your hand. To progress in this exercise, move your feet closer to the wall until you can do it without leaning against a wall ( see variation C below) .

Pelvic Tilt Variation C

Starting position: Mter you have mastered the pelvic tilt leaning against a wall, try it while standing upright.

Exercise: By flattening your back and raising your pubic bone in front (as if you were tilting a basin) , you can maintain good posture and help relieve or even prevent backaches. To check, put your hands on your hips. You will feel your hip bones move as your pubic bone tips up toward your chest.

Comfort Measures

Even if you stand and move properly, aches and pains are still common during pregnancy. The positions and exercises described below can help relieve some of these discomforts.

For Low Backache

Treatment of low back pain during pregnancy depends on the cause of the discomfort. Increased awareness of correct posture helps some women. Use of good body mechanics at work and at home decreases mechanical strain on joints, ligaments, and tendons that are softened and relaxed by hormonal changes. Positions and exercises that reduce lumbar lordosis (sway back) and/ or increase abdominal muscle tone, described below, also may prevent or relieve low back pain. If your back pain is severe or if these measures do not help, ask your caregiver for a referral to a physical therapist, who can diagnose the problem and treat it with cold packs, heat, hydrotherapy, massage, other exercise, or techniques that mobilize joints and connective tissue. Your caregiver or therapist might recommend a special garment that provides additional support to the abdomen and lower back.

Tailor-Sitting

Tailor-sitting ( or sitting cross-legged) is a comfortable way to keep the lower back rounded and relaxed.


Squatting

Many women find that squatting ( described on page 97) helps relieve low backache.

Pelvic Tilt on Hands and Knees

This exercise (described on pages 98-99) relieves low back pain by stretching the low back muscles and strengthening the muscles of the abdomen.

Knee to Shoulder Exercise

Starling position: Lie on your back with your knees bent and your feet flat on the floor.


Exercise: Draw one knee up toward your chest and hold it behind the thigh with one hand. Bring the other knee up and hold it, letting your knees spread apart around your abdomen. Keep your head on the floor while gently pulling your knees toward your shoulders until you feel a slight stretch in the lower part of your back. Hold f()r a slow count of five. Release the pull without letting go of your knees. Repeat five times. Lower one foot; then the other.

Note: In late pregnancy, you may wish to raise and pull only one leg at a time. Roll onto your side as soon as you finish the exercise. If this exercise causes light-headedness, do not do it.

For Upper Backache

Shoulder Circling

Starting Position: Stand or sit with your back straight, your arms relaxed, and your chin level.


Exercise: Raise your shoulders toward your ears, then slowly roll them forward, down, back, and up again. Think of making large circles with your shoulders. Imagine that someone is rubbing your back as you slowly make circles with your shoulders. Feel the relaxation. Finish with your shoulders back and down in a relaxed position. Do five rotations, then repeat, reversing the direction.

Upper Body Stretch

Starting Position: Sit tailor fashion or stand with your arms straight and extended in front of you.


Exercise: Cross your arms at the elbows; feel your upper back stretch. While , slowly breathing in, raise your hands toward the ceiling and gradually uncross your ( , arms. Reach upward so I}) you feel the stretch in your entire upper body.

Exhale as you lower your arms out to the sides and behind you with palms up. Feel the stretch across your chest and upper arms. With your arms down and behind you, stretch further by pressing your arms back with five gentle pulsing motions. Exhale with each stretch, making a "who" sound. Drop your arms to your sides and relax without slumping. Repeat five times.

For Aching Legs or Swollen Ankles

If you are bothered by aching legs, swollen feet and ankles, or varicose veins, do the following to promote better circulation:

To help prevent or reduce extessive swelling in the legs, try the following:

For Leg and Foot Cramps

Cramps in the calves or feet commonly occur in late pregnancy when you are rest ing or asleep. Cramps are caused by fatigue in calf muscles, pressure on the nerves to the legs, impaired circulation, or a calciumphosphorus imbalance in the blood. This imbalance can result from inadequate calcium intake or from eating large amounts of phosphorus, which is found in foods such as processed meats, snack foods, and soft drinks. Even with a good diet and careful attention to circulation in the legs, you may still get cramps, especially when you point your toes or when you stand or walk on your tiptoes. A muscle cramp disappears when the muscle is slowly stretched.

Relieving Leg Cramps

To relieve a cramp in the calf, straighten your knee and bend your foot up, bringing your toes toward your nose. Here are two ways of doing this:




Relieving Foot Cramps

A cramp in the foot tightens the muscles of the arch and curls the toes. To relieve the cramp, stretch out your toes and foot With your hand. To prevent cramping, do not curl your toes.

For Sudden Groin Pain

A common discomfort of pregnancy is a sudden pain in the lower abdomen or groin, on one or both sides. This may occur when you stand up quickly, or when you sneeze, cough, or laugh with your hips extended (lying down or standing) .The sudden stretching of one or both of the round ligaments that support the uterus causes the pain. These ligaments, which connect the front sides of the uterus to either side of the groin, contract and relax like muscles, yet much more slowly.

Any movement that suddenly stretches these ligaments, causing them to rapidly contract, causes pain. You can avoid this pain by moving slowly, allowing the ligaments to stretch gradually. If you anticipate a sneeze or expect to cough, bend or flex your hips to reduce the pull on these ligaments.

In labor, the round ligaments contract when the uterus contracts. This is beneficial, because they pull the uterus forward and align it and the baby with the birth canal for the most efficient and effective action.

Conclusion

pregnancy brings rapid and profound changes in your body shape, size, and weight that can make you feel awkward and uncomfortable. This chapter has focused on physical fitness and comfort measures that Will help you adjust as smoothly as possible to these changes and maintain or even improve your physical condition. Many women find pleasure in their pregnant bodies, especially when they can remain physically active and comfortable.

Chapter 7

PREPARATION FOR CHILDBIRTH: Relaxation, Comfort, and Breathing Techniques

During pregnancy you and your partner will want to prepare yourselves physically, emotionally, and intellectually for the extraordinary experience of having a baby. During labor you can help yourself immensely by using relaxation techniques, patterned breathing, and a variety of other comfort measures and body positions. This chapter includes complete descriptions of these techniques with guidelines for adapting them, and a practice guide-a step-by-step, week-by-week approach to childbirth preparation (pages 128-30) .

Though these techniques cannot guarantee a completely pain-free childbirth, they can reduce pain and stress to manageable levels in most labors. They also promote labor progress and give you more control over the experience. Along with the support you will have from your partner and others, these techniques and your adaptations of them are your resources for coping with labor. You may use them instead of, or in conjunction with, medical interventions. When you use these techniques and participate fully, the birth of your child will be rewarding, exciting, and fulfilling an experience to remember with satisfaction and joy.

Historical Overview

Over the last seventy years the efforts of many outstanding individuals have led to the development of the methods now used to enhance relaxation, reduce stress, relieve labor pain, promote labor progress, and strengthen early parent-infant bonds.

Grantly Dick-Read, a British physician, actively studied and promoted natural childbirth from the 1920s until the 1950s. He taught his obstetric patients that when a woman is afraid of labor, she becomes tense and thereby increases her pain. The more pain she feels, the more frightened she becomes, and the cycle is perpetuated and intensified. To interrupt this "vicious cycle,"he advocated education, relaxation, and controlled abdominal breathing.

In the 1950s, Dr. Fernand Lamaze, a French physician, developed his psychoprophylactic method, which he adapted from methods used by Soviet physicians. It is based on the theories of conditioned response developed by Pavlov. Psychoprophylaxis, which literally means "mind prevention, " involves the use of distraction techniques during contractions to decrease the perception of pain or discomfort. These techniques include various patterns of controlled chest breathing; a light massage of the abdomen, called effleurage,. and visual concentration on an object called a focal point. Elisabeth Bing, a physical therapist, and MaIjorie Karmel, an expectant mother, were trained by Dr. Lamaze and introduced and popularized the Lamaze method in the United States. They helped found the American Society for Psychoprophylaxis in Obstetrics (ASPO) , which promotes the Lamaze method through teacher training and education of parents and professionals. The Lamaze method has evolved over the years to incorporate ~ore flexibility; it now offers a greater variety of coping techniques.

In the 1950s and 1960s, Robert Bradley, an American physician, promoted and refined Dick-Read's methods. His major contribution, however, was to encourage husbands to participate as labor coaches. He founded the American Academy of Husband-Coached Childbirth .(AAHCC) to train teachers and promote the Bradley method.

Since the 1960s, Sheila Kitzinger, British anthropologist and childbirth educator, has inpfluenced childbirth preparation all over the world with her psychosexual approach. She sees childbirth as a highly personal, sexual, and social event. Kitzinger's methods emphasize body awareness, innovative relaxation techniques, and special breathing patterns.

During the 1960s the voice of the consumer in maternity care was given a great boost by the formation of the International Childbirth Education Association (ICEA) , whose members continue to promote the concepts of family-centered maternity care and "freedom of choice based on knowledge of alternatives."

In the 1970s the childbirth movement began to examine and criticize conventional obstetrical practices and emphasize nore "natural" physiological and psychologcal approaches. These included movement Jy the mother during labor and the use of the upright position to enhance the progress of labor (Roberto Caldeyro-Barcia and others) ; more spontaneous pushing techniques for birth (Kitzinger, Caldeyro Barcia,Joyce Roberts, and Elizabeth Noble); greater contact between parents and newborn (Marshall Klaus and John Kennell) ; gentler handling of the newborn (Frederic Leboyer) ; and a recognition of the emotional impact of support during labor, a homelike environment, and freedom for the mother to behave spontaneously (Michel Odent, Gayle Peterson, Klaus and Kennell, Niles Newton, and many more).

An Individualized Approach to Childbirth Preparation

Expectant parents have benefited greatly from the insights and wisdom of the people mentioned above and many others, but it is really the woman herself, with the help of her partner, caregiver, and others, who develops her own personal method for handling labor. Each woman has her own learning style, her own belief system, her own way of dealing with change, stress, and pain. For example, some people have a highly academic approach to learning about birth, finding the information fascinating and essential to their ability to cope. Others learn better through experience, discussion, observation, and practice. Some find distraction from pain to be the most effective way to cope, others focus directly on the pain, still others transform the pain in their minds and imagine something more acceptable. Some women love to be touched, massaged, held, and talked to when they are in pain. Others must be left undisturbed to explore and utilize their inner resources. You will find that the relaxation, patterned breathing, and comfort techniques described here are presented within a broad framework with guidelines for modifying and adapting them to suit your personality, your preferences, and your particular labor.

The Gate Control Theory of Pain

The Gate Control Theory of Pain, first described in the 1960s by R. Melzack and P. D. Wall, provides a very useful explanation of how pain perception can be increased or decreased. The following is a brief description of the Gate Control Theory and how it applies to childbirth pain.

A painful stimulus feels more painful under some circumstances than others. A familiar example is the headache that seems to go away during an exciting movie but returns when the movie ends. Or the bruise, acquired during an athletic contest, that goes unnoticed until after the game is over. Or the backache that feels so much better with massage or hot packs. In all these examples, the pain is still there, but your awareness of it is decreased when your brain receives other nonpainful or pleasant stimuli.

The Gate Control Theory states that the severity of pain is determined by the balance of painful and nonpainful stimuli that reach your consciousness.

In childbirth, you can increase the nonpainful stimuli and decrease the painful stimuli in numerous ways, which are described in this chapter. These techniques are powerful enough to reduce (but not eliminate) your perception of pain. They may be all you need to keep your pain manageable. If not, you may choose to use pain medications along with them. Some of the techniques are more helpful if you practice and adapt them to suit yourself before you go into labor. Others, such as hot packs, cold packs, baths, and showers, require no prior practice.

Relaxation

Relaxation-the art of releasing muscle tension-is the cornerstone of comfort during labor. The ability to relax comes more easily to some than to others. With concentration and practice, however, everyone can learn to relax. Many approaches to relaxation are presented in this chapter. Try them all, but concentrate on those that appeal to and work best for you. During labor, relaxation will help you do the following:

Conserve energy and reduce fatigue. If you are not consciously relaxing your muscles, you will most likely tense them during contractions. This increases your pain, wastes energy, decreases the oxygen available for the uterus and baby, and tires you.

Calm your mind and reduce stress. A relaxed body leads to a relaxed state of mind, which in turn helps reduce your stress response. There is evidence that distress in the laboring woman caused by anxiety, anger, fear, or illness produces an excessive amount of catecholamines (stress hormones) such as epinephrine (also called adrenalin) and norepinephrine (also called noradrenalin) .High blood levels of catecholamines can prolong labor by decreasing the efficiency of uterine contractions and can affect the fetus by decreasing the blood flow to the uterus and placenta.

Reduce pain. Relaxation decreases the tension and fatigue that intensifies the pain you feel during labor and birth. It also allows maximum availability of oxygen for your uterus, which may decrease pain, since a working muscle (like the uterus) causes pain if it is deprived of oxygen. In addition, the mental concentration involved in consciously relaxing your muscles helps focus rout;. attention away from the pain of contractions and thereby reduces your awareness of pain.

Learning to Relax

The first step in learning to relax is to become aware of how your mind and body feel when you are resting or falling asleep. Since your mind and body influence each other, you probably will notice a simultaneous release of muscle and mental tension when you relax. Your breathing pattern will be slow and even, with a slight pause between each inhalation and exhalation. This type of breathing will aid you in the relaxation exercises and during labor.

When yoU: practice relaxation, lie down on your side with plenty of pillows to make yourself comfortable, or sit in a comfortable chair with your head and arms supported. Mter you have learned to relax in these positions, practice relaxing while sitting up, standing, and walking, since you will need to relax in a variety of positions during labor.

When you are learning relaxation skills, begin in a quiet, calm atmosphere and progress to noisier, more active surroundings. Remember, hospitals are busy places, so you will need to be able to relax in the midst of activity. At the end of a practice session, lazily stretch all your muscles and get up slowly to avoid becoming light-headed or dizzy.

The next important step is to increase your body awareness by learning to recognize muscle tension. The following techniques will help you to detect and reduce the unnecessary tension that may develop during labor.

Body Awareness Techniques .

Tensing and Releasing Muscles

Starting position: Sit in a chair or on the loor. Try to relax all the muscles you do not leed to keep yourself upright.

exercise: Make a tight fist with your right land. Pay attention to how the muscles in 'Our forearm feel. They are hard when they lre tense. Touch those muscles with the fingers of your left hand. Now let go. Notice .lOW soft the muscles feel when you release he tension.

Next, raise your shoulders toward your ~ars. Notice how you feel when your shoulders are tense. Relax and lower your shoulders. Now release even more. Really relax. Did you notice a change? Often you can release residual muscle tension when you become aware of it.

Tensing and Releasing the Whole Body

Starting position: Lie down in a comfortable position.

Exercise: Tighten the muscles of your entire body-stiffen your abdomen, hips, and legs, then your back, neck, and arms. Keep the muscles contracted for about five seconds. Pay attention to how you feel-tense, tight, cramped, or uncomfortable.

Then let your body go limp, releasing the tension all over. You may start by relaxing your abdomen and releasing outward toward your arms, legs, and head. Think of the tension flowing out of your limbs. Breathe slowly. Sigh, relaxing even more. Feel yourself relaxing.

Discovering the Effect of Mind on Body

Your state of mind has a great influence on how relaxed or tense your body is. If you are anxious or frightened, your body will reflect these feelings by tensing. H you are confident and positive, your body will remain relaxed. When in pain you can. focus on these confident, positive feelings to help you release tension that might otherwise accompany and worsen your pain.

Exercise: Use the following visualizations to help you imagine contrasting reactions to labor contractions. Notice how they can affect the tension in your body. One can make you feel tense and afraid; the other can help you relax.

  1. As your contraction begins, you feel tension, first in your back. ...Oh-oh. Here it comes. This tight grip comes around to your front. ...It's building. "Oh no!" It's getting stronger and stronger. It hurts! You want to say, "Owww. Make it stop. I can't do it! I can't! " You clench your fists. You stiffen your back. You grit your teeth and squint hard in an anguished expression of pain. "Please! Make it stop!" The grip tightens around your middle. You feel weak. You feel helpless. You hold your breath. Won't it ever stop? The grip begins to fade. It's leaving, but you're afraid to let go. Is it really gone? Is it coming back? "Ohhhhh."

    How do you feel after reading the above visualization or hearing it read to you? Are you tense, upset? For contrast, try the following visualization of a labor contraction.

  2. Your contraction comes like a wave, starting deep within you as a small swell. Vague at first, it grows larger and larger, stronger and stronger. You wonder, "What shall I do?" It's building to a peak of strength, power, and pain. Your strength, your power, your pain. You can ride the crest of this wave, letting it carry you along. As the power sweeps through you, your uterus works-to open your cervix and to bring your baby closer. You do not fight the wave, you go limp, and in doing so you feel safe, supported, and strong. Your face is still and peaceful; your arms and legs are floatinglimp and relaxed. You are not afraid. You are open to this power. You are opening to this power. And now the wave eases; it ebbs; it flows back deep within you. You are at rest.

How do you feel as you visualize a contraction in this way? Do you find it less threatening? Does it help you interpret the contraction more positively than the first visualization? If so, you may wish to use such visualizations as you prepare for birth.

As you can see, your way of interpreting the pain of contractions can influence your physical response to them. It helps if you can visualize the pain as healthy pain with a positive purpose. Through knowledge and practice, you will be able to do this, and your labor will be far mor~fulfilling for you.

Practicing with Your Partner

While you are developing an awareness of tension and relaxation, your birth partner should also learn to recognize when you are tense or relaxed. He or she can detect signs of tension in several ways:


The way your partner checks you has a lot to do with your ability to relax. If he or she touches or moves you in a gentle mannernot dropping, shaking, or pinching your limbs-you will develop a sense of confidence and security. This trusting relationship carries over beautifully into labor. As you practice together, you will learn which parts of your body you have the most difficulty relaxing. For instance, you may have a particular "tension spot. " Many people under stress tighten their shoulders. Some reflect tension with a frown or anxious brow; others clench their jaws or fists. Your tension spots should receive special attention, both as you learn relaxation and during labor. Find out what eases tension in these areas: touch, massage, verbal reminders, warmth? Mter exploring the possibilities together, you will both know what works best in helping you to relax and stay relaxed.

Once you both are skilled in relaxation and spotting tension, you can practice by deliberately tightening a limb and having your partner try to detect the part you have tensed. Try contracting the muscles most likely to be tense during labor-the buttocks, thighs, back, shoulders, face, or fists. Once your partner has found the tension, have him or her help you relax.

Relaxation Techniques

Passive Relaxation

Once you can recognize tension in your muscles, the next step is to master the art of releasing tension. By focusing on different parts of your body and by releasing tension in each part, you can achieve a state of deep relaxation of both body and mind. This takes some concentration and conscious effort. When you start passive relaxation, have your partner read the following exercise in a calm, relaxed voice. He or she should read slowly, allowing you time to focus on and release each part of your body. Pleasant, relaxing music may also help. Once you have selected some appealing music, use the same music each time you practice and then use it during labor to create a familiar and relaxing environment.

Practicing Passive Relaxation

Find a comfortable position lying on your side or semisitting, with your head and all your limbs supported by the floor or bed and pillows. Take plenty of time getting as comfortable as you can so you do not need to use any muscle effort to hold yourself in that position. Depending on the position you choose, you may want to put pillows under one or both knees, behind your head, or under your abdomen to help you feel comfortable and relaxed.

  1. Take a long sigh, or yawn.
  2. Now focus way down to your toes and feet. Just let go. Think how warm and relaxed they feel.
  3. Think about your ankles-floppy and loose. Your ankles are very relaxed and comfortable.
  4. And now your calves. Let the muscles go loose and soft. Good.
  5. Now focus on your knees. They are supported and relaxed-not holding your legs in any position. They are very comfortable and loose.
  6. Think of your thighs. The large, strong muscles of your thighs have let go. They are soft and heavy, and your thighs are totally supported. Good.
  7. And now your buttocks and perineum. This area needs to be especially relaxed during labor and birth. Just let go. Think soft and yielding. When the time is right, your baby will make the journey down the birth canal, the tissues of your perineum will open and let the baby slide out. You will release, allowing the perineum to give and open for the baby.
  8. And now your lower back. Imagine that someone with strong, warm hands is giving you a lovely rub. It feels so good. Your muscles relax to the imagined touch, and your lower back is comfortable. Feel the warmth. Feel the tension leaving.
  9. And now let your thoughts flow to your abdomen. Let those muscles go. Let your abdomen swell as you breathe in and collapse as you breathe out. Your abdomen is free. Focus on how it moves as you breathe. Good. Focus on your baby within your abdomen. Your baby is floating or wiggling inside, free, warm, content, and secure within you.
  10. And now your chest. Your chest is free. As you breathe in, bringing air into your lungs, your chest swells easily, making room for the air. As you breathe out, your chest relaxes to help the air flow out. Breathe easily and slowly, letting the air flow in and flow out, almost like sleep breathing. Ease the air into your chest, ease it out. This easy breathing helps you relax more. The .relaxation helps you breathe even more easily and slowly. Good.

    Now try breathing in through your nose and out through your mouth-slowly and easily, letting the air flow in and flow out. At the top of the in-breath, you notice just a litde tension in your chest, which is released with your out-breath. Listen as you breathe out. It 5ounds relaxed and calm, almost as if you were asleep. Every out-breath is a relaxing breath. Use your out-breaths to breathe away any tension. This is very much like the slow breathing you will be using during labor. Good.

  11. And now your shoulders. Imagine you have just had a lovely massage over your shoulders and upper back. Let go. Release. Feel the warmth. Feel the tension slip away.
  12. Focus on your arms. With your outbreath, let your arms go limp-from your shoulders all the way down your arms, to your wrists, hands, and fingers. Heavy, loose, and relaxed.
  13. And now your neck. All the muscles in your neck are soft because they do not have to hold your head in any position. Your head is heavy and completely supported, so your neck can just let go and relax. Good.
  14. Focus on your liPs and jaw. They are slack and r~laxed. You do not have to hold your mouth closed or open. It is comfortable. No tension there.
  15. And now your eyes and eyelids. You are not holding your eyes open or closed. They are the way they want to be. Your eyes are unfocused and still beneath your eyelids. Your eyelids are relaxed and heavy.
  16. Focus on your brow and scalp. Think how warm and relaxed they are. Just let go. You have a calm, peaceful expression on your face, reflecting a calm, peaceful feeling inside.
  17. Take a few moments to note and enjoy this feeling of calm and well-being. You can relax this way anytime-before sleep, during an afternoon rest, or during a quiet break. This is the feeling to have in labor. During labor you will not lie down all the time. You will be walking, sitting up, showering, and changing positions; but whenever a contraction comes, you will allow yourself to relax all the muscles you do not need to hold your position, and you will let your mind relax, giving you a feeling of peace and confidence. It is thi& feeling that helps you focus on the positive accomplishment of each contraction, yielding to these contractions and letting them guide you in breathing and comfort.
  18. Now it is time to end this relaxation session. No need to rush. Gradually open your eyes, stretch, tune in to your surroundings, and get up slowly.

Touch Relaxation

With touch relaxation, you respond to your partner's touch by relaxing or releasing tense muscles. During pregnancy, touch relaxation is a pleasurable way to practicerelaxation. During labor, you use your companion's touching, stroking, or massaging as a nonverbal cue to relax.

Starling position: Lie down on your side or sit in a comfortable position.


Exercise:Contract a set of muscles and have your partner touch those muscles with a firm, relaxed hand, molding his or her hand to the shape of the part of your body being tensed. Release the muscle tension and relax toward your partner's hand. Imagine the tension flowing out of your body.

Your partner can use several types of touch (listed below) .Find out which you prefer, but practice all methods, since your preference could change during labor.

Still touch. Your partner holds his or her hand(s) firmly in place until he or she feels you release your tension.

Firm pressure. Your partner applies pressure with fingertips or the whole hand on the tense area. Your partner gradually releases the pressure; you respond by releasing tension as you feel your partner's gradual release.

Stroking. Your partner lightly or firmly strokes the tense area. When stroking your arms or legs, he or she strokes away from the center of your body.

Massage. Your partner firmly rubs or kneads tense muscles. This is commonly used for neck and back rubs, but any muscle group can be massaged.

Practicing Touch Relaxation

Practice tensing the following muscle groups, then releasing to your partner's touch; learn to release to still touch, firm pressure, stroking, and massage:

Active Relaxation

If you practice relaxing in many positions and during physical activity, you can prepare more realistically for labor, because in labor you will probably use many positions and be physically active. Your goal is to achieve the same relaxed feeling and mental state while active that you had with passive relaxation, when your entire body was being supported by pillows, the bed, or the floor.

Practicing Active Relaxation

Practice relaxing in many positions-standing (upright or leaning against a wall or your partner) , sitting, semisitting, on your hands and knees, kneeling with head and shoulders resting on the seat of a chair, squatting, and lying on your side. Different positions require that some muscle groups work, but they allow release of tension in others. Only by practicing in various positions will you be able to relax most effectively during labor. Imagine that you are having labor contractions while you practice relaxation and breathing patterns. Byvisualizing the intense sensations of labor contractions while relaxing, you can make each practice session a labor rehearsal.

The Roving Body Check

Sometimes you may think you are entirely relaxed, but when you focus on a particular body part (such as your arm, leg, or abdomen), you become aware that there is some tension there. The following exercise helps you release tension throughout your body, part by part. It combines the built-in tension-releasing properties of the out-breath with your own conscious release.

Practicing the Roving Body Check

Find a comfortable position. While breathing slowly and easily in through your nose and out through your mouth, focus on your right leg. As you breathe in, detect any tension in your leg. As you breathe out, deliberately release any tension from your leg. Take two breaths for this, if necessary. Then, with the next breath or two, focus on your left leg. Find any tension and release it as you breathe out. Repeat this exercise, dividing your body into about eight parts, as follows:

  1. Right leg
  2. Left leg
  3. Buttocks and perineum
  4. Chest and abdomen
  5. Back
  6. Right arm
  7. Left arm
  8. Head, face, and neck

By systematically releasing tension in each part as you release your breath, your entire body will be more relaxed at the end of the exercise than it was at the beginning.

You can use this technique during labor contractions. Your partner can help by telling you which part to relax with each breath, or by touching or stroking a different part for each breath.

Relaxation Countdown

After you have become aware of body tension and have mastered relaxation, learn the following technique to quickly release extra muscle tension. This is particularly helpful when you are trying to relax during labor. At the beginning of each contraction in labor, your "organizing breath " (see page 117) can be used as your relaxation countdown.

Practicing the Relaxation Countdown

Start by sitting in a comfortable position and progress to any position you might use


in labor-standing, on hands and knees, or lying down (see pages 144-45 for more on labor positions).

Breathe in through your nose. As you breathe out through your mouth, release the muscle tension throughout your body from head to foot. Count down frOIr! five to one to total body relaxation. At first use five slow breaths to accomplish this. With practice, you should be able to relax on the slow exhalation of one breath. Think of this countdown as a wave of relaxation that passes down through your body, from head to toe:

Control in Labor

For many women, the prospect of "losing control" in labor is the most upsetting part of the whole thing. They worry that the pain will be so intense that they will panic or do or say things they will regret later. To prevent this, some plan to use anesthesia to reduce the pain. Others work on mastering prescribed self-help techniques like those described in this chapter to lessen the pain or to keep themselves from acknowledging or reacting negatively to it.

One of the undeniable facts about labor is that you cannot consciously control your labor or your contractions. You can, however, control how you respond to them. In a sense, then, control in labor is a matter of controlling how you will respond to your labor, not controlling the labor itself. As you know, the emphasis of this book is on helping you to understand and work in harmony with the powerful forces of labor rather than resisting or fighting them.

Women also lose control when everything is done for them. Many women want :0 participate in decisions about their care iuring labor. Feeling left out makes them feel out of control. In family-centered care, the mother is consulted and her wishes are followed. She does not give up control.

Comfort Measures for Labor

Women respond differently to labor, depending on the nature of their labors, their sense of readiness, their coping ;tyles, and their goals and expectations. As {OU prepare and rehearse for labor, learn the various comfort measures and then idapt them to suit you. Analyze yourself and Llse this knowledge to develop your own style for labor. Think about what helps you relax: music, massage, soothing voices, a bath or shower, meditation, prayer, chantmg or humming, or thinking about or visuilizing pleasant places and pleasing ictivities. Plan to use these familiar comfort measures to help you relax in labor as well.

Unlike most pain, which is associated Nith injury, illness, or stress, the pain of labor is associated with a normal healthy body function. By recognizing your labor pain as productive and positive-a part of the process that brings the baby-you can llelp reduce the pain to a more manageable level. To cope with your pain, you may find it most helpful to "tune into it"-focus on it, iccept it, and tailor your response to it. Or {OU may prefer distraction techniques, concentrating on outside stimuli, to keep yourself from focusing on your pain.

Many women successfully use both tuning in and distraction. For instance, in early labor they relax, breathe slowly and easily throughout their contractions, close their ~yes, and visualize either something soothing and pleasant or the uterine contractions :opening the cervix and pressing the baby iownward. As labor intensifies, some continue in this way; others lighten and speed up their breathing. Then, during late labor (transition), when contractions are very intense and close, many women find that they cannot continue as before. They find they must open their eyes, focus outside (perhaps on their partner's face), and follow outside directions ( their partner guiding their breathing with verbal directions, with hand signals, or by breathing with them). Sometimes more complex breathing patterns are helpful.

The following comfort measures are based on relaxation, the key to pain control in labor. Learn and adapt them to suit yourself.

Attention-Focusing

During labor contractions, your attention should be focused on something. Many women prefer an internal focus. They might visualize exactly what is happening-contractions of the uterine muscle pulling the cervix open, the baby pressing down and opening the cervix. Others prefer to visualize something calming and pleasant-the beach, a mountain top, a happy memory, or they visualize themselves as above their contractions, like a gull above a stormy sea, soaring over, but very much in touch with the contractions. Still others visualize each contraction as a hurdle to be overcome, for example, a steep hill to be climbed, a footrace, a wave to ride.

You might also find it helpful to look at something. This visual focus is often called an external focal point. You may wish to look at your partner's face, a picture on the wall, a reminder of the baby (perhaps a toy) , an object in the room, a flower, or even a crack in the plaster. Some women focus on the same thing for many contractions; others change focal points often. Others focus on a line, such as the edge of a window, and follow that line visually during the contraction.

Many women find it helpful to focus on touch in the form of a particular rhythmic massage stroke or pressure on one area or a tight embrace. This is called a tactile focus.

Still other women focus on sQunds, an auditory focus-taped music, the soothi,ng voice of the birth partner, a tape recording of various environmental sounds (surf, rain, a babbling brook) , repeating rhythms, or other sounds.

Some women focus on a particular mental activity (a song, a poem, a chant, a mantra, Bible verses, a repeated saying, counting backward), breathing in a complex pattern, or the roving body check (page III) .Others focus on a physical activity, performing a series of particular movements (pelvic rocking, swaying, walking, dancing, effleurage, or others).

As you and your partner practice breathing and relaxing together through mock (pretend) contractions, try the attentionfocusing techniques described above. You will probably discover a preference for some over others. Be ready to try more than one if a particular focus loses its appeal in labor.

Massage and Touch

Effleurage is a light, rhythmic stroking of the abdomen, back, or thighs. It can help with relaxation and pain relief when done on bare skin by you or your partner.


Some women prefer an extremely light, even "tickly" stroking, while others find a firmer touch more soothing. As you and your partner prepare for labor, try varying the pressure and rhythm of effleurage until you find the most appealing stroke. Then practice it as part of your labor preparation. Effleurage over the lower abdomen, following the lower curve of the uterus, is most popular. Some people think of it as stroking the baby's head. Others like to stroke the abdomen in circles with both hands.

Many women use effleurage during contractions in labor. Use cornstarch or powder to make your hands slide more easily. Keep the massage rhythmic, pacing it with the slow breathing. If you find that your skin is becoming sensitive as the contractions intensify, you might try effleurage in a different area or discontinue it.

Other types of massage, such as firm stroking, rubbing, or kneading (squeezing and releasing) , are soothing and relaxing during both pregnancy and labor. Massage of the neck, shoulders, back, thighs, feet, and hands can be very comforting. Work together in pregnancy and find out how and where massage is most helpful and plan to use it in labor.


Another helpful form of massage for labor is firm pressure, used particularly over the lower back or sacrum during contractions. One technique is called counterpressure and is especially helpful for back pain during contractions. Your partner presses a fist or the heel of a hand on a particular area of your lower back or sacrum. During labor you may want your partner to press with considerable force, so he or she should hold the front of your hipbone with his or her other hand to help you keep your balance. The exact spot for applying pressure varies from woman to woman and changes during labor, so it is difficult to know in advance which spot will be best. As long as you know the technique, you and your partner will be able to apply it during labor. You may need a surprising amount of pressure, which may be very tiring for your partner after a few hours. It is worth the effort, however, because of the relief and comfort it brings. Your partner can take turns with another support person or the nurse to allow him or her to take a break. p<>Another helpful technique for alleviating back pain, the double hip squeeze, is described on page 176.

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS is a pain-relieving technique that has, until the past decade, been used primarily for chronic and post-surgical pain. More recently, TENS has also been used for labor pain (particularly back pain during labor) . Its use for labor is not widespread, though most physical therapy departments or clinics have TENS units available. Your caregiver must prescribe it for use in labor.

TENS uses low-voltage electrical current to create a tingling or prickling sensation in a small area of skin. A TENS unit consists of a hand-held generator (powered by a nine-volt battery-the same type used to power many electronic toys) connected by wires to four Band-Aid-size stimulating pads ( or electrodes) , which are usually placed on your back on either side of your spine.


The unit has several dials that control the intensity of the sensation and change the pattern of the stimulation ( quick or slow pulses, "bursts, " waves, and other patterns) .Either you or your partner holds and controls the unit. When the contraction begins, you turn up the intensity to the desired level. The sensations reduce your awareness of the pain. When the contraction ends, you turn it down. Many women have found TENS to be very helpful, while others have not.2 The following conditions seem to improve the effectiveness of TENS:

  1. Instruction in its use before labor.
  2. Application before labor becomes painful.
  3. Trying different stimulation patterns and having your partner work the controls so that you can focus on other coping techniques.

Baths and Showers

Warm water-in the form of a lingering bath, whirlpool bath, or shower-is a marvelous comfort measure for most laboring women. Contractions are usually less painful if you are in water. You are able to relax better because of the warmth and buoyancy of the bath water or the gentle massage provided by the shower. Find out if you will have access to a bath or shower during labor. In the shower, lean against the wall or sit on a towel-covered stool so you can rest. Direct the spray where it helps most. In the tub, lean back against a bath pillow or folded towels and relax. Some caregivers ask you not to take a bath if your membranes have ruptured. If so, you may use a shower. Sometimes the partner can accompany the laboring woman into the shower. You may be in the shower for a long time. Because the nurse will check on you frequently, your partner may wish to wear a swimsuit. Besides relieving pain, baths and showers sometimes lower elevated blood pressure and speed up slow labors.3 Sometimes the baby is born in the water because the mother is reluctant to get out of the tub, or because mother and caregiver have planned a water birth. For more information on water birth, see Recommended Resources.

Heat and Cold

Heat, applied to the low abdomen, back, groin, or perineum, is very soothing. An electric heating pad, hot water bottle, or hot compresses are good sources of heat. Hot compresses are simply washcloths or small towels soaked in hot water, wrung out, and quickly applied wherever you need them. As they cool, they are replaced. Covering them with plastic retains their heat longer.

A cold pack-such as an ice bag, frozen wet wash cloths, a rubber glove filled with crushed ice, a bag of frozen peas, a hollow plastic rolling pin filled with ice, "instant" cold packs, or frozen gel packs (camper's "ice" or the cold packs used for athletic injuries)-can provide a great deal of relief.Placed on the lower back for back pain during labor or on the perineum immediately after birth to reduce pain and swelling, a cold pack feels wonderful. For cold packs to bring comfort, however, you must be comfortably warm. If you are feeling chilled, the cold pack may make you uncomfortable.

Use common sense in deciding how hot or cold the compresses should be. When in labor you might easily tolerate compresses so hot or cold that they could damage your skin. Cover the cold pack with a towel to protect your skin.

Movement

Moving around during labor is another extremely useful comfort measure. Changing position frequently ( every thirty minutes or so)-sitting, kneeling, standing, lying down, getting on hands and knees, and walking-helps relieve pain and may speed up labor by adding the benefits of gravity and changes in the shape of the pelvis. Swaying from side to side, rocking, or other rhythmic movements may be comforting. If labor is progressing slowly, walking may speed it up again. The upright position may give you a greater sense of control and active involvement than lying down. See pages 144-45. in chapter 8 for a further description of positions for labor.

Beverages

Most laboring women lose their appetites when they begin active labor, but their need and desire for liquids continues throughout labor. You should therefore take in liquids, either by drinking or, if that is not allowed (as might be the case if a cesarean or general anesthetic is anticipated) , by an intravenous drip (IV) .In a normal labor, you can drink water, tea, or juice, or suck on popsicles between contractions. By quenching your thirst you are also meeting your body's requirements for fluids. If your caregiver does not allow fluids by mouth, if your labor is prolonged, or if you are nauseated, you probably will receive fluids intravenously. You can still move around and walk when receiving intravenous fluids, if the IV unit is placed on a rolling stand. Hourly trips to the bathroom to urinate will increase your comfort during contractions. If oral fluids are restricted, you may have a very dry mouth, so suck on ice chips, a wet washcloth, or a sour lollipop. You may also refresh your mouth and teeth with cold water, a toothbrush, or mouthwash.

Pattern Breathing

In this section, you will learn a variety of breathing techniques to use during the first stage of labor, while the cervix dilates completely, and pushing techniques for the second stage, when the baby is born.

All activities involving physical coordination and mental discipline-swimming, runIning, singing, playing a musical instrument, public speaking, yoga, and meditation - require that you regulate your breathing for effective and efficient performance. Labor is no different. Along with relaxation and other comfort measures, patterned breathing is used during labor and birth to relieve pain. Patterned breathing simply means breathing at any of a number of possible rates and depths. The pattern you choose depends on the nature and intensity of your contractions, your preferences, and your need for oxygen. By learning and adapting breathing patterns before labor, you can use them to help calm and relax you during labor. Each method of childbirth preparation-Lamaze, Bradley, Kitzinger, Dick-Read, and others-relies on some form of patterned breathing.

In keeping with our individualized approach, no single method is promoted here; broad guidelines are offered, which will help you develop the breathing techniques that will fit your preferences and needs. Some women find abdominal breathing more comfortable than chest breathing; other women find just the opposite. The important thing is not where you breathe, but that the breathing calms and relaxes you. Through practice, experimentation, and adaptation, you and your partner will find your own best way to use the breathing patterns in labor.

Avoiding Hyperventilation

Hyperventilation occurs when the balance of oxygen and carbon dioxide in your blood is altered, causing a light-headed or dizzy feeling, or a tingling sensation in your fingers, feet, or around your mouth. It may be caused by breathing too deeply, too fast, or both. Tension also seems to contribute to hyperventilation. While rarely serious, hyperventilation is uncomfortable and unnecessary because it can be prevented or easily corrected. If you have practiced and mastered the relaxation and breathing techniques before labor begins, it is unlikely that you will hyperventilate during labor.

If hyperventilation does occur, it can be corrected by these measures:

Note: If your partner hyperventilates when breathing along with you, he or she should use the above measures, too.

Three Basic Breathing Patterns (First Stage)

There are three basic patterns of breathing for labor: slow, light ( accelerated), and variable (tramition). You will use these breath ing patterns during your contractions to assist relaxation and ensure adequate oxygenation and to enable you to respond appropriately to the intensity of the contractions. It is most restful to begin using slow breathing in early labor and use it for as long in labor as it is helpful. Then you may want to switch to either the light or the variable pattern,. depending on which is most comfortable for you. Reserve the third pattern to use last. Some women use only the slow breathing throughout labor. Others use only slow and light or slow and variable breathing, while still others use all three. What you wind up doing will depend on four preferences and the intensity of your labor. We adVise learning all three patterns and using them as you need them in labor.

How to Use Breathing Patterns and Comfort Measures during Labor

Once the contraction begins, you
  1. Greet it with an organizing breath, releasing all tension as you breathe out (as in the relaxation countdown, page Ill).
  2. Focus your attention, either internally or externally.
  3. Begin patterned breathing-slow, light, or variable-depending on the intensity of the contraction, your perception of the pain, and which pattern seems to be working best.
  4. Use other comfort measures (massage, movement, heat or cold, bath or shower) if desired.
  5. Continue the breathing, relaxation, and comfort measures through the contraction.

When the contraction ends, you
  1. Take a finishing breath, as if to blow that contraction away forever.
  2. Relax, move around, and sip liquids until the next contraction; then repeat the above.

Pracrlce the following breathing patterns In all the body positions shown on the next page.Turn to the chart on pages 144-45 for discussion of each posirlon 's advantages and disadvantages.


Slow Breathing

Use slow breathing, the first level of patterned breathing, when you reach a point in your labor when it feels better to use it than not to use it. A good rule is to begin slow breathing when the contractions are intense enough that you can no longer walk or talk through them without pausing. Use slow breathing for as long as you find it helps you in labor-at least until you are well along in the first stage of labor. Shift to another pattern if you become tense and can no longer relax during contractions. Some women use only slow breathing throughout the entire first stage; others use all the patterns described here.

Slow breathing may be chest breathing or abdominal breathing. More important than whether you breathe with your chest or abdomen is that the breathing helps you relax.



How to Use Slow Breathing in Labor

  1. Take an organizing breath-a big sigh as soon as the contraction begins. Release all tension (go limp all over-head to foot) as you breathe out.
  2. Focus your attention (page 113) .
  3. Slowly inhal.e through your nose ( or if your nose is congested, through your mouth), and exhale through your mouth, allowing all the air to flow out. Pause until the air seems to "want" to come in again. Breathe about six to ten times per minute (about half your normal breathing rate).
  4. Inhale quietly but make your exhalation audible to those close by, keeping your mouth slightly open and relaxed. The audible breath out sounds like a relaxing sigh.
  5. Keep your shoulders down and relaxed. Relax your chest and abdomen so they can swell (rise) as you inhale and collapse (fall) as you exhale.
  6. When the contraction ends, take a final deep relaxing breath. Exhale as if sighing. Sometimes a yawn is a good finishing breath.
  7. Relax allover, change positions, take sips of liquids, and so on.

Note: Mter learning and practicing this pattern, a few women find it uncomfortable to breathe in through the nose and out through the mouth. If that is true for you, modify the pattern to all-nose or all-mouth breathing. The most important thing is that it is comfortable and relaxing for you.

How to Rehearse Slow Breathing for Labor

Rehearse the technique described above until you become completely comfortable and consistent with it. Then you will be confident and able to use the slow breathing to relax deeply. In labor you will need to use this pattern for sixty to ninety seconds at a time. Practice in different positions-sitting up, lying on your side, standing, on hands and knees, and even in the car. With each breath out, focus on relaxing a different part of the body (the roving body check, page Ill) so that you relax all parts of your body that are not necessary in maintaining your position.

Light (Accelerated) Breathing

Light (accelerated) breathing is the second pattern of breathing. Begin using it only if and when you find that slow breathing is no longer relaxing. If your partner notices that you are breathing more rapidly than six to ten times per minute or that you tense, grimace, clench your fists, or cry out at the peak of the contraction, he or she might suggest that you switch. Most women, though not all, feel the need to switch to light breathing at some time during the active phase of labor. Let the intensity of your contractions guide you in deciding if and when to use light breathing.

To do light breathing, breathe in and out rapidly through your mouth-about one breath per second. Keep your breathing shallow and light. Your inhalations should be quiet, your exhalations clearly audible.

If your contractions peak slowly, you may combine light breathing with slow breathing as follows: You begin breathing slowly when the contraction begins. Then your breathing accelerates and lightens as the contraction increases in intensity, remaining light and rapid over the peak. As the con- traction subsides, your breathing gradually slows and deepens. As with slow breathing, it helps to think of each out-breath as a relaxing breath.



How to Use Light (Accelerated) Breathing in Labor

  1. Take an organizing breath as soon as the contraction begins. Release all tension (go limp allover) as you breathe out.
  2. Focus your attention.
  3. Inhale slowly through your nose and exhale through your mouth, accelerating and lightening your breathing as the contraction increases in intensity. If the contraction peaks early, then you will have to accelerate early in the contraction. If it peaks more gradually, you will work up to peak speed more slowly. Keep your mouth and shoulders relaxed.
  4. As your breathing rate increases toward the peak of your contraction, breathe in and out lightly through your mouth. Keep your breathing shallow and light-at a rate of about one breath per second.
  5. As the contraction decreases in intensity, gradually slow your breathing rate, switching back to breathing in through your nose and out through your mouth.
  6. When the contraction ends, take your finishing breath - exhale as if sighing.
  7. Completely relax, change position, take sips of liquids, and so on.
How to Rehearse Light (Accelerated ) Breathing for Labor

This pattern is not as easy to master as is the slow breathing. Be patient and give yourself enough time to learn it gradually. Begin learning the light breathing pattern by practicing only the peak rate, which is about one breath per second, but can range between two breaths per second and one breath every two seconds. Try breathing at different rates until you are comfortable. The best way to calculate your rate is to count your breaths for ten seconds. If you count between five and twenty breaths, you are in this range. When you are able to do the light breathing effortlessly, comfortably, and consistently for about one to two minutes, you are ready to practice combining it with slow breathing (see the above description) . Start the practice contraction by breathing slowly, gradually lighten and speed your breathing to the peak rate, stay at that rate for thirty to sixty seconds, and then slow it down as the practice contraction subsides.

At first you may feel tense or as if you cannot get enough air. With practice it becomes easier and more comfortable. Mastering this breathing technique is like learning to breathe when you do the crawl stroke in swimming. Once you learn it, it becomes almost second nature and you swim much more easily and efficiently. During labor this pattern will seem more natural because your rate of breathing will be dictated by the pi1in and intensity of your contractions.

Breathing lightly through an open mouth may cause dryness, so use the following suggestions.

Variable (Transition) Breathing

Variable (transition) breathing, the third pattern, is really a variation of light breathing. It is sometimes referred to as "pantpant-blow" or "hee-hee-who" breathing, because it combines light, shallow breathing with a periodic longer or more pronounced exhalation. Variable (transition) breathing is used in the first stage if you feel the need to try something different from slow or light breathing. If you feel overwhelmed, unable to relax, in despair, or exhausted, a switch to this variation may help.

The variable breathing pattern begins with a quick organizing breath, followed by light, quick breathing at a speed ranging from two breaths per second to one breath every two seconds (just like the light breathing). After every two to five of these quick, light breaths, blowout a longer, slower, relaxed breath. This blow helps steady your rhythm; it can also help if you need to keep from bearing down with a premature urge to push (discussed on page 122).



How to Use Variable (Transition) Breathing in Labor

  1. Take a quick organizing breath as soon as the contraction begins. Release all tension (go limp allover) as you breathe out.
  2. Focus your attention. Your partner's face may be a reassuring focal point at this time in labor.
  3. Breathe through your mouth in light, shallow breaths, at a rate of five to twenty breaths in ten seconds, throughout the contraction.
  4. Mter every second, third, fourth, or fifth breath, blowout a longer breath. You do not need to take in a bigger breath for this. Keep the in-breath about the same as for all the others. Some women emphasize this blowing breath by making a "who" or "puh" sound as they exhale. Find the pattern you are comfortable with, then keep it constant throughout the contraction. Your partner might count for you ("one, two, three, four, blow") , or you might count to yourself for added concentration.
  5. When the contraction ends, take one or two deep relaxing breaths.
  6. Completely relax, sip liquids, move around, and so on.
Variation

Scramble breathing is another form of variable (transition) breathing, where you vary the number of pants per blow throughout each contraction. Your partner tells you or holds up a number of fingers to indicate the number of pants per blow. The number changes after each blow. Thus you might breathe as follows: one, two, blow; one, two, three, four, blow; one, two, three, four, five, blow; one, two, blow; and so on. If you prefer, you can choose your own scramble pattern ( one woman breathed her own phone number). These variations add a significant element of distraction, which may be a help during the most difficult part of the first stage.

How to Rehearse Variable (Transition ) Breathing for Labor

Add dlis breadling pattern to your practice sessions. Late first stage ( transition) contractions might last two minutes, or they might "piggyback," dlat is, come in pairs, so you need to be able to use dlis pattern for up to three minutes. Practice in various positions. Relax for only dlirty seconds or so between practice contractions to prepare yourself for the brief rest period between contractions in late first stage.

Working with the Urge to Push in Labor

The urge to push is an instinctive reaction to the pressure of the baby on the pelvic floor. It is characterized by a feeling of pressure and movement of the baby deep in dle pelvis, which causes an irresistible need to bear down or strain. When you get an urge to push in labor, you will either hold your breath, make grunting sounds as you breadle, or have a catch in every breadl. Ask your nurse or midwife to check for dilation at dlis time. If your cervix is fully dilated, you generally can begin bearing down and pushing when you feel the urge. If your cervix is not quite fully dilated but is very thin, soft, and stretchy, you should bear down only enough to satisfy the urge. If your cervix still has a dlickened area ( sometimes called a lip or an "anterior lip"), you may need to avoid bearing down altogedler until dle cervix dilates all dle way; odlerwise it may become bruised or swollen. Your birdl attendant will guide you at dlis time. Aldlough it is sometim~s very difficult and uncomfortable to keep from pushing when you have a strong urge, it is not harmful to postpone bearing down until dle cervix has dilated completely.

How to Avoid Pushing When Necessary

If you get a premature urge to push, lift your chin and blow lightly until the urge subsides. It may be helpful for you to vocalize at this time, actually saying or singing "pub, puh, pub" or "who, who, who." Then use your chosen breathing pattern for the rest of the contraction. This technique does not stop you from feeling the strong urge to push, nor does it keep your uterus from pushing. All it can do is keep you from adding your voluntary strength to the pushing effort.

How to Rehearse Avoiding Pushing in Labor

When you are rehearsing variable ( transition) breathing, occasionally incorporate an imagined urge to push. When your partner says, "Urge to push," lift your chin and blow, blow, blow until he or she says, "Urge p~sses. " As a variation, and to keep your partner alert, try occasionally holding your breath or grunting in the middle of a practice contraction. This should signal your partner to tell you to "blow, blow, blow."

Expulsion Breathing (Second Stage )

Once the cervix is fully dilated, the second stage of labor has begun. You may or may not feel an immediate urge to bear down (or push) with your contractions. The amount and speed of your baby's descent, her station and position within your pelvis, your body position, and other factors will determine whether the urge comes immediately or after a brief rest. Usually, with time or with a change to an up-right or squatting position, this resting phase of the second stage subsides and the urge to push increases.

Your responses to second-stage contractions depend on the sensations you feel. You will probably feel several surge.r-strong, irresistible urges to push-within each contraction. Each lasts a few seconds. You simply breathe in whatever pattern suits you best-slow, light, or variable-until you have an urge to push and your body begins bearing down. join in with this urge to push, bearing down for as long as you feel the urge. Then breathe lightly until either another urge comes or the contraction is over. You will probably bear down three to five times per contraction, with each effort lasting about five to seven seconds. Between contractions take advantage of the opportunity to rest and relax.

This reaction is called "spontaneous bearing down," (meaning that you react spontaneously to your urge to push) .It is recommended when labor is progressing normally and without medication. It is less effective when anesthesia is used, because anesthesia sometimes diminishes the pushing sensations and your ability to bear down effectively. When you have had anesthesia, your birth attendant or nurse will tell you how and when to push. This is called "directed pushing."

When practicing bearing-down techniques for the second stage, try to imagine what will be happening when you use them in actual labor. By visualizing the baby descending and rotating, you will be reminded of the importance of relaxing and bulging the pelvic floor. (See the exercise on page 97)

Positions for the Second Stage


just as movement and position changes are helpful for both comfort and progress in the first stage, they may be equally beneficial in the second stage. Rehearse bearing down or expulsion breathing in the positions shown on the previous page. Turn to the chart on pages 151-52 for a discussion of each position 's advantages and disadvantages.

The positions you use will depend on a number of factors: the speed and ease of delivery (you may not have time to change positions if the baby is coming rapidly, but if second stage is slow, you will have a chance to try them all) ; your willingness to move about; your mobility ( electronic fetal monitors, catheters, anesthetics, intravenous equipment, and narrow beds discourage mobility) ; and your birth attendant's preferences. When you prepare your birth plan, discuss delivery positions. Although many doctors and midwives are most familiar with the semisitting position (often with your feet in stirrups) on the edge of the delivery table or bed, they may be willing to try other positions if you ask, at least until a few contractions before the actual birth. Then your attendant may ask you to change to the position of his or her choice.

Spontaneous Bearing Down ( Expulsion Breathing)

How to Use Spontaneous Bearing Down in Labor



  1. Take an organizing breath as soon as the contraction begins. Release all unnecessary tension as you breathe out.
  2. Focus on the baby moving down and out, or on another positive image.
  3. Breathe slowly, letting the contraction guide you in accelerating and lightening your breathing as necessary for comfort. When you cannot resist the urge to push (when it "demands" that you join in), take a big breath, curl your body, and lean forward. Then bear down, while holding your breath or slowly releasing air by grunting or straining, whichever feels best at the time. Tighten your abdominal muscles. Most important of all, relax the pelvic floor. Help the baby come down by releasing any tension in the perineum.
  4. After five to six seconds, release your breath and breathe in and out until, once again, the urge to push takes over and you join in by bearing down. How hard you push is dictated by your sensations. (In practice, never push hard.) You will continue in this way until the contraction subsides. The urge to push comes and goes in waves during the contraction, giving you time in between to "breathe for your baby"-to oxygenate your blood to provide sufficient oxygen for the baby.
  5. When the contraction ends, slowly lie or sit back or stand up from a squat and take one or two relaxing breaths.

Avoiding Pushing as the Head Is Born

The breathing and bearing down described above continues for each contraction until much of the baby's head can be seen (crowning), at which time you will feel the skin of your vagina stretch and burn. At this point you may need to stop bearing down to allow the vagina and perineum to stretch gradually and reduce the likelihood of tearing or a too-rapid delivery. While the stretching, burning sensation is a clear signal to stop your bearing-down effort, your doctor or midwife will also give you directions at this point, telling you when to push and when to blow to stop pushing. To keep from pushing, continue blowing, as you do when avoiding the urge to push (page 122), until the urge to push goes away or until you are told to bear down again.

Directed Pushing

The previous description of the second-stage bearing-down technique is based on the assumption that you will feel a spontaneous urge to push, which will guide your response to your contractions. If, however, you do not feel your contractions because of anesthesia, or if you have no urge to push even after letting fIfteen or twenty minutes pass and trying gravity-enhancing positions (squatting, sitting, "dangling," or standing upright) , then you may need to follow a routine of directed pushing.



How to Use Directed Pushing in Labor

In this technique, your birth attendant, nurse, or partner tells you when, how long, and how hard to push.

  1. When the contraction begins, take two or three breaths, and when you are told to push, take a breath in, hold it, tuck your chin on your chest and bear down, tightening your abdominal muscles.
  2. Relax your pelvic floor muscles. Bear down for five to seven seconds. Quickly release your air, take another breath or two, and repeat the routine until the contraction eases off.
  3. When the contraction ends, slowly lie or sit back and take two relaxing breaths.

Note: This routine continues for each contraction until the baby's head is almost out. At this point the doctor or midwife will tell you to stop pushing to allow the baby to pass slowly through the vaginal opening. At the attendant's direction, immediately relax and let all the air out of your lungs. Pant, or blow quickly, if necessary, to keep from bearing down.

How to Rehearse Spontaneous Bearing Down and Directed Pushing for Labor

U se the practice sessions as rehearsals, going through the contractions as described for spontaneous bearing down. Remember the importance of relaxing the perineum while bearing down. In practice, bear down only enough to allow yourself to feel bulging of the pelvic floor. In actual labor, your body guides you in how hard to bear down. Some women find it helpful to rehearse these bearing-down techniques during perineal massage.

In addition, occasionally rehearse directed pushing, with your partner counting to five or seven while you hold your breath.

Prolonged Pushing

Prolonged breath-holding and pushing was once taught for all births, whether the mother could feel her urge to push or not. It is still more familiar to many birth attendants than other methods, and it is more widely advocated by them.



Prolonged pushing differs from directed pushing in the length of time the woman is expected to hold her breath and bear down-ten seconds or more instead of five to seven seconds. Although prolonged pushing may be beneficial under some circumstances (such as a very long second stage, inability to use a gravity-assisted position, or a large baby) , it is not a good idea to use prolonged pushing when progress is good. This kind of pushing, especially in the supine (back-lying) position, is associated with a decrease in the oxygen available to the fetus, a drop in the mother's blood pressure, and too-rapid stretching of the vaginal tissues, increasing the possibility of a tear and the need for an episiotomy.

Spontaneous bearing down and directed pushing efforts with breathing in between result in better oxygenation of the fetus and more gradual distention of the vagina. Unless the woman uses upright positions that promote fetal descent, the second stage may last longer with spontaneous or directed pushing than with prolonged pushing, but the fetus usually remains in good condition throughout.

Under some circumstances the advantages of prolonged pushing may outweigh the disadvantages. These are discussed in chapter 9; they involve situations when there is a need to speed the second stage. Your caregiver is the best judge of this. Since you will be using this technique only under the guidance of your caregiver, there is no need to practice it before labor.

Preparation of the Perineum (Perineal Massage )

perineal massage teaches you to respond to pressure in your vagina by relaxing your pelvic floor-a useful rehearsal for birth. It also is thought to increase the elasticity of the vagina and perineum, enhancing the hormonal changes that soften connective tissue in late pregnancy. You are more likely to avoid an episiotomy or serious tear if you practice perineal massage.5 (Episiotomy is discussed further in chapters 8 and 9.)

If you are interested in avoiding an episiotomy, you may find it very helpful to massage the perineum five to seven times a week during the last six weeks of your pregnancy. Be sure your caregiver knows what you are doing and why. Because perineal massage is somewhat unconventional and outside mainstream obstetrical care, some caregivers are not familiar with it. Some women or couples find it distasteful and do not want to do it. Others feel it is worthwhile if it can reduce the chances of having an episiotomy or a serious tear. Some find it enjoyable, especially after doing it for a while and learning to relax.

If you have vaginitis, a herpes sore, or other vaginal problems, you should wait until you are healed before beginning perineal massage, as it could worsen the condition.

What to Do

Either you or your partner can do the massage. The first few times, take a mirror and look at your perineum so you know what you are doing. Be sure your hands are clean and your fingernails are short. If you or your partner has rough skin, it might be more comfortable to wear disposable rubber gloves.

Make yourself comfortable, in a semisitting position (if your partner is doing it) or standing with one root up on the side of the tub or a chair (if you are doing it yourself).

  1. Lubricate your fingers well with oil or water-soluble jelly by squirting it onto your fingers from a squeeze bottle or tube. This method is preferable to dipping your fingers into the oil, since repeated dipping will contaminate the oil. Some people recommend wheat germ oil, available at health food stores, because of its high vitamin E content, but other vegetable oils or waterbased lubricants such as K-YJelly can also be used. Do not use baby oil, mineral oil, petroleum jelly, or hand lotion, as these are believed to be less well absorbed by the body than are vegetable or water-based products.
  2. Rub enough oil or jelly into the perineum to allow your fingers to move smoothly.
  3. If you are doing the massage yourself, use your thumb. Your partner can use the index fingers ( one at first, both when you are more used to it) .Place the fingers or thumb well inside the vagina (up to the second knuckle) , then do a Kegel (pelvic floor contraction) so that you can feel the muscle tense on your or your partner's fingers. Move thumb or fingers within the vagina in a rhythmic U movement while gently pulling outward and down toward the anus. Do this for about three minutes. This stretching increases the suppleness of your vaginal tissue (mucosa) , the muscles surrounding your vagina, and the skin of your perineum. Then massage briefly by rubbing the skin of the perineum between the thumb and forefinger (thumb on the inside, finger on the outside or vice versa) for about one minute. In the beginning, your vaginal wall will feel tight, but with time and practice, the tissue will relax and stretch more easily.
  4. Concentrate on relaxing your muscles as you feel the pressure and stretching. As you become comfortable with the massaging, increase the pressure just enough to make the perineum begin to sting or burn slightly from the stretching. (This same stinging sensation occurs as the baby's head is being born.)
  5. If you have any questions after trying the massage, ask your caregiver or someone who teaches or has used this technique.

Practice Time - Rehearsals for Labor

Try to use practice time for more than simply going through a number of techniques. Use this time as a rehearsal for labor. Think about and discuss when you might use the techniques and why. Review what you have learned about the emotional and physical events of labor. Use the Labor and Birth Guide, pages 162-64, to help you review. Most of all, use this time together to explore the basic techniques you have learned, to adapt them to fit your needs, and to learn how to work together.

Practicing with Your Partner

Here are some suggestions for how your partner might work with you during practice. Many of these same suggestions will be useful in labor as well.

How Much Should You Practice ?

It is probably not necessary to practice daily to master these techniques, especially if you are attending childbirth classes together. Spend enough time practicing to become completely comfortable with each breathing pattern and relaxation technique and to figure out any adaptations you want to make. Then review them often enough that they remain very familiar and comfortable for you. Some people need or want to practice more than others.

Suggested Guide for Practice

The following learning sequence, which is based on an eight-week preparation period, will help you master the techniques discussed in this chapter and in chapter 6 in a careful, organized way. Try to be~n about ten weeks before your due date to ensure that you finish even if the baby is born early. You will have to condense the sequence, of course, if your preparations begin later in your pregnancy.

Week 1

  1. Do all the conditioning exercises described on pages 96-99, except the variations.
  2. Practice body awareness (see pages 106-7).
  3. Practice passive relaxation with slow breathing, ten to fifteen minutes (see pages 108-10).

Week 2

  1. Continue the conditioning exercises, adding the variations.
  2. Continue passive relaxation for shorter periods (about five minutes) with your partner checking and providing feedback (see pages 107-8).
  3. Practice slow breathing in a contraction pattern (page 119), using many positions--side-lying, sitting, standing, leaning against a wall, on hands and knees, and squatting (see pages 144-45). Once mastered, practice three olle-minute contractions with time between for feedback, changing position, and so on. Have your partner observe and assist you in maximum relaxation in all positions; he or she should watch for consistency in your breathing pattern.
  4. Learn light (accelerated) breathing, (see pages 119-21). This may take several days. Experiment with depth and rate to find the best way for you. Have your partner observe for relaxation. You may need to practice five to ten olle-minute contractions each day for a few days. Once you have mastered the technique-whell you can relax and do it consistently-reduce the number of practice contractions.
  5. Incorporate the use of attention-focusing (see page 113) with all breathing patterns.

Week 3

  1. Continue your conditioning exercises.
  2. Learn touch relaxation, page 110.
  3. Continue practicing three slow-breathing contractions using different positions, with your partner observing for relaxation and consistency and providing feedback, suggestions, and encouragement.
  4. Continue practicing light breathing for three ninety-second contractions in different positions.

Week 4

  1. Continue your conditioning exercises.
  2. Continue touch relaxation.
  3. Learn effleurage and other massage techniques (see pages 113-14).
  4. Continue practicing slow-breathing contractions, adding the roving body check (see page 111).
  5. Continue using light breathing as before, with your partner conducting.

Week 5

  1. Continue your conditioning exercises.
  2. Continue touch relaxation and massage techniques with breathing patterns.
  3. Learn the relaxation countdown.
  4. Continue practicing slow breathing, using the roving body check ( see page 111) each time.
  5. Continue practicing light breathing.
  6. Learn variable (transition) breathing (see pages 121-22).
  7. Learn counterpressure, the double hip squeeze, and other techniques for back pain (see pages 175-76).

Week 6

  1. Continue your conditioning exercises.
  2. Practice active relaxation(see pages 110-1J).
  3. Incorporate relaxation countdown into your organizing and final relaxing breaths.
  4. Continue practicing slow breathing, incorporating the roving body check.
  5. Continue practicing light breathing, adding the roving body check. Think of "blowing out" tension with each out-breath.
  6. Continue practicing variable breathing.
  7. Learn ways to avoid pushing ( see page 122).
  8. Learn scramble breathing (see pages 121-22).

Week 7

  1. Continue your .conditioning exercises, particularly the pelvic floor bulging (see page 97). .
  2. Practice relaxation with each of the breathing patterns.
  3. Continue practicing slow breathing.
  4. Continue practicing light breathing.
  5. Continue practicing variable breathing, along with "scramble" breathing.
  6. Learn spontaneous bearing down in many positions. Have your partner help you by describing how you should be pushing (see pages 122-25).
  7. Learn directed pushing in many positions, with your partner telling you when and how long to bear down (see pages 125-26).
  8. Practice bearing down and suddenly blowing to avoid pushing during the same pushing contraction.

Week 8

  1. Continue your conditioning exercises.
  2. Rehearse for labor. Discuss the physical and emotional characteristics of each phase of labor, as well as the support and comfort measures likely to be useful. Practice several contractions for each phase, incorporating relaxation techniques, breathing patterns, and comfort measures. Use the Labor and Birth Guide on pages 162-64 as a review sheet.

Chapter 8

LABOR AND BIRTH

The Events of Late Pregnancy

During the last six or eight weeks of pregnancy, numerous complex interrelated events take place, as shown below. Birth is the climax. Each component of the fetalmaternal-placental unit contributes by triggering changes in other components, and thereby continues the process that results in the birth of a mature and capable baby to a mother who is ready to nourish and nurture her. The timing is usually perfect, although in 10 to 12 percent of births, the timing is off and a premature or postmature baby is born.



Presentation and Position

The doctor or midwife uses these terms to describe how your baby is lying within your uterus. Presentation describes the part of the baby that is lying over the cervix. For example, the most favorable and most common presentation (occurring 95 percent of the time) is the vertex presentation, in which the crown or top of the baby's head is down over the cervix. Other, more rare presentations are the frank lJreech (buttocks), footling lJreech (feet) , comPlete lJreech (buttocks and feet) , shoulder, face, and lJrow presentations. (These rarer presentations, which may cause difficulties in labor, are discussed in chapter 9.) Position refers to the direction toward which the baby lies within your body. The possible positions are anterior, referring to your front; posterior, referring to your back; and transverse, referring to your side.

If your doctor or midwife tells you the baby is occiPut anterior, it means that the back of the baby's head (the occiput) is pointing toward your anterior (front) .Here are some other common descriptions of the baby's presentation and position:

Left (or Right) Occiput Anterior (LOA or ROA). The back of the baby's head toward your left (or right) front.


Occiput Posterior (OP). The back of the baby's head is directly toward your back. See page 175 for information on what you can do in labor.

Right or Left Occiput Posterior (ROP or LOP). The back of the baby's head is toward your right ( or left) back.

Right or Left Occiput Transverse (ROT or LOT). The back of the baby's head is toward your right ( or left) side.

Right or Left Sacrum Anterior (RSA or LSA). The baby's tailbone or buttocks (sacrum) is toward your right (or left) front. This is how a breech presentation is described.

The Active Phase

As the latent phase draws to a close, your labor pattern changes. Your contractions may be painful, though manageable, each lasting a minute or more and coming close together-three to five minutes apart. This is the time when most people go to the hospital or birth center, or when the midwife or doctor arrives for a home birth. You may feel as if this now-intense labor has gone on for a long time without much progress. As you look back on how long it took to get to four or five centimeters you may feel discouraged if you think it will take that much more time to get to ten centimeters! You may wish you could call it quits for the day. You may feel trapped in the labor as you realize that there is no way out but to go on and complete the ~rocess. We sometimes refer to this realization as the "moment of truth."

These are typical reactions to the more demanding and more productive active phase of labor. In the latent phase, your spirits were high; in the active phase, you become serious, quiet, and preoccupied with the contractions. Earlier your partner's jokes were funny and the conversation entertaining; now you cannot listen. You may even feel resentful of any "small talk" around you. As you become more centered on your labor, your partner should move in closer, focus more on your labor, and share your serious, quiet mood. He or she should help you to relax, find comfortable positions, and maintain your focus and breathing. Most importantly, your partner can help you interpret what is going on. You may be discouraged because you seem to be progressing as slowly as before, yet the contractions are demanding so much more of you. The truth is, when you enter the active phase, labor is speeding up and you are accomplishing more with each of these intense, painful contractions. It is the knowledge that you are finally getting somewhere that renews your confidence and optimism.

Arrival at the Hospital

Once you decide to go to the hospital, call the maternity floor and anyone else you want to tell, get your bag and your birth plan, gather any last-minute items (a pillow and blanket, and a towel if your bag of waters is leaking) , and go. Do not drive yourself. If your partner is not available, have a backup plan for someone else to take you. Be sure you know which hospital entrance to use. In the middle of the night, the emergency room may be the only open entrance.

When you arrive, go first to the admitting office if it is open. Admitting procedures do not take long if you have preregistered. Otherwise it might take a while. If you are having painful contractions or are in active labor, the hospital staff can take care of the admitting procedures later. You or your partner will sign admission forms, including a general consent form. Most general consent forms are intimidating and make it seem as if you are giving the hospital permission to do whatever they want to you. Try to read this form before labor, and ask for clarification of any items you are uncomfortable with. Some patients simply cross out or reword the items that concern them and initial those changes before signing the form. Some add a statement that they want to be informed of reasons, risks, benefits, and alternatives before any treatment or procedure is done. It might be helpful to know that the general consent form may not be the only one you will sign. H you or your baby develops a problem requiring major procedures (such as cesarean section, other surgery, a septic workup, or in some hospitats, epidural anesthesia) , you will probably be asked to sign another consent form.

You can take a wheelchair or walk to the maternity floor. A nurse usually greets you, assesses your condition, your labor, and your baby's well-being, and then calls your caregiver. The nurse checks the same things that are checked at your prenatal exam: She or he will ask questions about what is happening and about your medical history, and will check your weight, pulse, blood pressure, temperature, the baby's heart rate and position, your contractions, and the dilation of your cervix. The nurse will also get urine and blood samples. If you are making progress in labor, you will put on a gown (you may wear a hospital gown or bring your own) and proceed with the usual care during labor. If it appears that you are still in very early labor (or prelabor), the nurse might suggest that you leave the hospital for a while, until the labor pattern changes. This is usually a good idea, because if you get to the hospital too early, labor can seem awfully long and discouraging.

Initial Procedures for a Home Birth

Once you call your midwife or doctor for a home birth, she or he will arrive and make similar assessments to those described for hospital admission. If you are progressing in labor, the caregiver will bring in the essential implements, medications, an oxygen tank, and other equipment. She or he may remain with you from then on or, if labor is still quite early and you are comfortable on your own, may leave for awhile. Your caregiver may work with an assistant, \who may remain with you.

Positions for First Stage

Position Advantages Disadvantages
Standing
  • Takes advantage of gravity during and between contractions
  • Contractions less painful and more productive
  • Fetus well aligned with angle of pelvis
  • Relieves backache
  • May speed labor
  • Tiring for long periods
  • May be impossible with anesthesia
Standing and leaning forward
  • Same as with standing
  • May be more restful than standing
  • Same as with standing
Walking
  • Same as with standing
  • Movement in pelvis encourages descent
  • Tiring for long periods
  • Difficult or impossible with anesthesia, analgesia, or electronic fetal monitoring
Sitting upright
  • Good resting position
  • Some gravity advantage
  • Can be used with electronic fetal monitor
  • May slow labor progress if used for long periods
Semisitting
  • Same as with sitting upright
  • Vaginal exams possible
  • Same as with sitting upright
  • Increases back pain
Sitting, leaning forward with support
  • Same as with sitting upright
  • Relieves back pain
  • Good position for back rub
  • Same as with sitting upright
Hands and knees
  • Helps relieve backache
  • Assists rotation of baby from OP position
  • Allows for pelvic rocking
  • May be used when other positions cause a drop in fetal heart rate
  • Vaginal exams inconvenient for most caregivers
  • Hands and knees may go to sleep or hurt after a while
  • May interfere with external fetal monItor traCIng
  • May be tiring for long periods
Kneeling, leaning forward with support
  • Same as on hands and knees
  • Less strain on wrists and hands than in hands and knees position
  • May interfere with external fetal monitor tracing
  • May be tiring for long periods
Side-lying
  • Very good resting position
  • Convenient for many interventions
  • Helps lower elevated blood pressure
  • May promote progress of labor when alternated with walking
  • Safe if pain medications have been used
  • Contractions may be less effective and longer
  • May be inconvenient for vaginal exams
Squatting
  • Takes advantage of gravity
  • May be comfortable and relieve backache
  • May enhance fetal alignment and descent within pelvis
  • May not enhance descent of baby if station is high
  • Tiring for long periods
  • Legs can go to sleep if used for long periods
Back-lying (supine)
  • Convenient for caregiver for procedures and vaginal exam
  • May be restful
  • Convenient for electronic fetal monitoring
  • May cause supine hypotension and fetal distress
  • May increase backache
  • Psychologically vulnerable
  • Labor contractions found to be longest, most painful, and least productive

Working with Your labor

After these initial procedures, make yourself comfortable. Try pressure and cold packs on your back or hot compresses on your lower abdomen, groin, and back. Go to the bathroom once an hour, because a full bladder is uncomfortable and can slow labor. Change position frequently unless you are very tired and need to rest or unless the contractions are coming so fast you cannot move; try to walk and sit rather than lie in bed. Some laboring women make the mistake of staying immobile in bed throughout labor. Lying down may increase the pain of contractions and slow the progress of labor. Take advantage of gravity by standing and walking for at least part of the time. (See the photos on page 118 and the chart on pages 144-45 for a discussion of positions. ) You may want to alternate activity with rest. It is important to get fluids, so drink something after each contraction or suck on a popsicle or ice chips. To gauge your progress, at each vaginal exam find out the effacement and dilation, as well as the station and position of the baby.

Continue your relaxation and breathing techniques. This is a good time for lots of encouragement from your partner, who can praise your efforts, rub your back and legs, count off every fIfteen seconds in the contraction, and remind you to move around, drink fluids, and go to the bathroom. Relaxation is the key at this time. Make a special effort to keep from tensing during contractions.

You will want to continue slow breathing (see page 117) for as long as it helps you relax. If your breathing begins to sound tense or labored, if you are unable to keep the rate slow, or if you find you cannot maintain your focus and remain relaxed, even after renewed efforts and more active encourgement from your partner, switch to light (accelerated) breathing (see page 119' .This may give you just the boost you need. Light breathing follows the pattern of your contractions, lightening and quickening as the contraction intensifies, then slowing and deepening as the contraction subsides. Used in this way, the breathing pattern can help you tune in to your labor contractions and calm you with its rhythm.

The Transition Phase

The transition phase represents the peak of difficulty in most labors, not necessarily because the pain is greater, but because the contractions are longer and closer together, there is more pressure in the pelvis, and the accompanying physical and emotional signs are intense. The cervix dilates the last one or two centimeters, the baby's head leaves the uterus and presses down lower in the birth canal, and your body prepares for the expulsion stage. Relatively short, the transition phase usually lasts from five to twenty contractions. These contractions, the longest of your labor, will give you the shortest rest in between. You will probably be tired, restless, and irritable, totally consumed by your efforts to cope. The intensity of transition is almost overwhelming and you will need much reassurance and help to get through.

During this phase you are truly in a transition-from first to second stage. Not only is your cervix dilating the last couple of centimeters, but the baby is beginning to descend. The head slips through your cervix and into your vagina. Your body shows some of the signs of the second stage, although labor is still technically in the first stage. You will probably have some very intense new feelings to cope with. For example, your diaphragm may be irritated by the involuntary spasms that are the precursors of bearing down. As a result you may begin hiccuping, grunting, or belching. You may find yourself holding your breath and straining at times during each contraction. This is what is known as "the urge to push." Nausea and vomiting are common. The baby's head, pressing through your vaginal wall against your rectum, feels like a bowel movement and may cause a backache or aching thighs. Trembling of the legs, which may spread throughout the body, and a heavy discharge .of bloody mucus from the vagina reflect the increased downward pressure. Contractions may be irregular, with double peaks, and may last 90 to 120 seconds with only 30-second rests between. Despite the intensity and pain of the contractions of transition, you may doze off during the short rests between contractions, as if your body is conserving every bit of energy for the work of contractions. Dozing is helpful, but the moment the next contraction begins, your partner should wake you and help you focus and begin breathing so the contraction does not get ahead of you.

During transition, you become very focused on your labor; nothing else matters. You may worry that something is wrong. You may feel frightened by the intensity of labor and very dependent on those around you. You may feel transition will last forever, that you cannot take any more. But as one woman said, "When you can't take any more, there's no more to take."Transition pushes you to your limits, but with good support and the knowledge of where you are and what you need to do, you will meet the challenge because transition is short.

Gettjng through Transition

Recognition is one of the keys to coping with transition. If you are experiencing the extreme sensations of transition and believe you are only five or six centimeters dilated, you will probably become discouraged. Remember that labor is a progressive process. "You are not where you were at the last vaginal exam. You are beyond that point," is a guideline to remember after you have passed the latent phase, especially if your sensations and emotional responses change during contractions. Know the signs of transition described above and be ready for them any time after you enter the active phase of labor. When a woman and her partner know where they are, they are heartened by their progress and see the pain and difficulties of transition in a more positive light-transition is bringing the baby closer.

Understanding the normal feelings, reactions, and events of transition is another .key. Pain, nausea, trembling, despair, dependence, crying, an urge to push, and an inability to relax and breathe "perfectly" are normal responses during transition. They do not mean anything is wrong. It is when you think that your labor is worse than it is supposed to be that you begin to worry and seek relief with pain medications or anesthesia. Pain medications, of course, are an option, but do not take them because you fear your transition is abnormal. The medication can only reduce pain, it does not remove the other symptoms.

Reassurance and kindness from your partner and caregiver are essential. You need to know that you and your baby are all right, that your sensations are normal, that you are coping well, and that this difficult time will be short.

Finally, more active support and direction from your partner and caregiver may help you through transition. Your partner might "take charge" by getting you to look at him or her, pacing or conducting your breathing with hand movements or by breathing with you. Your partner gets very close to you, helps you focuS, and encourages your every breath. Switch to a variable breathing pattern if light or slow breathing seem ineffective. If you have a premature urge to push, blow or pant to keep from pushing. (The breathing patterns for transition are described on page 121) Many women like being held close at this time; others do not want to be touched but find visual and verbal contact very helpful. Hot, moist towels on the lower back, lower abdomen, and perineum can be soothing. Changing positions between contractions sometimes brings relief.

Women often worry that transition will be too much for them, that they will lose control, panic, and behave in a way they will later regret. They have heard of women who lost control, struggled, screamed, or begged for relief from the pain. These impressions of childbirth probably came from women who were unprepared, frightened, and groggy or confused from medication.

You can get through a normal transition without pain medications, especially if you prepare in advance, have good support, know what is happening, and use relaxation, breathing, and comfort techniques. Be assured that you will not change character or lose the ability to respond to clear, simple directions. Your labor partner should not mistake moans, groans, or other sounds during transition for cries of agony. Many women find transition easier to manage if they vocalize or make noise during the contractions. If so, they should be encouraged in making these sounds. Some women, on the other hand, go into a state of deep relaxation and remain very still and quiet during their contractions. There is no single correct way to handle transition; responses to childbirth pain are very individual.

The Second Stage of Labor-Birth of the Baby

After dilation is complete, transition ends and the second stage of labor begins. A new series of physiological events begins; your baby gradually leaves the uterus, rotates within your pelvis and descends through the vagina, and is born.


Signs of Second Stage

The urge to push. This urge-the most significant sign-coin,cides roughly with full dilation, although many women experience it before full dilation, others experience it sometime later, and a few not at all. (See page 122 on how to handle a premature urge to push. ) The urge to push is a combination of powerful sensations and reflex actions caused by the pressure of the baby in the vagina during contractions. As difficult to describe as labor contractions, the urge to push is a strongly felt need to grunt or hold your breath and bear down. It occurs several times within a contraction, and is responsible for your pressing the baby downward. It is as compelling and difficult to control as a sneeze, an orgasm, or vomiting. For many women, joining in with the urge to push is one of the most satisfying aspects of the entire birth experience. For others it is disturbing and painful.

Relief from sensations of transition. This is another sign of second stage. The pain lessens, you calm down and cheer up, and you become less focused on your labor and more aware of those around you. Now you can collect yourself for pushing your baby out of your body. During the first stage, you cooperate with your labor contractions by relaxing as much as possible and using positions and movement to enhance the process. During the second stage you cooperate with your labor by voluntarily bearing down and assuming appropriate positions.

Key Concepts

Two key concepts should guide you and the staff during the second stage:

The importance of not rushing. Although both you and the staff are anxious to get that baby out, do not rush. Follow your body's signals; bear down or "push" spontaneously as the urge demands and allow time for yoUr vagina to open. By not rushing, your vagina can stretch open gently, decreasing the likelihood of damage.s You will also use your energy more efficiently. By joining in, holding your breath, and bearing down only when you cannot resist the Urge to push, you will be working in harmony with yoUr uterus and not wasting yoUr effort.

By bearing down for five to six seconds at a time and taking several breaths between bearing-down efforts, you take in more oxygen and make more oxygen available to your baby than if you hold your breath and strain as long as possible. Although there is very little exchange of oxygen across the placenta during contractions, when the uterus relaxes, exchange resumes and the fetus benefits.

It often seems as though the staff is in a rush to get yoUr baby out, imploring you to push as long and hard as you can, without regard for your urge to push. Prolonged maximal bearing down in a normal labor, with or without anesthesia, is usually not necessary and sometimes causes problems (fetal distress, failure of the baby to rotate, arrest of descent, possible perineal tears) that would not have occurred with spontaneous bearing down.5 Prolonged maximal pushing is best reserved for times when progress is inadequate or the baby is already in distress and other interventions (forceps, vacuum extractor, or cesearean) are being considered. Discuss this with your caregiver in advance and with the nurses when you arrive at the hospital. Include your wishes in your birth plan.

The importance of different positions.

Progress and comfort should guide your choice of position. Feel free during the second stage to use positions that are comfortable, that alter progress, either by enhancing slow progress or slowing too rapid progress, or that provide other advantages.

Positions for Second Stage

The chart on pages 151-52 lists a variety of possible positions for second stage and their advantages and disadvantages. (Also, see the illustrations on page 123.) The most common position in North America is semisitting, with legs raised in stirrups or with feet either in footrests or resting on the bed. Although this is convenient for the birth attendant, it is not always the best for the mother's comfort or labor progress. It is a good idea to know all of the positions and their advantages and disadvantages, and be prepared and willing to try them all. Sometimes switching to anew position makes edical intervention (such as a vacuum extractor or forceps) unnecessary. If one position is very uncomfortable, or you make no progress in that position, try another. Positions that take advantage of gravity are an asset and may aid progress and descent.

When the second stage is progressing at a reasonable pace-not too fast or slow-use whatever positions seem most comfortable. If the second stage is going very fast, try a gravity-neutral position such as side-lying to slow it down. Sometimes, even if it hurts, you may have to get into another position, especially if descent is not taking place or if the baby's heart is adversely affected by your position. When birth is imminent, assume the position favored by your doctor or midwife.

The second stage lasts from fIfteen minutes to over three hours. The multigravida's second stage is usually faster than it was with her first birth. As with the first stage, the second stage can be divided into three phases: atent, active, and transition. The three )hases share similar characteristics with the :hree phases of the first stage. The latent )hase of both stages is characterized by high ;pirits, little pain, and slow progress. Both lctive phases are characterized by total mental absorption, rapid progress, and intense :ontractions. Both transition phases bridge lnto the next stage, and are characterized by intense pain and confusion over what to do.

The Latent (Resting) Phase

The latent or resting phase of the second stage is characterized by a lull in uterine activity, a brief rest for you, a pause after the intensity and confusion of transition, and excitement over your baby's imminent arrival. Contractions may be weak and farther apart for ten or twenty minutes, descent may slow or stop temporarily, and your urge to push may be nonexistent or easily satisfied with slight bearing-down efforts. This resting phase takes place because your baby's head has slipped through the cervix, causing your uterus, which had been stretched tightly around your baby, to become a bit slack. It needs time to tighten down around the rest of your baby's body. Then strong contractions resume and your urge to push becomes powerful. This temporary lull is normal and very welcome as a chance to rest and recuperate after transition; it is no cause for alarm.

If your baby is at a very low station when the second stage begins, or if she is descending very fast, you may skip this resting phase, or it may be very brief. You will move right into the active phase as soon as your cervix is fully dilated. If the latent phase lasts for more than fifteen or twenty minutes, your caregiver may ask you to try a gravity-enhancing position, such as squatting, to encourage rotation, descent, and an urge to push.

Positions for Second Stage

Position Advantages Disadvantages
Semi-sitting
  • Convenient for birth attendant
  • Some gravity advantage when compared with lying flat
  • Easy to get into on bed or on delivery table
  • May aggravate hemorrhoids
  • May restrict free movement of sacrum when more room is needed in pelvis
  • May slow passage of head under pubic bone
Side-lying
  • Gravity-neutral
  • Useful to slow a very rapid second stage
  • Favorable if mother has high blood pressure
  • May improve chances of an intact perineum
  • Takes pressure off hemorrhoids
  • May reduce backache
  • Easier to relax between pushing efforts
  • May not be familiar to birth attendant, who may need to adjust his or her technique for delivery
  • Is unfavorable if you need to speed secon stage
Hands and knees
  • Gravity-neutral
  • Helps assist rotation of an OP baby
  • May improve chances of intact perineum
  • Takes pressure off hemorrhoids
  • Allows for free movement, rocking back and forth, tilting pelvis
  • May reduce backache
  • Same as for side-lying
  • Tiring for long periods
Lying on your back with legs pulled back rasing head to push
  • Pulling legs back and apart helps widen pelvic outlet
  • Sometimes helps press baby's head beneath pubic bone
  • Supine hypotension
  • Maintaining position exhausts mother and may work against gravity
Squatting (with or without sideways movement or kneelillg on one knee)
  • Takes advantage of gravity
  • Widens pelvic outlet
  • Requlres less bearing down effort
  • May enhance rotatIon and descent in a difficult birth
  • Helpfull if mother does not feel urge to push
  • Difficult to get into on an ordinary bed (a birthing bed with squatting bar helps)
  • Difficult for birth attendant to see penneum
  • May promote too rapid expulsion, leading to perineal tears
  • May be uncomfortable
Sitting on toilet or commode
  • Helps mother relax tense perineum for effective bearing-down
  • Takes advantage of gravity
  • Toilet may not be available nearby
  • Mother must move for birth continued
Supported squat or ".dangle". (in an UprIght posItion, mother "dangles," supported under her arms by her partner, who may stand and support her with his or her arms or SIt high on bed or counter and support her with his or her thighs)
  • Enhances descent in difficult birth
  • Permits relaxation of pelvis, allowing baby to spread pelvic bones
  • May improve chances of an intact perineum
  • ElimInates external pressures on pelvis from bed, chair, stretched muscles, etc.
  • Takes advantage of graVIty
  • May be hard work for sUp port person, if standing
  • If support person is sitting, may require woman and partner trading places in bed
  • Awkward for caregIver who may requIre mother to change position for birth
Semilithotomy (backlying with head and shoulders elevated legs In Stirrups, and hIps on edge of delivery table)
  • Slight gravity advantage over lying flat
  • Mother able to view birth
  • Mother can see birth attendant, which IS reassurIng
  • Convenient for attendant
  • May be necessary for interventions (forceps, episiotomy, etc.)
  • Stirrups support legs when anesthesia causes loss of mother's muscle control
  • Leg cramps common
  • May be frightening to give birth over edge of table
  • Restricts sacral movement
  • Possible supine hypo tension
  • Restricts mother's efforts, which could prolong delIvery
lithotomy (lying on back with legs raised in stirrups and hlps on edge of delivery table)
  • Convenient for attendant
  • May be necessary for interventions (forceps, episiotomy, etc)
  • Works against gravity
  • May be frightening to give birth over edge of table
  • Leg cramps common
  • Difficult to view birth or birth attendant
  • Supine hypotension
  • Restricts mother's efforts, which could prolong delivery

The Active (Descent) Phase

During the active phase of the second stage, your baby descends and you will feel powerful contractions and an irresistible urge to push. You may find bearing down with all your strength extremely rewarding. You can feel progress. The baby's head distends your vagina and presses on your rectal wall. You may feel alarmed by the full, bulging feeling. You may be afraid to let the baby come down and may tense your pelvic floor , against it, while raising your hips as if to escape from it. This will increase pain and slow progress. The most important thing for you to do during pushing efforts is to relax your pelvic floor and bulge your perineum ( as in the pelvic floor bulging exercise on page 97) .Prenatal perineal massage, in which you relax your perineum while it is being stretched, is excellent preparation for second stage.

Your partner's reminders to "relax," "let the baby out," "open up," "bulge your bottom," or "ease the baby out" are very important at this time, certainly more important than directions to "push, push, push." Your caregiver or partner might press hot, moist towels against your perineum to help you relax and appropriately direct your bearing down efforts. Clenching your jaw and clamping your lips together is a sign that you are probably tensing the muscles in your vagina. By relaxing your face, particularly your mouth, you may be more able to let go below. Sometimes, even though it hurts, you have to push anyway. If you allow yourself to let go and push despite the pain, you will find it feels better than holding back.

As the active phase progresses, your perineum begins to bulge, your labia part, and your vagina opens as your baby's head descends with each bearing-down effort. Between efforts, your vagina partially closes and your baby's head retreats. Soon, your baby moves further down and her head becomes clearly visible. The joy and anticipation you now feel will give you renewed strength. You may be able to see the baby's head in a mirror. You may want to reach down and touch it. These concrete reminders will help you bear down more efficiently. During this phase, your baby descends and usually completes rotation to the occiput anterior position. Sometimes, for a few contractions during this phase, your baby's head looks and feels strange-soft, slimy, wrinkled, and blue. This may be alarming to you or your partner. The wrinkles are caused by the normal squeezing of the head by the vagina; the loose skin of the baby's scalp forms wrinkles until the baby's head moves down a little further. The blue color of the skin is normal. The entire baby is blue while inside the uterus, but she pinks up within seconds after birth.

The Transition ( Crowning) Phase

The third phase of the second stage is the transition or crowning phase, when your baby passes from inside your body to outside. It begins when your baby's head crowns (that is, it no longer recedes between bearing-down efforts). This phase represents the maximum stretching of your vaginal opening and is characterized by a stinging, burning sensation sometimes called the "rim of fire." Strong bearing down at this time increases the pain and the likelihood of a serious tear of your vagina or perineum. Think of the "rim of fire" as your body's signal to stop your bearing-down efforts. Breathe with a light panting or blowing pattern-do not hold your breath-and relax your vagina as the head crowns and emerges. Some birth attendants support the perineum with hot compresses, or massage it with oil or K-Yjelly to assist gradual stretching, or maintain steady pressure on the baby's head to keep it from coming too rapidly. Many caregivers perform an episiotomy at this point. This surgical incision of the perineum enlarges the vaginal outlet as the perineum is stretching.

Episiotomy

The use of episiotomy, once a standard practice, has become controversial in recent years. Some caregivers' episiotomy rates are as high as 80 or 90 percent, while others' are as low as 10 to 20 percent. Recent scientific studies have found little benefit to routine episiotomy, and some real risks.6 As shown in the chart on the next page, many of the long-held beliefs about the advantages of routine episiotomy simply could not be confirmed by these studies.

As a result of the accumulated evidence against routine episiotomy, many caregivers now use techniques to protect the perineum from tearing and to avoid episiotomy, except when the fetus is in distress or when the perineum is unable to stretch. Others are not convinced.that avoiding an episiotomy is a good idea and have more confidence in their skills in performing and repairing episiotomies than in avoiding them.

If this matter is important to you, discuss it with your caregiver at a prenatal visit. Rather than asking if he or she does routine episiotomies, ask his or her opinion on episiotomy and how often women need one. Those caregivers with high episiotomy rates tend to believe that a tear is always worse than an episiotomy, and that an intact permeum has probably been overstretched. rhose with low rates believe an intact permeum, which can be expected about half the time, is the best result. They point out that most spontaneous tears are smaller than the average episiotomy and that serious large tears are more likely with an episiotomy dIan without one.

If you wish to avoid an episiotomy, you should realize that you have a 50 percent chance of a tear, but dIat most of dIese tears are smaller or about dIe same as dIe average episiotomy. The more experienced your caregiver is in avoiding episiotomies, the better your chances are for an intact perineum or a minor tear. Besides choosing dIe right caregiver, you can do other dIings to help safely avoid an episiotomy. During pregnancy, eat a balanced diet to promote healthy tissues and do perineal massage (described on page 126). During the second stage, use appropriate positions and bear down spontaneously widIout excessive straining. At the time of birth, follow your caregiver's instructions and pant as the baby's head crowns and is born.

FurdIer discussion on dIe advantages and disadvantages of episiotomies can be found in dIe chart on page 187.

Research Findings on Common Beliefs about Episiotomy

The findings below come from comparative studies of routine versus selective episiotomy. Many caregivers base their practice of routine episiotomy on these beliefs.
Belief Finding
Shortens second stage True, by 5 to 15 minutes. An early episiotomy can cause hemorrhage in the mother, so caregivers must do an episiotomy when most of the second stage has passed.
Spares baby from brain damage or other harm Apgar scores and newborn problems were the same. With fetal heart rate monitoring, those babies who need to be delivered quickly are identified and an episiotomy is performed.
Prevents tears Approximately one half of all women who have no episiotomy will have no tear and need no stitches. Smaller tears (first or second degree) are prevented, but larger (third and fourth degree) tears are far more likely with episiotomy. There may be more tears toward the front of the vagina when an episiotomy is not performed. Caregiver skills and techniques may be a factor here.
Preserves strength of pelvic floor No differences were found up to 3 years after birth.
Prevents stretching of pelvic floor The pelvic floor has already stretched considerably before the episiotomy is performed.
Reduces likelihood of future pelvic floor problems: leaking of urine (incontinence), uterine prolapse ("fallen uterus"), cystocele (protrusion of bladder into vagina), rectocele (protrusion of rectum into vagina) , sexual difficulties Incontinence was the same three year later. Sexual difficulties were no different. No differences in the other problems, although there have been no studies that have followed women for more than 3 years after birth.
Is easier to repair Debatable, since approximately half of the women in the selective episiotomy group need no repair, and since the very extensive tears are far more likely to occur when episiotomies are performed.

Birth

Your baby emerges, first dIe top of dIe head to dIe ears, dIen her face-bluish-gray and soaking wet. Mter her head is out, it rotates to dIe side. This allows her shoulders to slip more easily dIrough the pelvis. One shoulder (the one near your pubic bone) emerges, and then the rest of the baby comes radIer quickly. You or your partner may want to help lift the baby out. The entire baby appears bluish at first and may be streaked wid! blood. She also will be partially covered with the white, lotionlike vernix. Wid! her first breath, which comes within seconds, her skin begins to turn to more normal flesh tones. All babies, whether dark- or light-skinned, go through these color changes in the first minute or two of life. Some are quite ruddy until their respiration and circulation adjust to normal. To assist respiration by clearing your baby's airway of mucus, blood, meconium, or amniotic fluid, your doctor or midwife may suction your baby's nose and mouth as soon as her head is out and again later. Your baby may be placed on your abdomen or in your arms to await the delivery of your placenta. (See chapter 13 for more information about the advantages and disadvantages of routine suctioning and the appearance of a newborn.)

How do you feel, now that the baby is born? Women 's reactions vary. You may first feel disbelieving, then grateful and relieved that the baby is out and that the contractions are over, or nearly so. These feelings may predominate over your interest in the baby at first, especially if it has been along, tiring labor. Or you may focus immediately on the baby. Many women are surprised, awed, or full of wonder at their baby's appearance. The first moments, waiting for the baby to begin breathing and crying, are suspenseful. Everyone's attention is on the baby, intently awaiting the gurgling, grimacing, and crying as the first breath is taken. Smiles of relief and joy greet the baby's first cry. Then you await the birth of the placenta. You may find yourself unable to focus entirely on your baby because your caregiver is inspecting your perineum and checking for separation of your placenta, which may be painful and distracting. The full impact-the feelings of fulfillment and of love for your baby and your partnermay not come until after your placenta is born and your caregiver has finished the afterbirth tasks. Then you can devote yourself completely to your baby.

Your partner may be overwhelmed with emotion at this time-deep joy and love for you and the baby, giddiness, exhaustion, relief. Tears may flow. The baby becomes the focus of attention.

The Third Stage of Labor-Delivery of the Placenta

The third stage, the shortest of all, begins with the birth of your baby and ends when your placenta is born. It lasts about ten to thirty minutes. Mter your baby is born, there is a brief lull, then your uterus resumes contractions and separates itself from the placenta. You might need to continue relaxation and patterned breathing ,because the uterus sometimes cramps vigorously. You might, on the other hand, be so I engrossed in your baby that you hardly notice the third stage. Some parents enjoy seeing the placenta after it is delivered.

Immediately after the birth, your baby will receive close medical attention. As soon as "his breathing is established and the baby is dried off, your caregiver performs a routine examination. Your baby's overall condition is evaluated twice-at one minute and again at Ifive minutes-using dle Apgar score, a grading system devised by Dr. Virginia Apgar. Five areas are graded, each widl a maximum of two points, making ten dle highest possible score. The chart below illustrates how newborns are evaluated.

The baby receives a total score each time dle test is done. A first (one-minute) score of seven to ten indicates a normal baby (babies seldom receive a "ten"; most babies' hands and feet are bluish for a while, lowering dleir Apgar score) ; four to six indicates mild to moderate depression; zero to dlree indicates severe depression. A score of six or less means dlat dle baby needs extra medical attention and more observation. The second (five-minute) score is usually higher dlan dle first, indicating improvement widl time and/or medical assistance. While Apgar scores are helpful, especially in detecting babies who need extra immediate medical attention, dley are not perfect indicators of dle baby's overall healdl. A physician or midwife will perform a thorough newborn exam widlin a few hours of birdl to provide a more accurate assessment of your baby's condition.

ClamPing and Cutting the Cord

The umbilical cord is cut soon after the birth. It is first clamped in two places and then cut with scissors between the two clamps. Sometimes the father or partner makes the cut. The exact timing of cord clamping and cutting is a subject of some disagreement.

Some people believe that by delaying the clamping of the cord, the baby receives more oxygen. This is not true, because even though blood continues to flow back and forth between placenta and baby, it does not contain oxygen. The placenta ceases transferring oxygen as soon as the baby is out, even before it separates from the wall of the uterus.

The amount of blood passing to the baby is influenced by the timing of cord clamping and the position of the baby in relation to the placenta. When the uterus contracts, it squeezes blood out of the placenta into the baby's body. If the cord is clamped then, the baby will have a higher blood volume. Between contractions, the baby's heart pumps blood back to the placenta (it is the baby's heartbeat that causes the cord to pulsate) .If the cord is clamped between conctractions, the baby's blood volume is lower. The shift of blood between the placenta and baby can also be affected by gravity. If the baby is held high above the level of the placenta, more blood flows from baby to placenta. If the baby is held below the placenta, blood flows from placenta to baby. Within a few minutes, exposure of the cord to the air causes expansion of Wharton's jelly (a substance contained within the cord) and compression of the blood vessels in the cord. From then on, there is no movement of blood in either direction.

Timing of cord clamping and cutting, then, does not affect the baby's oxygen levels but does influence the blood volume. Whether clamping takes place between contractions, during a contraction, or after the cord stops pulsating will influence the volume of blood within the baby's circulatory system. A low blood volume can lead to anemia; excessive blood volume can overload the baby's circulatory system and increase the chances of newborn jaundice. To achieve the optimal blood volume, the caregiver places the baby at the level of the placenta ( on the mother's abdomen) until the cord stops pulsating.

Discuss the timing of cord clamping with your doctor or midwife and be sure to include your preferences in your birth plan. There are some circumstances when immediate cord cutting is necessary-for example, with a short cord or a cord wrapped tightly around the neck.

The Fourth Stage of Labor-Recovery

The fourth stage begins when the placenta is born and lasts until your condition is stable, as indicated by your blood pressure, pulse, lochia (the normal vaginal discharge of blood from the uterus) , and uterine tone. This usually takes about one or two hours. If anesthesia was used, if labor was difficult or prolonged, or if delivery was by cesarean, the fourth stage may last longer.

After birth the uterus immediately be'gi,ns the process of involution (returning to its nonpregnant state). By continuing to contract, the uterus shuts off the open blood vessels at the site of the placenta, preventing excessive blood loss, and sloughs off the extra lining that built up during the pregnancy. You will begin passing lochia immediately and will need to wear a sanitary pad.

Your nurse or midwife will check your uterus frequently to make sure that the fundus (the top of the uterus) remains firm after the birth. If it is relaxed, sheor he will massage it firmly to cause it to contract, which can be very painful. You might check your fundus yourself and, if it seems soft, massage it yourself. This way you can keep your uterus fIrm with less discomfort. This fundal massage cannot be ignored, because the uterus can bleed excessively if it is not firm.

To massage Your Uterus
Lie flat on your back and check your fundus by pressing several areas of your abdomen above your pubic bone. If you feel your uterus as firm as a grapefruit, you do not need to massage it. If you cannot feel your uterus, massage as follows:

With one hand slightly cupped, massage your lower abdomen firmly with small circular movements until you feel your uterus contract and become firm. It may be painful. If you cannot make your uterus contract, tell your nurse or midwife.

During the first minutes after birth, you may experience trembling in your legs, pain as your uterus contracts ( afterpains, a common occurrence, especially in multigravidas) , and swelling and discomfort in your perineum from the stretching or stitches. A warm blanket helps relieve trembling, and an ice pack on your perineum reduces discomfort and may control swelling. Use slow breathing if necessary for the afterpains.

You may feel hungry and thirsty-not at all surprising, since you have been working hard and have probably missed some meals. You will probably hold your baby and let her nuzzle at your breast. Many babies are ready to suckle at this time. (See page 271 for advice on the first feeding.)

Your New Family

While your body is settling down after the birth, your family is settling down also. You, your partner, and any other family members or close friends will savor these first moments with the baby. The labor stimulates a state of wakefulness and alertness in the baby that may last for several hours. During this time, your baby is likely to become calm and alert, and she will begin observing and sensing the new sounds, smells, sights, touches, and tastes around her. If the light is not too bright, she stares, particularly at faces. You can ask to dim the lights or use your hand to shield your baby's eyes from the bright light. As your baby cuddles with you, gazes into your face, or suckles at your breast, you will probably find her fascinating and irresistible. This is a time of falling in love and is a significant step in attachment, or bonding. Your partner also will want to hold her close, perhaps skin-to-skin, and enjoy these first moments together.

In most hospitals, routine care of the healthy newborn includes time for the baby and her family to be together. Check your hospital's policies; if you wish to be together in privacy for an hour or more after birth, discuss the possibility with your doctor or midwife and the nursing administration. If necessary, include thi,s wish in your birth plan, or get a doctor's order for delaying the baby's admission to the nursery. Some family-centered hospitals do not admit healthy babies to the nursery. The babies stay with their mothers and go to the nursery only if they develop problems. Routine observations or procedures can be performed on the normal newborn in the presence and even in the arms of the mother or partner. See chapter 13 for a description of procedures in newborn care.

Mter one to several hours, the baby usually falls deeply asleep. The initial exhilaration that you feel after the birth may give way to fatigue, the aftermath of labor. At this time, someone who is awake and alert should observe your and your baby's vital signs. In the hospital, a nurse will do the job. Mter a home birth, the observations are made by the midwife, a birth assistant, or an informed and rested friend or relative. Your partner may be as tired as you and may be unable to take on these responsibilities until he or she gets some sleep.

The fourth stage begins your adjustments to your nonpregnant state and the new state of parenthood. The "real " baby replaces the "imagined " baby; your body begins the process of involution; and you begin the important work of reviewing, understanding, and gaining perspective on your labor and birth experiences.

Chapter 9

LABOR VARIATIONS, COMPLICATIONS, AND INTERVENTIONS

Each birth experience is unique. Some labors and births are very short, some are taxingly long, and some require surgical intervention (episiotomy, cesarean birth) or instrumental delivery (forceps, vacuum extraction) .You can expect that your experience will be different from your mother's, your sister's, or even your own prior experiences. Because no one can predict what kind of labor and birth you will have, you will want to prepare for all possibilities and include your ideas and wishes in your birth plan. This chapter discusses variations and complications in labor and birth and how they can be handled both by you with special effort and by your caregiver with medical or surgical interventions.

A labor variation presents additional problems and challenges beyond the typical labor but is still within the wide range of normal. A variation in itself does not pose dangers to either the mother or the baby, but it does pose problems that require the mother and her partner to draw more deeply on their resources.

A labor complication presents problems to the mother or baby that cannot be solved by the extra efforts of the mother and her partner. Such labors require medical assistance and intervention to ensure an optimal out come. Sometimes a variation becomes a complication when, despite all the mother's efforts, the problem remains unsolved. Other complications are emergencies that pose immediate problems for the moth~r or baby and require prompt medical attention.

Monitoring Techniques

BY monitoring your condition and your baby's during labor, your doctor or midwife becomes aware of labor variations and can detect most complications. The monitoring techniques described below help identify variations and complications, and they help your caregiver decide how to manage your labor, especially if it is a difficult one.

Monitoring the Mother

Periodic vaginal exams by the nurse or caregiver determine the dilation of your cervix, and the station, presentation, and position of your fetus. They are recorded on a time chart or labor graph to show how your labor is progressing. The frequency and intensity of your contractions will be observed by the nurse or midwife, who will assess them either by feeling your contractions with her hand or by using an electronic monitor (see pages 185-86) .Throughout labor, your nurse or midwife will assess your blood pressure, temperature, pulse, urine output, and fluid intake.

Monitoring the Fetus

Fetal Heart Rate

The fetal heart rate responds to changes in the availability of oxygen or to other stresses; it is one indicator of fetal wellbeing. Your caregivers will evaluate the baby's heart rate, noting any changes and the relationship of these changes to uterine contractions, fetal movements, the administration of medications, your position, or other factors. They monitor the fetal heart rate in two ways: auscultation (listening and counting the heartbeats) with a special fetal stethoscope or with a hand-held ultrasound stethoscope called "the Doppler"; or with an electronic fetal monitor (EFM) , a machine that detects and prints out a graph of fetal heartbeats. The machine receives impulses from either an ultrasound device placed on your abdomen or a scalp electrode attached to your baby's head (or other presenting part). The mother's uterine contractions are detected and graphed on the printout at the same time. (See pages 184-86 for more information.)

Amniotic Fluid

The appearance of the amniotic fluid gives useful information about the baby's conidtion. A strong odor may indicate an infection. A pink or red color may indicate bleeding from the placenta. A green or dark color means the baby has expelled meconium from her bowels, which is a warning sign that she has been stressed. If meconium is present, your caregiver will check the fetal heart tones frequently to determine the degree of fetal distress. At delivery, your caregiver will probably suction the baby's nose and mouth as soon as the head is out, and then suction again more deeply as soon as the baby's entire body is born. This is done in hopes of removing meconium from the baby's airway before she breathes it into her lungs, which can create breathing problems or pneumonia.

Fetal Stimulation Test

If fetal distress is suspected because of observed fetal heart rate changes, your caregiver may seek to confirm the diagnosis by pressing or scratching your fetus's scalp during a vaginal exam ( the fetal scalp stlmulation test) or by making a loud buzzing, clapping, or clanging noise near the uterus ( the fetal acoustic stimulation test) .If the fetal heart rate speeds up, it is a good sign that your baby is all right. If not, it may indicate fetal distress.

Fetal Scalp Blood Sample

If your caregiver suspects fetal complications, he or she may take a sample of scalp , blood from a small cut in the fetus's head. The blood'sample is analyzed for changes in the blood due to a lack of oxygen.

The Need to Start Labor

Sometimes problems arise for either the mother or the fetus in late pregnancy, and the doctor or midwife and the parents I agree that the best way to handle the prob- :i~ lem is to start labor. The decision is usually ~ made after examining the mother, running lab tests, and testing for fetal well-being and maturity (see chapter 3) .

Some of the most common reasons for starting labor are a clearly prolonged pregnancy, membranes that have been ruptured for a long time, pregnancy-induced hypertension (PIH) , preeclampsia, a fetus who is no longer growing or thriving in the uterus, and particular illnesses in the mother ( diabetes, heart disease, and so on). When any of these conditions is suspected or known, the mother and fetus are watched closely. If it appears that one or the other might be harmed if the pregnancy continues, labor is started.

If you are in such a situation, there may be time for you to try some ways to start your own labor. If you are successful, you may avoid a medical induction of labor, a procedure that has some disadvantages, or you may cause enough cervical changes to make a medical induction easier and more likely to succeed. If, because of medical problems, you do not have time to use these techniques, or if they do not start your labor, then your caregiver has several methods available for inducing labor. These are described on page 169 and in the chart on pages 183-84.

What You Can Do to Start or Stimulate Labor

When it is important that labor start, or when labor is progressing too slowly, you might try these measures. Consult your caregiver before trying any of these techniques, because they carry some risks, as do the medical methods of inducing labor.

Walking

Long walks (thirty minutes or several hours) may help start labor, but are more effective in keeping labor going than in starting it. If it is important for you to go into labor soon, you may want to use the other more effective and less tiring methods listed below.

Acupressure

Firm finger or thumb pressure over particular acupuncture points sometimes starts contractions or makes them stronger. One such point ( called "Spleen 6") is located four fingerbreadths above the inner anklebone. You press the inside of your shin bone, angling forward and in. This is a painful spot. Try pressing three times for tell to fifteen seconds each time, resting for a few seconds in between.


Caution: Because pressure on Spleen 6 can cause contractions, you should not do it to yourself until it is appropriate for you to gb into labor. To practice finding the acupuncture point, try it on a nonpregnant friend or your partner.

Another method of ripening the cervix or causing contractions involves stimulation of particular acupressure points with TENS ( transcutaneous electrical nerve stimulation).l (See pages 114-15 for a description of TENS.) The points used are Spleen 6, located above the inner ankle bone, and Liver 3, located on the top of the foot. (Exact locations should be determined by your caregiver. )

Bowel Stimulation

You can sometimes start labor by stimulating your bowels to contract and empty. This may increase the production of prostaglandins, which cause the cervix to ripen.

Orgasm, Clitoral Stimulation, Intercourse

Sexual excitement, particularly orgasm, causes contractions of the uterus. Prostaglandins are released into your bloodstream under these circumstances and act on the uterus and cervix. Prostaglandins are also present in semen, and after intercourse they act directly on the cervix. Manual or oral stimulation of the clitoris, even without orgasm, may also be effective in starting labor. Intercourse, manual stimulation, and oral-genital stimulation can be done as long as the membranes are intact and it is comfortable for you and your partner. If your membranes have broken, only clitoral stimulation should be done, as nothing should enter the vagina. Blowing into the vagina is dangerous and should never be done. Hyou choose these techniques, make them as pleasant as possible. Try to forget your goal of starting labor, and enjoy the sexual experience.

Nipple Stimulation

Stimulating your nipples causes the release of your own oxytocin, which contracts your uterus and often succeeds in either ripening the cervix or starting labor. You may have to repeat this measure after a few hours or for half a day.

Caution: Occasionally, nipple stimulation causes contractions that last too long (more than sixty seconds) or are too strong (painful) , and the baby may not tolerate them. To protect against these potential problems, you might do nipple stimulation first in the hospital or clinic while your contractions are measured by an electronic fetal monitor. This is actually how a test of fetal well-being ( the contraction stress test) is carried out. Then, if all is well, you can go home and continue nipple stimulation. Some caregivers are more comfortable with nipple stimulation if such a test is done first. Another way to protect against too long or too strong contractions is to time the contractions caused by the nipple stimulation. H they are painful or if they last longer than one minute, decrease the nipple stimulation (from both breasts to one; from continuous to intermittent) .

Herbal Tea and Tinctures

Some caregivers recommend teas or various tinctures to induce labor. They should be used only with the knowledge and guidance of your'caregiver, since they contain active ingredients that enter the bloodstream, have potential undesired side effects, and therefore represent a medical approach to inducing labor. For example, one of the most common, blue cohosh tea, causes your uterus to contract, but can also cause your blood pressure to rise to unsafe levels.5

Medical Induction of Labor

There are several methods used by physicians and midwives to start labor: stripping the membranes, artificial rupture of membranes (AROM) , prostaglandin gel, and intravenous Pitocin. For a descriptio~ of these methods, see the chart on page 183.

The choice of method depends on the state of your cervix and the philosophy of your caregiver and hospital. If you are scheduled for an induction, find out which method will be used so you will know what to expect.

Short, Fast (Precipitate) Labor

APrecipitate labor lasts less than three hours. Though a short labor probably sounds appealing, a precipitate labor presents its own special problems and challenges. The latent phase of a precipitate labor passes unnoticed or so quietly and uneventfully that you miss the early signs of labor. Suddenly, you find yourself in active, hard labor without time to prepare psychologically. The first noticeable contractions can be long and very painful. You may feel panicked and confused, unprepared and discouraged. You may lose faith in your ability to handle labor.

If you are planning a hospital birth, you hurry off to the hospital while trying to cope with these strong, almost continuous labor contractions, all the time thinking that this is early labor and feeling overwhelmed by the thought of what is yet to come! At the hospital, you may be met with a flurry of activity and an unfamiliar doctor or midwife. You may feel anxious if your partner was unable to accompany you. As a result, you may experience feelings of loneliness, a lack of direction, and panic. In fact, you may feel like giving up and taking all the medication available to you to make the pain go away. Your partner is caught off Iguard, too, and may be shocked by the sudden intensity of your labor and surprised by your reaction to what he or she believes is early labor.

What You Can Do

Do not give up on yourself. Trust your ability to get through this. Try not to tense with , your contractions. Try each level of breathing, starting with slow breathing, to find the level that helps you cope. Have a vaginal exam before you make any decision about pain medication. You may have dilated to eight or ten centimeters. If labor has pro~ressed this rapidly, birth will soon follow md anesthesia may be unnecessary or may :ake effect too late to help you. What you [leed more than anything is reassurance that this labor is normal and is progressing very rapidly. You also need help in handling the painful contractions.

Because your contractions will be intense and very effective, you may have the urge to push before the hospital staff is ready. When the second stage begins, lie on your side and pant or gendy bear down, rather than using an upright position. This will give your birth canal and perineum more time to stretch, decrease the likelihood of tearing, and protect your baby's head from being pressed through the vagina too rapidly.

Mter the birth, you will probably feel relieved that you and the baby are safe, but stunned that it is over so quickly. You may need to review what happened. Talk with the staff and your partner to put the pieces together. You may also experience disappointment because your labor passed so quickly you were not able to savor it, use all the breathing and relaxation techniques, or share it with your partner as you had planned.

Rapid Birth without Medical Help

Sometimes labor progresses too rapidly for you to get to the hospital in time. Babies are occasionally born in cars or at home under these circumstances. What if you are alone or with only your partner when the baby starts to come? Initially, you may panic and temporarily forget all you know about labor, birth, and coping techniques.

If the baby is truly about to be born, it is far better to stay home, where it is warm and comfortable, than to attempt to rush to the hospital. If the baby starts to come during your ride to the hospital, you '11 have to pull over to the side of the road, deliver your baby, and then continue to the hospital. Usually, babies born under these circumstances are in excellent condition, but the following guidelines will help you and your partner during such an emergency and ensure the best possible outcome.

Signs of an Imminent Birth

Getting HelP

Before the Birth

Follow as many of these suggestions as time allows:

During the Birth

When you and your partner first see the baby's scalp at the vagina, it will be wet and somewhat wrinkled, and it may be streaked with blood and vernix in places. The pressure of the baby's head bulges your perineum and opens your anus. With the contractions, you will see more and more of the baby's head. With labor progressing so rapidly, try not to bear d9wn. Instead, raise your chin and pant or "puh, puh" as lighdy and rapidly as you can. Sometimes, as your baby's head descends, you will pass some stool (bowel movement) .If this happens, your partner or attendant should wipe it away with tissues or toilet paper to keep the area clean. He or she should remind you to keep your thighs and pelvic floor relaxed.

As the head emerges from the vagina and as "crowning" begins, make extra efforts to relax, pant, and keep from pushing. If the head is delivered slowly, it lessens the risk of injury to the perineum.

Once the head has fully emerged, your partner or attendant should use the clean handkerchief or tissues to wipe away excess mucus from around the baby's nose and mouth. If the membranes cover the baby's face, he or she should break them with a fingernail and peel them away. Wipe the baby's face. Most babies are quite blue at first but turn pink quickly after birth.

A baby's head is usually born facing your back. Mter the head is born, the baby Will turn ninety degrees to face your thigh so the shoulders can be born. At this time your partner or attendant can gently support the baby's head but should not pull on it. He or she should feel the baby's neck to see if the umbilical cord is around it. If so, the cord may slow the birth. Your partner or attendant should gently slip the cord over the baby's head.

With the next contractions, you can bear down smoothly to deliver the shoulders and the rest of the baby's body. You or your partner can support the body; remember that the baby will be wet and slippery.

After the Birth

Care of the Baby

Usually the baby begins breathing and crying immediately. Place the baby on his side or stomach on your bare abdomen, with his head slightly lower than his body to drain any mucus remaining in his nose and mouth. Be sure his nose and mouth are clear so that he can breathe. Wipe away any mucus, and dry the baby completely, especially his head, to help keep him warm. Cover his head with a hat to prevent further heat loss. He will stay warmest with his skin next to yours (no blanket in between) and a warm blanket or any available cover over both of you.

Do not cut the cord. It is safer to wait until a doctor or midwife can clamp it properly and cut it with proper equipment. There is no rush because the blood vessels within the cord begin to close when the cord is exposed to air, automatically stopping the blood flow. You will know the blood flow has stopped when the cord stops pulsating.

Care of the Mother

Your contractions will resume after a slight lull and they will cause the placenta to separate from the uterine wall and slide down into the vagina. Bear down to deliver it. You can kneel or squat if it does not come out easily. Wrap the placenta in a towel or newspapers and place it on the bed. Place a sanitary pad, folded diaper, or small towel 'on your perineum to absorb the heavy vaginal flow.

You can start breastfeeding right away. It makes your uterus contract and reduces the bleeding. Even if the baby does not suck, his nuzzling at your breast may cause your uterus to contract. Your uterus will be at the level of your navel, and should feel firm like a large grapefruit. If your uterus is not firm, and the baby is not nursing, stroke your nipples or have your partner do it. In addition, massage your lower abdomen firmly until your uterus contracts. Do not continue the massage if your uterus is firm, but check it from time to time and massage again if necessary.

You should get medical attention after all this. The baby's cord needs to be clamped and cut, the baby should be checked, and you should be checked to be sure the entire pl~enta was born, the uterus remains contracted, and there are no vaginal injuries. Have someone call the emergency aid number (usually 911) if it has not already been called, while you tend to the baby.

Possible Problems

Baby does not breathe spontaneously. Place the baby's head lower than his body and rub his back or chest briskly but gently. If he does not respond within thirty seconds, hold his feet together and smack his soles sharply. If he still does not respond, repeat the procedure. If the baby still does not breathe, check his mouth with your finger for mucus, then place the baby on his back and tilt his head back to straighten his airway from face to chest. Place your mouth over his nose and mouth and your fingers on his chest. Blow gently until you feel or see his chest rise a little. Do not blow hard. Remove your mouth. Continue this sequence, one blow every three seconds, until the baby responds or medical help arrives. This is mouth-to-mouth resuscitation, one of the techniques used in infant CPR ( cardiopulmonary resuscitation) . Every parent should learn how to do CPR. Check with your hospital, fire department, or Red Cross office to find a course.

Excessive bleeding from the birth canal. Some bleeding normally occurs after labor and delivery, during the third stage. However, if you lose more than two cups of blood, you may be hemorrhaging. Hemorrhage is characterized by a steady flow of blood and symptoms of shock (rapid pulse, pale skin, trembling, faintness, cold, sweating).lfyou or your partner suspects hemorrhage, firmly massage the top of your uterus until it contracts, and encourage the baby to nurse (or stroke your nipples). To avoid shock, elevate the lower half of your body.

If the bleeding appears to come from tears at the vaginal opening, press an ice pack and towels firmly against the perineum. Apply firm pressure. Call the hospital or 911 for assistance or go in to a hospital where the staff will assess you and give the appropriate medical assistance.

Placenta does not come. If the placenta does not come within thirty minutes be sure to stand or kneel to get the help of gravity. If it still does not come and no help has arrived, you or your partner will need to call the hospital for guidance.

In an emergency situation, your options are limited. Luckily, in most areas aid cars and experienced paramedics are only minutes away. If an emergency home birth becomes necessary, remember what you have learned about relaxation, breathing techniques, and the birth process. An emergency birth can be hectic, but if you respond calmly and wisely, the experience will always be precious to you, despite its unconventionality.

Prolonged Labor (First Stage )

A labor that lasts longer than twenty-four hours after progressing contractions begin (see page 139) is considered a prolonged labor. More important than the length of labor is the phase of labor in which the progress slows. Along prelabor (a long period of time with continuous nonprogressing contractions) or a long latent phase can discourage, exhaust, and emotionally drain you, but it is unlikely to be due to an obstetrical problem. On the other hand, a labor that slows or stops in the active phase or later is more likely to turn into a complication.

Prolonged Latent Phase

If your labor is slow in starting or you are experiencing a long latent phase, do not assume that your entire labor will be prolonged. In most cases, labor will progress normally once you reach the active phase. A slow beginning of a long latent phase may simply mean that your cervix has not moved forward, ripened, or effaced before labor and that your early contractions are having to accomplish these things before they can effectively open the cervix. Your cervix needs time, and you need patience and the reassurance that a slow early labor is not a complication.

What You Can Do

Try not to become discouraged or depressed. Visualize the contractions bringing your cervix forward, ripening and effacing it. Try to accept your slow progress as temporary and appropriate under the circumstances. Alternate among distracting, restful, and labor stimulating activities. Nurture yourself with food or drink, back rubs, or long baths or showers. You may find you can get more rest in a tub (filled high with warm water) than anywhere else. Baths also sometimes temporarily slow a nonproductive labor pattern, thus giving you more rest. Try the various methods of stimulating labor (see pages 167-69). Try distractions, such as a movie, a walk in the park or on the beach, food preparation, a shopping trip, or a visit with friends or relatives. Think of something to do that helps keep your mind off the contractions. You do not need to time every contraction; it is too depressing. Time four or five contractions in a row; then wait a few hours or until the labor has changed before timing another series of contractions.

Medical Care

If your contractions become exhausting or go on for more than twenty-four hours despite your efforts, you and your caregiver may turn to medical interventions. There are two major approaches: attempting to stop contractions and help you rest by using medications (such as tranquilizers, uterine relaxants, sedatives, alcoholic beverages, or morphine) ; or stimulating more effective contractions by using procedures such as stripping the membranes, breaking the bag of waters, giving prostaglandins to ripen your cervix, or inducing labor with Pitocin.

Prolonged Active Phase

Labor that slows or stops once the active phase has begun may be a more serious problem than a prolonged latent phase. A prolonged active phase can result from inefficient uterine contractions, an unfavorable presentation or position of the baby, a small pelvis, or a combination of these factors. Immobility, restriction to bed, a full bladder, drugs that slow or stop labor, fear, anxiety, and stress can all contribute to a prolonged active phase.

What You Can Do

The solution will depend on the problem. For instance, a full bladder can prevent the baby's descent, so empty your bladder every hour. If you have received drugs that may have slowed your labor, allow time for them to wear off. It may be possible to speed excretion of the drug by drinking liquids. If you have been lying still in one position, try walking or standing (positions that make use of gravity) , or try shifting positions in bed from lying on one side or another to sitting or to resting on your hands and knees. You can use these positions even if you are attached to an intravenous line and an electronic fetal monitor. To enhance contraction effectiveness, try nipple stimulation, walking, and standing.

If you are discouraged, tired, anxious, or fearful, you will need reassurance, encouragement, help with relaxation, and other comfort measures such as a bath, massage, or shower. Ask for help, not only from your partner, but also from the staff caring for you. Do not neglect these resources-they can sustain you.

Medical Care

During a prolonged active phase, you can expect your caregivers to closely evaluate the progress of your labor and the wellbeing of your baby. Nurses will give you more vaginal exams, checking for progress in dilation, descent, or rotation. They will monitor the fetal heart rate more, probably with the electronic fetal monitor. Intravenous fluids to prevent dehydration and medications for relaxation and pain relief become more likely and more welcome if your labor is unduly long. Eventually the doctor or midwife may rupture the membranes in an attempt to speed the labor or administer Pitocin to increase the frequency and intensity of your contractions.

If the baby is under stress, as indicated by the fetal heart rate in response to contractions, or if labor continues to lag, even with Pitocin, you and your doctor may decide a cesarean birth is necessary.

The Occiput Posterior

One of the most common reasons for a prolonged active phase is the occiput posterior (OP) position, where the back of the baby's head is toward the mo(her's back. Approximately one woman in four begins labor with the baby in the OP position, which is associated with longer labors because the baby must rotate further to get to the anterior position. Dilation and descent may not take place as efficiently when the baby is OP. By transition, however, most babies in the OP position have turned to an occiput anterior position (OA), though some turn even later. Other "persistent" occiput posterior babies are born in that position with their faces toward their mother's front (sometimes called a "sunny side up" delivery).


If your baby is OP, you may have considerable back pain during and sometimes between contractions, because the hard round part of your baby's head (the occiput) presses on your sacrum (lower back) , straining the sacroiliac joints and causing pain in the entire low back area.

What You Can Do

Rotation of the baby. To encourage the baby to rotate, change position every twenty to thirty minutes to take advantage of gravity and movement:

Relief of back pain. To help relieve the accompanying back pain, use these measures


Prolonged Labor (Second Stage )

Sometimes labor slows or stops after the cervix is fully dilated for many of the same reasons that cause a prolonged active phase. In those cases, the prolonged second stage may be handled with the same measures. In addition, there are other possible problems that can arise only in second stage. A delay in second stage can occur when the pelvic inlet (upper part) is large enough for the baby to enter, but the pelvic outlet (lower part) is not large enough for the baby to rotate and descend. H this is the case, problems do not arise until the baby is quite low in the pelvis. Another possible, but rare, problem is a short cord, which limits the descent of the baby or causes the fetal heart rate to slow during contractions. A third, also rare, problem occurs if the birth of the baby's shoulders is delayed after the birth of the head-shoulder dystocia. This serious complication arises when the shoulders are so broad or in such a position that they do not fit through the pelvis. It is not possible to do a cesarean section after the head is out. Instead, skilled maneuvers by the doctor or midwife, with the cooperation of the mother, are used to rotate the baby and deliver the shoulders. Time is of the essence, since the baby's oxygen supply from the cord may be reduced.

What You Can Do

If you have a problem with descent during the second stage, you should change to gravity-enhancing positions (pages 151-52). If there is no apparent progress after twenty to thirty minutes in one position, change again. Do not continue doing something if it is not effective. Squatting and the supported squat (or "dangle") are perhaps the best aids to descent, since they not only use gravity but also allow maximum enlargement of the pelvic outlet.6 These positions might provide enough room for a baby in the occiput posterior position to rotate, or they might enlarge a relatively small pelvic outlet enough for the baby to pass through. You might also try the standing, semisitting, and hands and knees positions.

If tension in your perineum seems to interfere with effective bearing-down, even with hot compresses and reminders to relax, sitting on the toilet may encourage release of the perineum.

If using various positions does not enhance progress, you may need to use prolonged pushing with more forceful bearingdown to get the baby moving. At this time the advantages of prolonged pushing may outweigh the disadvantages described in the discussion of expulsion breathing in chapter 7. Your birth attendant directs your pushing at this time.

Medical Care

Close medical observation is necessary if the second stage is prolonged. Your caregiver will carefully monitor the fetal heart rate. Hthe fetus seems to be tolerating the contractions and positions, the caregiver will encourage you to continue your efforts. (Remember that lying on your back often causes a drop in the fetal heart rate). But if your attempts are unsuccessful, if you are exhausted and unable to push effectively, if you have received medications that inhibit your efforts and slow your labor, or if your fetus is responding poorly, procedures such as vacuum extraction, episiotomy, forceps delivery, and cesarean section may be used. (See the chart on pages 187-88 and chapter 10 for information on cesarean birth. )

Prolapsed Cord

Though rare, a prolapsed cord is an extremely serious complication. H the umbilical cord slips through the cervix into the vagina before the baby is born, it can be pinched between the baby and the partlyopened cervix or the mother's bony pelvis. Especially during contractions, Prolapsed Cord this compression of the cord can drastically reduce oxygen to the fetus, which can be a life-threatening emergency for the baby.


A prolapsed cord is most likely ( though still rare) if your membranes suddenly rupture and your baby is in a breech or transverse presentation or her head is "floating" and not engaged in your pelvis. At your prenatal checkups in late pregnancy, find out if your baby is breech, transverse, or high. If you know that your baby is high, breech, or transverse, and your membranes break with a gush, you should take the following precautions until medical care is available: Get into a knee-chest position in which gravity can move the baby away from your cervix and off the cord, which may have prolapsed. You mayor may not be able to feel the cord in your vagina. Someone needs to arrange for immediate transportation to the hospital, and you should remain in the knee-chest position in the car or ambulance. Once you arrive at the hospital, a nurse will check for a prolapsed cord, and if necessary put her or his hand in your vagina to hold the baby off the cord. A cesarean delivery will be performed as soon as possible.

Difficult Presentations

About 5 percent of the time, the baby is in a presentation other than vertex. Face and brow presentations occur less than 0.5 percent of the time and usually prolong labor. The shoulder presentation (transverse lie) occurs rarely, in about one in five hundred births. Because a baby in this position only occasionally turns to a head-down presentation, a cesarean delivery is usually necessary.

Finally, the breech presentation (with buttocks, legs, or feet over the cervix) occurs 3 to 4 percent of the time. (The incidence rises with prematurity or twins.) This is the most common of the difficult presentations.

Breech Presentation

There are three types of breech presentations: frankbuttocks down and legs straight up toward the face; complete- sitting crosslegged; and foot- jling-one or both feet down. The frank breech is the most common. Although breech deliveries usually turn out Complete Breech well, they are riskier to the baby than the vertex presentation. A breech presentation increases the chances of a prolapsed cord, because the baby's buttocks or feet do not cover the cervix and thus do not prevent the descent of the umbilical cord into the vagina. This is most likely to occur when the membranes rupture with a gush.

Because the baby's feet and body are delivered before his head in a breech birth, the baby's head can compress the cord at the cervix or within the birth canal, reducing the oxygen available from the placenta to the baby. Another added risk exists because the baby's feet and buttocks are small enough that they can be born before the cervix dilates enough for the birth of the head. This may result in a delay in the birth of the head and in fetal distress. Another risk is spinal cord injury, if the head of the fetus is hyperextended (bent back) .

What You Can Do

Try to keep informed about your baby's presentation and position, which are checked at each prenatal visit during late pregnancy. Most babies assume their birth position by thirty-four to thirty-six weeks. Others turn later, even during labor. If your baby is breech at thirty-six weeks, you may try the "breechtilt" position to encourage your baby to turn. This position involves tilting your body so your hips are higher than your head. lie on your back wiili your knees bent and your feet flat on ilie floor. Raise your pelvis, and slide enough firm cushions beneaili your buttocks to raise iliem ten to fifteen inches above your head. You may also lie head down on an ironing board or a similar flat board tilted wiili one end on a chair, ilie oilier on ilie floor. lie in iliis position for about ten minutes three times a day when ilie baby is active. For your comfort, make sure your stomach and bladder are empty. Try to relax your abdominal muscles. Your baby will probably squirm as his head presses into the fundus, and he may seek a more comfortable position. This technique does not always work, but since it is harmless, it is worth trying.

Another technique utilizes sound to turn a breech baby. This harmless technique is not uncomfortable, as is ilie breech tilt position. It involves placing earphones from a tape player just above your pubic bone and playing music for ilie baby during his active periods. Or your partner can talk to ilie baby wiili his or her head in your lap. The music or voice should be at a volume that is comfortable for you to listen to. You can do it for as long as you like. The rationale is this: We know that ilie fetus can hear very well and responds to sound coming from outside ilie womb. We iliink iliat if ilie fetus hears plea&ing sounds coming from low in the uterus, he might move his head down to hear it better. While not always successful, numerous women who have tried this technique have reported iliat ilieir babies turned. While it is possible that tlie babies would have turned spontaneously, this harmless and enjoyable technique may be useful.

Medical Care

There are several medical approaches to breech presentation: external version, vaginal birili, and cesarean birth

External version. This procedure, done at about thirty-seven to thirty-eight weeks, involves turning the baby from a breech to a head-down presentation. Before the version is performed, ultrasound is used to confirm that the baby is still breech and to visualize the site of placental attachment. Also, a nonstress test is usually done before and after the version to determine that the baby is doing well. A tocolytic drug (for example, terbutaline) is given to you to relax your uterus and decrease your risk of preterm labor contractions. Then, using ultrasound for guidance and to observe the fetal heart rate, your caregiver presses and pushes on the baby through your abdomen, turning him to a head-down position. If the baby shows signs of fetal distress ( as indicated by his heart rate) , the procedure is stopped. In the unlikely event that the placenta begins to separate during the version or that the baby is in distress after the procedure is stopped, a cesarean section might have to be performed. Sometimes the version is unsucceSSful, that is, the baby does not turn. Sometimes after a successful version, the baby turns back later. Studies of external version indicate that it is a safe and quite successful procedure, and it lowers the cesarean rate for breech presentations.

Vaginal or cesarean birth of the breech.

Many physicians evaluate each breech presentation individually and weigh the risks carefully before deciding whether a vaginal or cesarean birth is best. Doctors who are skilled in vaginal breech deliveries consider the size and gestational age of the baby, the type of breech presentation, the size of the pelvis, and other factors. Some doctors require that a woman have had a previous vaginal birth. The best candidate for a vaginal breech birth is a term baby estimated to weigh less than eight pounds who is in a frank breech presentation with a well-flexed head ( chin on chest) within a roomy pelvis. Careful monitoring and medical interventions during labor are likely in this situation. When these conditions are met and the caregiver has been trained to manage vaginal breech births, outcomes have been shown to be better with vaginal than with cesarean delivery.


Some women are not candidates for a vaginal breech birth because of obstetrical factors or because their physicians prefer to deliver all breech babies by cesarean. In addition, some women attempting a vaginal breech birth develop problems in labor that require a cesarean birth. For these reasons, the cesarean birth rate for breeches is very high.

Preterm (Premature) Birth

A preterm birth, by definition, occurs before the thirty-seventh week of gestation. If you experience any of the signs of preterm labor (page 53) , call your caregiver. Mter evaluating your condition, your baby's health, and the progress of labor, your caregiver may decide to try to stop labor. The methods used to prevent premature labor ( described on page 53) are more likely to succeed if preterm contractions are detected early, before two centimeters of dilation.

When labor and birth appear inevitable or desirable, the focus of care shifts to managing your labor for the best possible outcome and providing necessary special care for your baby after the birth. Your baby's heart rate will be assessed very frequently or by continuous monitoring. Systemic pain medications that affect fetal heart rate and depress newborn respirations will probably be discouraged. Therefore, in early labor you should plan to use relaxation and breathing patterns for pain relief. In active labor or during birth, you may continue these .techniques or you may request regional anesthesia. Episiotomy and forceps are sometimes used in an attempt to protect the premature baby's head.

Since the health 'of the baby is paramount and she may be in need of medical attention, you may not be able to hold her immediately after birth. Most premature infants are taken to a special nursery. Depending on how small and immature the baby is, her care may involve prolonged hospitalization and possibly long periods of separation from you. In most hospitals, parents are encouraged to visit and care for their babies. Participating in the care of your baby benefits both of you. (For more information on care of the premature infant, see page 254.)

Twins

The birth of twins is more complicated than the birth of a single baby. The added stretching of the uterus and the combined weights of the babies and one or two placentas often cause premature labor. Early rupture of the membranes is more common with twins and is another cause for prematurity. Generally, labor with twins progresses normally, but sometimes the overstretched uterus cannot work as efficiently, and labor progress is slow. Because of the high incidence of prematurity and increased chances of postpartum hemorrhage, you should expect more medical supervision and more interventions than are usual with the birth of a single baby at term.

The most common and favorable presentation for the birth of twins is with both babies head down (vertex) .Ultrasound during labor might be indicated to identify the positions of the babies. The results help your caregiver determine the best type of birth-vaginal or cesarean. H the first baby is head down and the other one is breech, the second baby might be turned after the birth of the first baby. The second twin is usually born within thirty minutes of the first, and the delivery of the placenta(s) will occur after both twins are born. The probability of cesarean birth is higher in twin or multiple pregnancies due to the increased likelihood of complications such as preeclampsia, prematurity, breech presentation, prolonged labor, and prolapsed cord.

Third Stage Variations and Complications

postpartum hemorrhage is the most common problem of the third stage of labor. It is defined as a loss of at least five hundred milliliters (about two cups) of blood during the first twenty-four hours after birth.

The three major causes of postpartum hemorrhage are uterine atony (poor uterine muscle tone) , lacerations or tears of the cervix or vagina, and retention of the placenta or placental fragments. Of these, uterine atony is the most common cause of hemorrhage. The treatment of postpartum hemorrhage depends on the cause. If bleeding is serious, you may need intravenous fluids or a blood transfusion.

Uterine Atony

To encourage your uterus to contract, you or your caregiver can massage your uterus. Nursing your baby also helps the uterus to contract by stimulating the release of your body's oxytocin. If these measures do not control bleeding, your doctor or midwife may give you medications such as Pitocin to promote uterine contractions (see pages 218-19).

Lacerations

Lacerations or tears of the cervix, vagina, or perineum sometimes occur with or without an episiotomy. They will be sutured to control bleeding. Occasionally, packing the vagina with sterile gauze is also required to stop bleeding.

Retention of the Placenta

If the placenta or fragments of it are retained in the uterus, they interfere with postpartum uterine contractions, allowing the blood vessels at the placental site to bleed freely. Your caregiver will manually remove the placenta, clots, or fragments, administer Pitocin, and massage your uterus. You can help by massaging your uterus yourself, and by breastfeeding your baby. Very rarely the placenta cannot be separated from the uterine wall (placenta accreta) , and the only safe treatment for this rare but serious complication may be a hysterectomy (removal of the uterus).

When a Baby Dies or Has a Birth Defect

Birth defects, stillbirth, and death resulting from birth trauma, infection, and disabilities are relatively uncommon but do occasionally occur. If you are faced with a birth defect or the death of your baby, your agony, sadness, and loneliness are deep and long-lasting. Being prepared by deciding what you would do if your baby dies or is deformed can help you in the first painful days.

If your baby dies before you go into labor, you have to consider how you want. the labor managed. Will labor be induced, and if so, when? Do you want to write a special birth plan? Do you want to be awake and participate in the birth? Would an additional support person be helpful? If you have a stillbirth or your baby dies soon after birth, you will also have these options to consider. Would you prefer to recover on the postpartum floor where other mothers and babies are, or somewhere else in the hospital, or would you prefer to take an early discharge? Do you want an autopsy to help find a cause for the baby's death?

What might make your memories of the baby more meaningful? Many counselors recommend that parents see and hold their dead or dying baby. Naming or baptizing the baby, taking photographs, footprints, or a lock of hair are ways to acknowledge the baby's life and provide memories. A funeral or memorial service provides an opportunity for family and friends to come together to grieve, say good-bye to the baby, and express their concern and love for you. Later, you may want to join a support group of parents who have experienced a similar loss. They are there for as long as you need them. While nothing takes away the pain of losing a baby, this support can help you emotionally at a very difficult time.

If the baby has a birth defect, is premature, or is very ill, you have other decisions to make. In most cases, you or your partner can spend time with your baby, even if he is in a special care nursery. If the baby is transferred to a hospital that specializes in seriously ill babies, your partner may have to divide his or her time between visiting you and the baby. You may be able to have an early discharge from yo~r hospital so that you may visit. You may want to provide your baby with the special nourishment of your colostrum and breast milk, either by breastfeeding or by pumping your milk to be fed to your baby.

You will have many questions about your baby's condition, the treatment, and what to expect now and in the future. Your baby's doctors and nurses can help you get the information you need and show you how you can best help your baby. Parent support groups exist for those whose babies are premature or disabJed. They are immensely helpful with emotional support and practical help.

If your baby dies or has health problems, you will need time to review and reflect on the birth 'experience. Recalling the events with your partner, childbirth educator, the attending nurse, or your caregiver and writing a birth report can help you put the pieces together. A counselor, therapist, the hospital chaplain, or your priest, rabbi, or minister can help you work through your emotions. Friends and family can help you with the numerous practical details that must be attended to: care of other children; Itransportation; food preparation; notification of business associates, friends, and relatives; answering the phone; and more. Helpful books are listed in Recommended Resources.

If your baby dies or has health problems, you will need time to grieve. Grieving is painful and exhausting, but it must be experienced. You and your partner will experience and reexperience many feelingsshock, disbelief, fear, anger, guilt. Eventually, after months or even years, you will reach a level of acceptance, although the sorrow will linger. Be gentle with yourself. Give yourself time to heal emotionally and physically. Lean on the people and the commun~ty . resources that are most supportive.

There are good memories as well as painful ones. Allow yourself to acknowledge your baby's life and savor the good memories from pregnancy, the birth, and the time you had with your baby. Your baby is a special part of you and will always exist in your memories as an important person in your life.

Medical Interventions in Labor and Birth

Medical interventions in labor are procedures carri.ed out by your caregiver or nurse to alter the course of labor, provide diagnostic information, or prevent complications. All medical interventions carry some disadvantages (just as medications do) , and they should not be used "1, unless they are necessary. There is disagreement within the obstetrical community over how routine some of these interventions :: should be. You will Want to know what your " caregiver considers a desirable routine intervention (and why) .Ask if your caregiver will give you a chance to solve problems in labor and birth by using your own techniques, such as changing positions, comfort measures, relaxation, breathing patterns, and time. Your birth plan should r~include your preferences regarding the use I of interventions. The following chart describes and outlines the benefits and risks of various interventions.







Chapter 13

CARING FOR YOUR BABY

Common concerns about Newborns

Newborn Jaundice

A yellow tint to the baby's skin and in the whites of the eyes, called jaundice, is caused by large amounts of bilirubin in the blood. (Bilirubin forms normally as red blood cells break down.) Because a newborn's liver is immature, he is less able to handle the bilirubin in a normal way until he is a week or two old. Mild jaundice (sometimes called "physiological jaundice") is considered harmless and occurs in about 50 percent of full-term and 80 percent of premature babies. It is the most common type of jaundice in newborns. It usually appears on the second or third day after birth, peaks, and then goes away, disappearing before the end of the second week.

Jaundice can also be the result of certain blood incompatibilities, such as when the mother is Rh hegative and her baby is Rh positive, or when certain differences in the mother's and baby's blood types exist, (referred to as an ABO incompatibility) .

Jaundice is sometimes associated with infection, significant bruising of the baby during birth, or certain drugs taken by the mother during labor (for example Pitocin, some sulfa drugs, and Valium) . Very rarely, jaundice occurs with breastfeeding. With "breast milk" jaundice, the bilirubin levels begin to rise after the third daX of age and usually peak between the seventh to tenth day. Diagnosis is made by ruling out all other possible causes. (See pages 281-82 for more on breast milkjaundice.) You may be dIe first to notice jaundice in your baby. H so, notify your baby's doctor or nurse. H significant jaundice occurs, your doctor will order a test of the baby's blood, obtained bya heel stick, to measure dIe blood's bilirubin level and look for other causes such as infection. If the bilirubin level is high, the baby may be treated with phototherapy (light therapy) or in severe cases, with an exchange transfusion, in which all the baby's blood is removed and replaced widI intact red blood cells. H jaundice is associated with infection, the baby will receive antibiotics. With phototherapy, the naked baby wears eye patches to protect his eyes and is placed under special lights (bililights) dIat help to break down dIe bilirubin in the skin. A newer form of phototherapy utilizes a plastic body wrap and fiberoptic lights.

The baby does not wear eye patches and dIe parents can feed and hold dIe baby without interrupting treatment. Among physicians, dIere is a lack of consensus as to the effectiveness of phototherapy, the circumstances under which treatment is desirable, and just how serious jaundice may be. Newborn jaundice is a field of great research activity (see Recommended Resources and pages 281-82 for more onjaundice).

Circumcision

Circumcision, the removal of the foreskin covering the head (glans) of the penis, is probably the oldest surgical operation known, dating back some six thousand years. It is a ritual of the Jewish religion and one of the puberty ceremonies of some Islamic, Mrican, and New Guinean cultures. It is also commonly performed in North America, more in the United States than Canada, for nonreligious reasons as a matter of parental choice. Performed by physicians (usually the obstetrician or family physician) , circumcision is a surgical procedure that requires written permission from the parents. Since the decision about circumcision is up to you and your partner, discuss the subject during pregnancy when you have more time to gather information. While you are making this decision, you might consider whether other males in the family, schools, and community have been circumcised. You may feel that your son should look the same. In reality, however, the rate of circumcision today is about 60 percent in the United States (much lower in Canada) , so the social pressure to circumcise may be lower than ten or twenty years ago when circumcision rates in the United States were much higher. In Canada, circumcision has never been routinely performed for nonreligious reasons. The circumcision status of a child may have no greater implications than the other physical differences that exist between individuals.

Facts to Consider

Care of the Circwncised Penis

If you choose to have your son circumcised, ask the medical staff about care of the penis. They often suggest frequent diaper changes, gentle washing with soap and water, and application of Vaseline or petroleum jelly to aid healing and prevent irritation. You can expect very slight bleeding, but report any excessive bleeding or swelling to your doctor. Some babies sleep more comfortably on their sides until the area has healed.

Care of the Uncircumcised Penis

The foreskin of an uncircumcised newborn does not usually retract (pull back) .It is normally joined to the glans, so avoid forcing it back over the end of the penis. It will gradually become looser, and between three and five years of age most boys' foreskins are fully retractable. Normal bathing provides adequate cleansing during infancy.

Spitting up

Many babies spit. up milk during or after a feeding. Some babies spit up more than others. Your baby is more likely to spit up if he cries hard before a feeding, eats too much too quickly, or swallows air during the feeding. Some babies have an immature sphincter muscle at the top of their stomachs, which allows milk to come up with air bubbles. Spitting up is usually not harmful, but you can reduce it by burping your baby during and after feedings (burp newborns after each breast or after each two ounces of formula) , not overfeeding him, handling him gently, and positioning him in the following ways after feeding: on his side, sitting in an infant or car seat with his head elevated twenty to thirty degrees, or laying him on his tummy. Babies outgrow the tendency to spit up by five to nine months of age.

If spitting up seems to be associated with pain, call your baby's doctor. Continuous or frequent forceful (projectile) vomiting is more serious and can lead to dehydration. H your infant vomits after two or dIree consecutive feedings, consult your baby's doctor.

Bowel Movements

A newborn's stool pattern is different from an adult's. Your baby's first bowel movements will consist of meconium, a sticky, green-black substance present in dIe intestine before birdI. For two to six days following birth, his stools will be a mixture of meconium and milk by-products, spinachgreen or yellow in color. Later, your baby will have yellow, green, or brown stools widI or widIout curds. The frequency and consistency of stools depend on the individual baby and on the food he is fed. Breastfed babies should have a stool after each feeding or at least three or four large runny stools a day once your milk is in. Formula fed babies may have fewer stools.

Constipation, hard, dry stools that are difficult to pass, is rarely found in breastfed babies. Some older breastfed babies have only one bowel movement per week. These babies are not constipated; their more mature digestive systems are efficiently using more of their mothers' milk. Call your doctor, however, if your baby seems constipated. Your baby probably has diarrhea if his stools are mucousy, foul smelling, more frequent than usual, blood-tinged, or watery ( dIe diaper shows a water ring around the stool) .When in doubt, note dIe color, consistency, and frequency of your baby's stool; dI~n call your doctor.

Dtaper Rash

Many substances can irritate your baby's skin, including urine and stool, some laundry products, inadequate diaper washing, or chemicals used in some disposable diapers. To prevent or treat diaper rash caused by urine, change diapers frequently, rinse the diaper area with water at each change, and avoid plastic pants, which retain moisture.

You can reduce irritation from laundry detergents by running the diapers through an extra rinse cycle or by changing to a milder product, such as Dreft. To reduce the amount of ammonia retained in the diapers, add half a cup of vinegar to the diaper pail or the rinse water. Other treatments for diaper rash include exposing the rash to fresh air for a few hours each day, blow-drying your baby's clean bottom with a hair dryer set at medium heat, or applying a commercial ointment to the clean, dry, irritated skin. (You can remove the heavy white ointment with a cotton ball moistened with baby oil.) H diaper rash persists, consult your physician.

Facial Rashes

Mild rashes on the face commonly occur in the first months of life. The rashes--smooth pimples, small red spots, or rough red spots-come and go and rarely require treatment.

Prickly Heat

This common, warm-weather rash appears on overdressed or overwrapped babies. Found most often in the shoulder and neck regions, prickly heat looks like clusters of tiny pink pimples surrounded by pink skin. As it dries, the rash becomes slightly tan. Prickly heat may look worse than it apparently feels to your baby. To avoid this rash, keep him from becoming overheated.

Cradle Cap

Cradle cap is a yellowish, scaly, patchy condition found on the scalp or sometimes behind the ears. Daily washing or brushing of the scalp may prevent cradle cap and will help treat it if it does appear. Comb or brush out the scales, using a baby comb, fingernail brush, or soft toothbrush; wash with mild soap. Continue this procedure until the scales are gone. Neither baby oil nor vegetable oil helps.

Newborn Breathing Pattern

Periods of irregular breathing are normal in newborns but may be frightening to new parents. When your baby is sleeping, he will snort, gasp, groan, and even occasionally pause in his breathing. These irregularities disappear in a month or two.

Crying

A newborn who is not eating or sleeping may spend a lot of time crying, and most parents feel frustrated when they cannot understand why their baby cries. This is a natural reaction. Remember to stay as calm as possible. Your tension is contagious; move slowly and calmly around a crying infant. Mter you have ruled out hunger, consider whether the baby needs cuddling, rocking, walking, or your attention. Is he overdressed, underdressed, sick, or bored? Does he need to burp? Does he have diaper rash or colic? Is he just plain tired? Exhaustion commonly causes crying. If nothing seems to calm him, he may simply need to be put to bed and allowed to cry a while to settle himself. (Set the timer between five and fIfteen minutes or it may seem like an eternity. ) Patting or stroking his bottom or back or gentle rocking may also help him relax.

Many infants have a regular fussy time every day. Unfortunately this period often occurs in the late afternoon or evening, when everyone else in the house is tired and wants peace. You might find that attention and cuddling quiet him down. If not, consider these suggestions:

Some parents fear that if they give their babies too much attention, they will spoil them. A newborn, however, cannot be spoiled. He needs feeding, attention, cuddling, and handling to develop a trust in your ability to meet his needs. Enjoying and responding to your baby is not spoiling him. When your infant cries, he needs more care, not less. Your newborn infant is not manipulating you when he cries for attention; he simply has no other way to tell you he needs something. You might have trouble figuring out exactly what he wants, but pick him up, cuddle him, and trust your instincts and feelings.

Colic

Colic is another reason that babies cry. No one knows the exact cause of colic, so it is sometimes difficult to confirm. You may suspect colic, however, if your baby cries incon solably at about the same time every dayoften between 6 and 10 P.M. or after most feedings. The infant draws his knees up in pain and screams loudly for two to twenty minutes; then the crying stops, only to resume later. He may pass gas from the rectum. Despite the apparent discomfort, colicky babies seem to thrive.


Try comforting your baby by doing the following:

fhe colicky period is very stressful for par~nts. It may seem impossible to maintain a calm atmosphere. Try to keep in mind that colic does not produce any lasting harmful effects and that it usually disappears by the third or fourth month. Consult your doctor if constant crying is associated with vomiting, a cold, a fever, or hard stools.

Playing with Your Baby

play is more important to babies than it is to adults. For an adult, play is usually a form of recreation; for a baby, it is a means of learning about himself and the world around him. When he grabs and shakes a rattle, gums and chews a teething ring, squashes and squeaks a rubber duck, he is learning that he can make things happen. He learns about himself, as well as about the objects he is playing with.

When you talk, coo, laugh, hug, and kiss your baby, he learns that certain things he does make an impact on you. Learning activities (play) for a baby during an average day might include singing and talking; caressing, touching, and cuddling when changing or feeding him; a massage after a bath; moving to different rooms; games, such as peek-a-boo; and playte toys.

baby exercises

Much has been written about baby exercise, and some community centers feature classes in infant stimulation and parent-baby exercises. The purpose is twofold: to educate parents about their infants' physical growth and development, and to teach parents some appropriate and fun ways to play with their babies. By using these simple exercises, you not only play with your baby, but you learn more about his capabilities and limitations. These exercises will probably not speed up your baby's development, since growth and development normally occur in an orderly and predictable fashion with or without infant exercise. But you can enhance your baby's development by giVing him the chance to use the muscles he is already learning to control.

The baby exercises discussed in this section are designed for babies one week to three months old. (Exercises for mother and baby are described on pages 233-34.} A young baby (one to six weeks} may have tightly flexed legs and arms. If you gently jiggle or pat his hands, arms, or legs, you may help relax his muscles and they will move more easily. Keep your movements slow, gentle, and rhythmic. Try singing songs to him as you move his limbs. Mter a few sessions, he will relax and seem to anticipate the movements.

Exercise or play with your baby when he is in the quiet-alert state-wide awake, calm, and attentive. If he is fussy, hungry, upset, or sleepy, chances are you will not enjoy yourselves. Unless otherwise noted, do the following exercises on the floor or on a firm surface. As your baby grows older, you may want to do other exercises.

Arm Cross

Aim: To relax chest and upper back muscles.


Exercise: With your baby on his back, place your thumbs in your baby's palms. When he grasps them, open his arms wide to the side. Bring them together and cross his arms over his chest. Repeat slowly and gently, using rhythmic movements.

Arm Raising


Aim: To facilitate flexibility of the shoulders.

Exercise: With your baby on his back, grasp your baby's forearms or hands. Raise them over his head, then lower them to his sides. Repeat slowly and gently, using rhythmic movements. Alternate arms-while one goes up, the other goes down.

Leg Bending


Aim: To facilitate flexibility of hips; may help baby pass gas.

Exercise: With your baby on his back, 'grasp lower legs and gently bend his knees up toward his abdomen and chest. Gently lower his legs until they are straight. Repeat several times. Alternate, bending one leg while straightening the other.

Inchworm


Aim: To bring about exte~sion of legs and back.

Exercise: With your baby on his tummy, bend his knees under him, holding his feet with your thumbs against the soles. Thumb pressure on his soles will cause him to straighten his legs and move forward like an inchworm.

Baby Bounce


Aim: To comfort baby or ready the baby for play.

Exercise: Place your baby on his back or tummy on a foam rubber pad, bed, your lap, or any soft, bouncy surface. Slowly and gently press the bouncy area around the baby ( or bounce baby on your lap) so the baby rocks up and down. Use a gentle, rhythmic up-and-down motion, and he will relax. You may also try patting your baby rhythmically on his chest, back, arms, and legs.

Baby Massage

Massage is the language of touch. With a massage, you can calm and soothe your baby and communicate your love and care. During massage, keep the following points in mind. A nice way to start is with a bath. Then, after making sure the room is warm, remove the towel or receiving blanket, and put your baby on the floor. (You can also sit with the baby on your lap or kneel in front of him.) Baby lotion and baby oil soak into the skin too fast, so use vegetable oil, massage oil, or cornstarch. Put the oil or cornstarch on your hands first, then rub your hands together to warm them. Tell your baby what you are doing or sing a song. Rub gently during the first month; as the baby gets older, you can exert more pressure.

Once you have touched the baby, keep at least one hand in contact with him until the massage is over. Don't massage your baby's trunk if his stomach is full. Be sensitive and responsive to his reactions; stop if he is not enjoying himself. If he is enjoying himself, and he probably is, here are some motions you can try:

Medical Care

Immunizations

Immunizations protect your child from certain potentially serious diseases. Since many of these illnesses occur in the first years, it is important to immunize your child early and keep to a regular schedule. Immunizations are given at your doctor's office or, for a minimal fee, at public health clinics.


The first vaccinations immunize against diphtheria, whooping cough (pertussis), tetanus (DPT) , Haemophilus influenzae type B (Hib), and polio. The DPT and Hib vaccines are given by injection; the polio vaccine by mouth. Later, measles, mumps, and rubella vaccines (MMR) may be given by injection, either alone or in combination. In addition, boosters of DPT, Hib, and polio vaccines are given.

Keep a record of your child's immunizations. These records will be required by day cares, schools, and camps throughout his life. If the immunization schedule is interrupted, resume it where you left off in the series, rather than beginning again.

Possible Reactions

Many parents are concerned about the risks from immunizations and possible adverse reactions in their infants. It is true that each vaccine carries possible risks as well as benefits. Health care providers believe that in almost all cases, the risks of potentially serious childhood diseases gready outweigh the risks of immunizations.

Following a DPT injection your baby may have local pain and tenderness at the injection site, a slight fever, and mild irritability for one or two days. Your doctor may suggest that you give acetaminophen to your baby to relieve these symptoms. On rare occasions, severe adverse reactions occur. If your baby cries inconsolably, develops a high fever, has convulsions (shaking or unresponsiveness), or becomes limp or pale, notify your doctor immediately.

DPT injections are usually not given to an infant who had a serious reaction to a previous injection, to an infant who is ill, or to an infant who has had previous convulsions or other nervous system problems.

Reactions to the Rib vaccine include redness and swelling at the injection site and a mild fever. About I percent of those vaccinated have a higher fever (above 101.4 degrees Fahrenheit [38.5 degrees Celsius] ) . Fever and tenderness at the injection site last about a day or two. Rare allergic reactions have also been reported.

Reactions to the polio vaccine are uncommon. In rare instances ( one in five to ten million doses), symptoms of polio (such as high fever, muscle weakness, or paralysis) appear in the person who is vaccinated or someone who comes in contact with that person. For example, the person who changes the diapers of the infant may be exposed to polio because the virus is shed in the baby's stools up to two months after the vaccination. Individuals whose immune systems are depressed due to drugs or illness should not provide care for a recently immunized infant. Others should wash their hands well after every diaper change.

Following an MMR injection, a child may develop a mild fever. Seven to twelve days later, he may develop a rash and fever that lasts a day or two. Some children develop mild, brief joint pain two weeks or so following the vaccination, which may show up as a limp. If any other symptoms such as high fever or convulsions occur (a very rare event) , these should be reported to your doctor immediately.

When to Call the Doctor

If you are worried about an illness in your baby, call your doctor. Before you call, however, give careful thought to, and then note on paper, your baby's temperature and all the symptoms that worry you. Here are some things your doctor may wish to know:

Physical symptoms. Abnormal temperature, breathing difficulties, coughing, vomiting, diarrhea, constipation, fewer wet diapers, rash.

Behavioral symptoms. Loss of appetite, listlessness, unusual fussiness or irritability, change in typical behavior and activity level (for example, if your baby loses interest in his surroundings or is unable to muster a quiet smile).

Home treatment. What have you done to treat the illness, and how has your child responded? Have you given your child any medications? What and when?

General considerations. Has there been recent exposure to illness? Is anyone at home or day care sick?

Have a paper and pencil handy to write down your doctor's suggestions. Also, know your pharmacist's phone number, as the doctor may want to call in a prescription.

Colds

It is normal for babies to have a slight, stuffy, rattly noise in their noses. Your infant probably has a cold, however, if he has a very runny nose, is fussier than usual, has trouble eating and sleeping, and perhaps has a slight fever.

To lessen the chance of a cold, minimize the number of visitors (adults and children) when the baby is very young. People with colds should stay away. You will probably want to consult your physician for your baby's first cold. He or she may suggest a cool-mist vaporizer, sleeping in a semireclined position (place a folded blanket or pillow under the head end of the mattress) , clearing the nostrils gently with a bulb syringe, using nose drops, or giving medication.

Medications

Use the following guidelines when giving medications or vitamins to your baby:

A Word about SIDS (Sudden Infant Death Syndrome )

Almost every parent worries about SillS at some time. You may know someone whose baby died of SillS, or you may have read about it. There is no way to minimize the loss and grief caused by SillS, but the following facts might help you put your fears and worries into perspective:

It is helpful to remember that SillS occurs rarely. Howe~r, if you have lost a baby to SillS, be assured there was nothing you could have done to cause, predict, or prevent it. SillS support groups are available to help parents cope with their loss. Your doctor, public health nurse, or childbirth educator can help you locate a group.

Or contact the SillS Alliance, 10500 Little Patuxent Parkway, Suite 420, Columbia, Maryland 21044, (800) 221-7437.

Conclusion

Getting to know and falling in love with your new baby begins before birth and continues over time. If you know what to expect, what is normal, and how to interpret her cues, and if you can appreciate that she has her own unique personality, your role as a parent will be easier and more satisfying. Remember, no one loves your baby or cares more about her well-being than you. She senses this and thrives on your love.

Chapter 14

FEEDING YOUR BABY

Prenatal Preparation for Breastfeeding

If you have chosen to breastfeed, the first step is to become familiar with your breasts. Look at yourself in the mirror, keeping in mind that while the size and shape of breasts and nipples vary from woman to woman, these factors have virtually no effect on your ability to produce enough milk for your baby. You may notice that your breasts are larger now and possibly more tender than they were before you became pregnant. The veins are more visible. The Montgomery glands ( the small bumps on your areolae) are also larger. Colostrum, which has been present in your breasts since the middle of pregnancy, may leak from your breasts or appear as a dried crust on your nipples. If leaking does not occur, do not worry; you will continue to produce colostrum. All these changes are positive signs that your breasts are preparing to produce milk for your baby.

Women are sometimes advised to express colostrum from their breasts as another way to prepare for breastfeeding. The benefits of this practice probably do not outweigh the possible risk of causing pre term labor by stimulating the breasts. Use other methods instead.

Conditioning or toughening your nipples to prevent soreness has not been shown by any large, scientific study to be effective. In fact, sore nipples are usually due to poor positioning of the baby's mouth on the areola (a poor latch). Most women experience a little nipple soreness in the first few weeks of breastfeeding, usually when the baby first latches on. This soreness should fade within a few minutes. You should avoid using soap, tincture of benzoin, or alcohol on your areolae and nipples, as these products dry the skin. You might also try exposing your nipples to sunshine or to the air for several minutes daily. In regions of the world where women's breasts are not covered with clothing, problems with sore nipples are rare.

An important part of preparing for breastfeeding is to take a breastfeeding class or get a comprehensive book on breastfeeding (see Recommended Resources) .You will learn what to expect and how to feed your baby.

Flat or inverted Nipples




Because flat or inverted nipples can cause problems with initial breastfeeding, you need to know whether you have them so you can begin treatment in late pregnancy. Check yourself for flat or inverted nipples by placing your thumb above and forefinger below your breast on the edge of your areola and gently compressing your areola. This simulates the action of your baby's mouth on your areola during feeding. The nipple should protrude or stick out. If it flattens or indents, you have a flat or inverted nipple. This problem may make feeding difficult because the baby cannot grasp enough of your areola in his mouth to suckle well.

For flat or Inverted Nipples

Flat or inverted nipples can sometimes be helped to protrude by using the following techniques to stretch the underlying tissue and help the baby attach.

Caution: Stimulation of the nipples sometimes causes uterine contractions and could theoretically cause premature labor in a woman at risk. Discontinue nipple stimulation if it causes contractions.

Breast cups or shells. These two-piece plastic dome-shaped cups or shells are placed over the areola to draw out the nipple. The cups work by exerting a continuous, gentle pressure on the areola, causing the nipple to protrude through an opening in the inner plastic ring. Wear these cups in the last trimester of your pregnancy, starting with an hour each day and gradually working up to several hours. Because the skin may become moist under the plastic, be sure to dry your nipples each time after you wear the shells, or choose a shell that has' air holes for constant ventilation. You may continue to wear these cups after the baby is born if your nipple problem persists. For a short time after removing the cups, your nipple will protrude more than usual-perhaps enough to help your baby latch on more successfully.


Nipple stretching. Stretching the nipple tissue several times a day during the last weeks of pregnancy may help correct flat or inverted nipples. Try the following stretching exercises:

Hoffman's Technique Your partner's sucking on your nipples during lovemaking stretches the nipples and can be helpful. Prenatal preparation provides important emotional benefits, too. Until pregnancy, the breasts are perceived by most people primarily as sexual objects; a change in attitude toward them is helpful for successful breastfeeding. Handling your breasts, checking your nipples, and taking a breast- feeding class help you and your partner make this important transition to thinking of the breasts in terms of their functionnourishing a baby.

Breastfeeding Basics

First Feedings

you can help establish your milk supply and avoid some early breastfeeding problems by nursing your baby as soon after birth as possible and by allowing your baby to suckle frequently. When mothers breastfeed within an hour after birth and feed their babies frequently, their milk comes in sooner (within twenty-four to forty-eight hours after birth) and engorgement is less of a problem than when they wait to begin breastfeeding.

The first feeding is special. You and your baby get to know each other better and begin the beautiful, synchronous interaction that characterizes breastfeeding. If you have never breastfed before, the technique of feeding may seem awkward and cumbersome at first. But you can be reassured that the skill of breastfeeding improves with experience. Here are some suggestions:




What to Do

  1. Make yourself comfortable with your baby's body tipped toward you. Cradle your baby's head comfortably in the crook of your arm. Let her back rest on your forearm and cup her buttocks in the palm of your hand (this is called the cradle hold).
  2. Grasp your breast with your free hand behind (not touching) your areola with thumb on the top and four fingers below. Compress the breast with your thumb and forefinger, centering your nipple with the baby's mouth.
  3. Stroke or tickle your baby's lips with your nipple to stimulate her rooting reflex and to get her to open her mouth. Once her mouth opens wide (as wide as a yawn), pull or roll her rapidly toward you and hold her close, so that she is pressed tummy to tummy against your body. Be patient, because it sometimes takes a long time before your baby opens her mouth wide enough. Just keep stroking her lips. Bring your baby to your breast rather than bringing your breast to your baby.
  4. Make sure to get as much of your areola as possible in your baby's mouth to ensure a good latch. (Her nose will be touching your breast.) Unless your breasts are quite large, she can still breathe. She will not allow herself to smother. If you feel you need to help her to breathe more easily, lift your whole breast a little and bring her buttocks in closer to rearrange her position and give her more breathing space.
  5. Let your baby suckle at the first breast for as long as she wishes (at least ten to fIfteen minutes), and then offer the second breast. This advice is much more appropriate than the instructions that you might get to limit I feedings at each breast to five minutes or Ifewer in hopes of preventing sore nipples. Five minutes is hardly enough time to get Istarted. During the first feedings after birth, the let-down reflex may not take place for three minutes or more after you begin the feeding. Once breastfeeding is established, the let-down occurs within seconds after the baby begins to suckle.12 Research has shown that limiting the amount of time your infant spends at the breast merely delays rather than prevents the onset of sore nipples. The most critical factor in nipple soreness is the baby's latch (described above). When the baby's mouth is properly positioned on the nipple, soreness is rarely a serious problem.
  6. When your baby is finished nursing at one breast, she will stop sucking and release the breast. If you need to take the baby off the breast, do so by placing a finger in the corner of her mouth until you break the suction. Then move her away from your breast.
  7. Burp the baby, but do not be concerned if the baby does not burp until your milk comes in.
  8. Allow your baby to nurse from the other breast.

Initial Nursing Difficulties

Some babies seem to know how to feed right from the beginning, while others seem uninterested, sleepy, or have difficulty latching on to the nipple. If you have difficulty getting started, the following suggestions may help:

The initial nursing may be different than you expected. Your baby may tentatively lick and mouth your breast; she may struggle to get your areola in her mouth. Or she might immediately latch on to your areola, tug, and suck vigorously. Energetic nursers sometimes grasp and pull on the nipple so Ifirmly they surprise you and cause some pain. You may experience painful uterine contractions (afterpains) with the let-down reflex, especially if this is not your first baby. Relaxation and slow breathing may help in either case.

Do not despair if your baby does not nurse on the first try. Whether she suckles or not, the stimulation of her nuzzling, licking, and being close to your body encourages milk production. Sometimes babies are tired from a long labor or drowsy from the , effects of some medications. Perhaps you also are tired following a long, difficult labor. Rest and nourishment will relieve your fatigue, just as rest and time will help your baby. With your patience and perseverance, she will almost certainly learn to nurse quite efficiently.

Burping Your Baby

Babies sometimes swallow air along with milk while breast or bottle feeding. You should burp your baby during and after feeding to help her get rid of the air. Try these burping methods to find the one that is most effective for your baby. With each method, use a burp cloth to protect your clothes. If there is no burp after several minutes, just lay her on her tummy or side or continue feeding.


Over-the-shoulder. Place your baby high on your chest with her head peeking over your shoulder. Support her well across her back and buttocks. Gently pat or rub her back until you hear a burp.

Over-the-lap. Place your baby on her tummy across your lap. Gently rub or pat her back until you hear a burp.

Sitting and rocking. Sit your baby sideways on your lap. Place your thumb and first finger under her chin with your palm supporting her chest and your other hand supporting her back. Gently rock her back and forth. You might lightly rub or pat her back until you hear a burp.

Frequency of Feeding

Breastfeeding on demand means feeding the baby when she is hungry rather than on a schedule. It probably means feeding every one to three hours. Breastfeeding eight to eighteen times in twenty-four hours is the best way to establish an adequate milk supply. Begin each successive feeding with the breast your baby last nursed from, since babies usually nurse most vigorously at the first breast. This will make sure that both breasts get an equal amount of stimulation.

You might use a safety pin in your bra strap to remind you which side to begin with, or palpate your breasts and begin feeding on the side that feels more full. Feed from the first breast for as long as the baby is interested (ten to twenty minutes on average) and then offer the second. If your baby remains with you in your hospita! room, you will know when she needs to be fed. But if she spends some or most of her time in the nursery, you will want to ask the nursing staff to bring your baby to you when she is hungry, day or night. Also keep in mind that full-term, healthy babies do not need supplementary bottles of formula, sugar water, or water if they are breastfed frequently and on demand from both breasts. Their requirements for nourishment and fluids will be met as long as breastfeeding is not limited. Policies restricting feeding time are often based on requirements for formula-fed babies and cannot be applied to breastfed babies.

Supplementary bottles of formula and water have several disadvantages. Formula and sugar water contain calories that diminish your baby's hunger and interfere with her desire to nurse. Furthermore, sucking on a bottle nipple is entirely different from suckling on your breast, and it can result in "nipple confusion," the inability to nurse well at both breast and bottle and the development of faulty sucking patterns, conditions that are difficult to treat. If nipple confusion does occur, it may help to avoid the use of bottle nipples and pacifiers until nursing is well established. If for some reason your baby must receive supplements of water and formula in the first several weeks, it may be helpful to offer them bya Supplemental Nutrition System (SNS) , a medicine dropper, a cup, or a syringe feeder to avoid nipple confusion. The Supplemental Nutrition System and syringe feeder include a container of milk attached to a tube that is placed alongside the mother's nipple. As the baby suckles, milk from the container flows through the tube and the baby gets extra milk, along with breast milk. The baby does not use a rubber nipple.

How to Know When Your Milk Comes In

You will know your milk has come in when your baby begins to gulp and swallow rapidly while nursing. You may see some milk in the corners of her mouth; your breasts may be heavy, hard, and tender; you may feel the tingling sensation of your milk letting down; and milk may drip from your other breast while your baby is nursing.

First Weeks

In the early weeks after birth, your baby will nurse everyone to three hours. Over time, your baby will consume more at each feeding, and reduce the total number of feedings each day.

Babies do not always nurse on a regular schedule. Sometimes they nurse four or five times in five or six hours and then sleep for a stretch of several hours. If your baby sleeps five to six hours at a stretch at night, be sure to feed her frequently during the day so she will get all the nourishment she needs. If your baby sleeps a great deal during the day and awakens frequently at night to feed, you may try awakening and feeding her every two to four hours during the day in order to change the night-feeding pattern. This is worth trying, but not always successful.

Generally, avoid pacifiers in the early weeks. Besides causing nipple confusion, they may satisfy your baby's sucking needs . while interfering with nursing and adequate nutrition. Some babies are happy to suck pacifiers and not eat. These babies will not gain weight well. Other babies seem to nurse constantly without ever giving their mothers a rest. Offering a pacifier to a baby who is nursing well will have less impact on breastfeeding than offering one to a baby who feeds less vigorously and frequently.

Growth Spurts

At about three weeks, six weeks, three months, and six months, your baby may suddenly change her feeding pattern and return to more frequent nursing. She may be fretful, irritable, and more sensitive to stimuli during this time, and she may seem to need to nurse constantly. She is probably experiencing a growth and developmental spurt, and nursing frequently is her way of stimulating you to make more milk to meet her needs and to comfort herself. Do not be troubled by her increased demands. Usu- ally, within about a week, your baby's needs will level off once again.

Enhancing Milk Flow

Breast massage before a feeding or breast pressure during a feeding enhances the flow of milk from your milk-producing glands. If done before feeding or pumping, breast massage speeds your let-down reflex. An impatient, fussy baby will latch to the breast more easily if she does not have to wait long for the milk to flow abundantly. Pumping is often more productive if you "prime" your breast first with breast massage.


Before a Feeding

There are several techniques for massaging your breasts before feeding:

During a Feeding

Breast pressure during feeding enhances milk flow, helps to empty clogged ducts and makes more high calorie hindmilk available to the baby.13 This technique is especially useful for sleepy babies, babies with a less vigorous suck, and babies who are gaining weight slowly.


Once the baby has latched well, pay attention to her pauses in suckling. When she pauses, gently press your fingertips against the milk-producing glands located in the upper outer quadrant of your breast, near your underarm. You will notice a burst of suckling as milk is pressed toward the milk sinuses and into your baby's mouth. If the baby pauses again, rotate the position of your fingertips and press another quadrant of your breast. Be careful not to press too close to your areola as this can interfere with your baby's latch.

Involving the Family

Although you are the one who produces milk and feeds your baby, your partner's and family's support and encouragement are often the key factors in keeping you going in the face of difficulty. Your family can help you eat and drink well, allow you to rest by caring for the baby, and shield you from unnecessary stress. If they can relieve you of some or all of your day-to-day chores, you will be free to devote yourself to caring for yourself and establishing breastfeeding.

Some Early Breastfeeding Problems

Almost every woman has some problems or questions with breastfeeding in the first weeks after birth. Some of these are common and predictable and can be handled quite easily. Others are more serious and require more information and assistance. Following are some of the more common breastfeeding problems and suggestions for solutions.

Is the Baby Getting Enough Milk ?

A number of signs can tell you if your baby is getting enough milk. A baby who feeds well every two hours or so for twenty to forty minutes with occasional shorter or longer periods between feedings will have six to eight wet diapers each day. Mter passing his meconium stool, a breastfed baby may have ! a loose stool with each feeding, or at least three or more stools a day for the first month. It is common to have a stool after every feeding. Later, as he matures, he may have a bowel movement every other day or even once a week. Your baby's elimination patterns along with his contentment after being fed are good indications that he has received enough milk. Most importantly, your baby's doctor will watch his weight gain and growth to determine if he is getting enough milk. Most babies lose weight shortly after birth-as much as 5 to 10 percent of their birth weight. They usually regain it within two or three weeks. If your baby's weight gain seems to be slow, it could be due to any of the following factors.

Limited sucking time. The let-down may not occur if suckling is limited to a few minutes on a side. This means that the baby will not get the high-calorie hindmilk and will not gain as expected. Your baby needs at least ten to twenty minutes of vigorous suckling at each breast to get the hindmilk.

Gas bubbles. Swallowed air can make the baby feel full. Be sure to burp your baby before changing to the other breast and after the feeding. Scheduled reedings. A newborn breastfed baby, especially a slow-gaining baby, needs to be fed more frequently than every three or four hours. Allow your infant to nurse on demand or whenever he seems interested (at least eight to eighteen times in twentyfour hours).

Sleepy baby. If your baby is very drowsy during the feeding, pauses for long intervals, or even falls asleep, he may spend a long time at the breast without getting much milk. To wake up your baby, try stroking the soles of his feet with your fingernail or rubbing his thighs or tummy. Avoid wiggling your breast or rubbing his cheeks which may dislodge a good latch and interrupt the feeding. If these techniques are not enough, make sure he is not overbundled. Then try burping him and switching to the other breast, which can be done several times during one feeding to keep him awake. You may also use breast massage (see page 276) to press milk down toward the nipple and interest him with the flow of milk.

If your baby goes for long stretches without feeding, try waking him every two to three hours during the day and every four hours at night. If the baby was preterm or has had other problems, your doctor may suggest feeding more frequently. If your baby is sleeping so soundly that you simply cannot rouse him, it is better to wait a half hour and try again than to continue the frustrating and futile effort of waking up a baby who is deeply asleep. If this happens often, record the baby's feeding and sleeping on the Sleep and Activity Chart (page 262) for two or three days and call your baby's doctor with this information.

Limiting feedings to one breast. Offering only one breast at each feeding may result in inadequate milk production. Switch to the other breast after your baby finishes feeding at the first breast. The baby might nurse very little on the second breast at first, but he will nurse more as he grows.

Nonnutritive sucking. Some infants satisfy their sucking needs without nursing by sucking on their own fists, fingers, tongues, lips, or pacifiers, or by chewing and sucking on the tips of their mother's nipples. Once their sucking needs are satisfied in this way, they may not appear hungry, leading their mothers to think they do not want to nurse. These babies may have problems gaining weight.

Difficulty with the let-down reflex. Anxiety, fatigue, inadequate nipple stimulation, and excessive amounts of alcohol, caffeine, and smoking all may inhibit the let-down reflex.

Fatigue, insufficient intake of fluids and calories, or poor diet. These may reduce your milk supply but are less common reasons for inadequate milk supply. Spend a day in bed with the baby to replenish a declining milk supply. Pick a day when you have help with meals, household chores, telephone calls, and your other children. Spend the day nursing your baby as often as possible, eating and drinking well, sleeping, nurturing yourself, and letting others nurture you. Besides helping to restore your milk supply and helping you catch up on needed rest, this is a wonderful way to learn more about your baby. Then, over the long term, pay attention to your need for rest, to your food and fluid intake, and to the quality of your diet.

Poor latch. If the baby has not positioned his mouth properly on the nipple, he will not be able to compress the milk sinuses well and will not stimulate a let-down reflex. If the baby's mouth makes a "clicking" sound during sucking, it may indicate that the suction is breaking with each sucking ~ffort. For the whole feeding, hold the newborn baby tight against your body, close enough that his nose touches your breast. It is possible to start with a good latch and later have the baby's mouth slip down to the nipple tip as your arm tires. A pillow beneath your arm may prevent this. See page 272 for a description of a good latch.

Treatment

If you wonder if the baby is getting enough milk, try the following:

Engorgement

Engorgement is an inflammation of the breast with swelling in the tissue surrounding the milk-producing glands. It is accompanied by an accumulation of milk in the ducts. It occurs when the "milk comes in usually the second or third postpartum day. Your breasts swell, become firm and warm to the touch, and painful. Keep in mind that engorgement may be prevented or at least reduced by allowing the baby to nurse early and frequently for an adequate time and with a proper latch. Engorgement usually subsides after a few days. Pumping to remove the milk your baby does not take will relieve~ not aggravate, engorgement.

Treatment

Sore Nipples

Sore nipples may occur at any time but are most common during the first weeks of breastfeeding. Soreness may range from discomfort only when the infant first grasps the nipple to continuing pain throughout and between feedings. Sore nipples can almost always be treated successfully. In severe cases, the nipples may crack and bleed, but even these cases can be successfully treated without stopping breastfeeding.

Sore nipples are usually caused by improper positioning of the baby's mouth on the areola (improper latch) .Flat or inverted nipples are more prone to soreness. Less commonly, sore nipples are due to overvigorous pumping or hand expression, a very vigorous baby whose gums clamp hard on the areola and whose suckling may srape the tissue of the areola, or an infection of the areola. They are not prevented by prenatal nipple "toughening" exercises (rubbing or pulling the nipples), as was once believed. The common belief that limited suckling reduces or prevents nipple sore ness has also been shown to be a myth.14 Frequent unlimited suckling with a good latch is not associated with an increased incidence of sore nipples.

Treatment of Sore Nipples

Due to Problems with Latch

Treatment of Sore Nipples Due to Overvigorous Pwnping or Milk

Expression

Thrush (Yeast) Infection

If your nipple pain continues even between feedings; is sharp, deep, or searing; and persists even when you have a good latch, you might have a thrush infection. The areolae or nipples may appear slightly pink but are usually unremarkable in appearance. If you or your baby have taken antibiotics, if you have had a vaginal yeast infection, or if your baby has or has had thrush, an areolar thrush infection is possible.

Treatment of Sore Nipples Due to Thrush

Consult your doctor or midwife. Thrush infections are most effectively treated by applying a prescription medication to your areola and to the baby's mouth and by treating any vaginal yeast infection.

Breast Pain on Let-down

Some women experience a sharp, deep pain behind the areola at the beginning of each feeding. The pain, which subsides when the milk is flowing, does not indicate a problem and will usually go away in time without treatment. It is probably caused by oxytocin, which shortens and widens the ductules and ducts and facilitates the flow of milk through them.

Physiologic Jaundice in the Newborn

Physiologic jaundice usually begins on the second or third day after birth. It is not a reason to discontinue breastfeeding or to give water or formula. (See pages 249-50 for a discussion of newborn jaundice.) Physiologic jaundice in breastfed babies is often the result of insufficient breastfeeding. In fact, it has been called "lack of breast milk" jaundice. The most effective way to prevent jaundice in the breastfed infant is to feed frequently and to not limit feedings. This will help the baby to have bowel movements, which is his way of excreting bilirubin. Since very little bilirubin is excreted in urine, water bottles are not helpful-in preventing or treating jaundice.

Breast Milk Jaundice

Breast milk jaundice, a rare condition, does not occur until the baby is five to seven days old and is thought to be caused by a substance sometimes found in breast milk that interferes with the normal metabolism of bilirubin. The bilirubin accumulates, causing the jaundice. To slow the rise in bilirubin or reverse a high bilirubin leyel, you may be asked to stop breastfeeding and feed with formula for twelve to twenty-four hours. This is usually enough to lower bilirubin levels and is diagnostic for breast milk jaundice. If there is another rise, interrupting feedings once again may be suggested. Eventually the bilirubin levels fall or stay down and no other treatment is necessary. You should pump your breasts during the periods you are not nursing to maintain your milk supply

Interrupting breastfeeding in this way is very stressful when you are trying to establish your milk supply. You should be reassured that your milk is not "bad"; your baby is simply not able to handle it yet. Your baby is not likely to be harmed by this rise in bilirubin level. Treatment

Leaking

Milk often leaks from the breasts in the first few weeks or months of nursing. This subsides as your breasts become more finely tuned and they "learn" how much milk to make and when to let it down. Leaking usually occurs when your breasts are very full, when you are feeding from the other breast, when you hear a baby cry, or when you are sexually aroused. Treatment

Clogged Ducts

Redness, pain, swelling, or a lump in the breast can mean either a clogged duct or mastitis ( an infection) .If these symptoms occur in an area in one breast and you do not have a fever or other flu-Iike symptoms, you may have a caked, clogged, or plugged duct. If untreated, this could lead to mastitis. Any lump dIat does not respond readily and go away with the following treatment should be evaluated by your doctor or midwife. Treatment

Mastitis

Mastitis is an infection of the breast, which can occur at any time while you are nursing. Symptoms include a tender, reddened, hot breast; headache; nausea; fatigue; chills; and fever. Many women feel as dIough dIey have a severe flu. If you have these symptoms, suspect mastitis and call your caregiver right away. Treatment

Infection of both breasts could indicate a Group B beta streptococcal infection, which means you may have to interrupt breastfeeding.16 Your doctor or midwife can help you decide if you should stop breastfeeding until this type of mastitis is resolved.

If mastitis occurs frequently during the course of breastfeeding, more prolonged low dose antibiotics may be helpfull.