" Our Lamaze instructor… assured our class…that our cervix muscles would
become 'naturally numb' as they swelled and stretched, and deep breathing
would turn the final explosions of pain into 'manageable discomfort.' This
description turned out to be as accurate as, say, a steward advising
passengers aboard the Titanic to prepare for a brisk but bracing swim. —Mary
Lightening (dropping) - descent into the pelvis causing the abdomen to protrude at a lower position than previously. Increasing pressure in pelvis and rectum Weight change (plus or minus) Fluctuating energy levels Passage of mucus plug (up to a few days prior) Pink or bloody show Increasing Braxton-Hicks "False labor" - means it does not dilate the cervix or result in delivery = PreLabor
TABLE 17.2: PAIN RELIEF DURING LABOR AND DELIVERY Type of Pain How It Works Risks to You or Your Baby Other Considerations
blood pressure), difficulty in regional block for pain
into the space between urinating, and severe
the spinal cord and the 2% of cases). Not
appropriate for women with "walking epidural")
complete relief in 85% cm dilated. May also
of women, partial relief diminish ability to push,
Injected into the spinal Can cause maternal
flat on your back for several hours after delivery to avoid developing a postspinal headache, though new technology in spinal needles has made this complication rare.
inserted into the tissues Lasts only 45 to 60
that baby's health would be compromised.
Provides rapid pain relief in Not effective for all
the perineum for the actual women. Can't be used if
extraction). A less popular option today than in the past.
Non-medicinal pain relief Acupuncture: Needles are inserted in your limbs or ears to block pain impulses. Hypnosis: A woman who has been trained in self-hypnosis may be able to use these techniques to relax herself during labor. Transcutaneous electronic nerve stimulation (TENS): A battery-powered stimulator is connected by wires to electrodes placed on either side of your spine. You can use the accompanying handset to regulate the amount of stimulation your lower back receives to block the transmission of pain impulses to the brain. Laboring in water: According to childbirth educator Penny Simkin, the relief that women get from laboring in warm water is second only to that provided by an epidural. Laboring in water helps counteract the effects of gravity, something that can make labor less painful. We'll be talking more about the benefits of laboring in water in our section on water birth below. Relaxation and positive visualization: Women who have been trained in relaxation methods and positive visualization are able to put these techniques to work during labor. Most childbirth classes include this type of training. Other: The use of music, massage, position change, heat or cold application, counter- pressure, reassuring touch from a caring support person, and adequate hydration can also provide relief. Episiotomy An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening before the birth of the baby's head. It is generally needed in cases of fetal distress, shoulder dystocia (that is, when the shoulders are stuck), a vaginal breech delivery, an especially fragile baby being delivered, and a forceps delivery. It is also done as a preventive measure by many caregivers if it appears that without one a potentially serious laceration may occur. Most caregivers agree that it should be used when warranted, but not routinely. Unofficially… The episiotomy was invented in Ireland in 1742 as a means of assisting with difficult births. It was not, however, widely performed until the mid–20th century. Today, 80% to 90% of first-time mothers and 50% of women having subsequent births can expect to have an episiotomy.
Two types of cuts are made when an episiotomy is performed:
Medio-lateral: This is an episiotomy that slants away from the rectum. Median: A median cut is made directly back toward the rectum. Labor consists of three distinct stages:
1.the first stage, which ends when the cervix is fully dilated; 2.the second stage, which ends with the birth of the baby; 3.the third stage, which ends once the placenta has been delivered. The three stages of labor typically last for 12 to 14 hours for first-time mothers and 7 hours for women who have previously given birth. TABLE 17.3: APGAR TEST
wel the lungs are working to oxygenate the blood
measures the strength and regularity of the heart beat
The Apgar test is performed twice: once when your baby is one minute old and again when your baby is five minutes old. A baby with a one-minute combined score of seven or over is doing well; a baby with a score of five or six may require resuscitation; a baby with a score of four or less may be in serious trouble. Unofficially… The Apgar test is named for pediatrician Dr. Virginia Apgar, who developed it. A memory device that many caregivers find helpful when assessing a newborn is to assign the terms "appearance, pulse, grimace, activity, and respiration" to the letters of "APGAR." One tool your physician may use in assessing your body's readiness for labor is the so- called Bishop scoring system, in which a score of 0 to 3 is given for each of the following five factors:
4.dilatation 5.effacement 6.station 7.consistency 8.position of cervix If your score exceeds 8 (see Table 17.4), your cervix is considered to be favorable for induction.
Note: If your labor starts but is weak, is erratic, or stops, your caregiver may augment your labor by using some of the techniques that are used to induce labor.
There are certain circumstances in which labor should not be induced, however. These include pregnancies in which either vaginal delivery is excessively risky or where additional stimulation of the uterus could add unacceptable risk, such as those pregnancies in which
1.the placenta blocks the cervix (placenta previa); 2.the placenta is prematurely separating from the uterine wall (placental abruption); 3.there is an usual presentation of the baby that would make vaginal delivery dangerous
4.the baby is believed to be too large for your pelvis to accommodate (cephalopelvic
5.you have an active genital herpes infection; 6.you are carrying multiples; 7.there is evidence of fetal distress; the uterus is unusually large (due to the increased risk of uterine rupture if you have polyhydramnios or are carrying multiples).
Methods of induction If your caregiver decides to induce or augment labor, he will probably use one or a combination of the following methods:
9.Artificial rupture of membranes (AROM): The caregiver ruptures the membranes
using a device that looks like a crochet hook. The procedure will be virtually painless if your cervix has already begun to dilate but can be quite painful if it is only one centimeter or less. If this procedure—known as an amniotomy—fails, your labor will have to be induced using other, more invasive methods. Once your membranes have been ruptured, you've reached the point of no return: you're going to have your baby; it's simply a matter of time.
Watch Out! Some caregivers will rupture your membranes to speed up a sluggish labor. Once your membranes have been ruptured, your labor will become faster and more intense. Make sure that you're psychologically prepared for these more intense contractions.
8.Prostaglandin E suppositories or gel: Prosta-glandin E suppositories or gels help
ripen the cervix (make it more favorable for induction). According to the American College of Obste- tricians and Gynecologists, 50% of women will go into labor spontaneously and deliver within 24 hours with just a single application of the gel; others will require some other method of induction.
9.Misoprostol: Misoprostol tablets placed high in the vagina can also help to ripen the
cervix and induce labor. This new technique is still considered experimental and the drug is not approved by the FDA for this purpose. However, many caregivers are impressed by its safety, effectiveness, and ease of use compared to Prostaglandin E
10.Pitocin: Pitocin is the synthetic form of oxytocin—a hormone that is produced
naturally by your body and that is responsible for causing your uterus to contract during labor. If it is used when your cervix is already ripe, a Pitocin-induced labor won't be all that different from a natural labor. If, on the other hand, your cervix isn't ripe, it may take several hours of exposure to Pitocin in a series of separate attempts over a period of two to three days to get labor started. This is why many caregivers use Prostaglandin E or Misoprostal as a warmup to Pitocin. When you are first hooked up to an intravenous drip, a small amount of Pitocin will be injected. This is because your caregiver will want to monitor the strength of your contractions and your baby's response to them before upping the dosage. It's very difficult to predict how a particular mother and baby will react to the drug. Sometimes, contractions caused by a Pitocin drip can be stronger, longer, and more painful than non-Pitocin-induced contractions, and there are shorter breaks between them. You may require pain medication to help you cope with the contractions, and you will
probably need to be hooked up to a fetal monitor for the majority of your labor. In some cases, however, a small dose of Pitocin (especially if the membranes are ruptured) is all that is required to get labor started, and, once started, your contractions will continue on their own without any further need for Pitocin.
Cervical dilators: Cervical dilators are a mechanical method of dilating the cervix. Laminaria (sticks of compressed and dried sea-weed or synthetic materials) are placed in the cervix. As they absorb water and swell, they force your cervix to dilate. Cervical dilators are considered to be approximately as effective as Prostaglandin E; in other words, they are able to get labor started within a 24-hour period in about 50% of women. There are three main types of breech positions, as you will see from the following figure.
10. the frank breech (when the baby's legs extend straight upward), 11. the complete breech (when the baby is sitting cross-legged on top of the cervix), 12. the footling breech (when one or both of the baby's feet are pointing downward).
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