MANAGING PAIN DURING CHILDBIRTH
It takes a lot of pushing and stretching to move a baby the size of a melon through a cervical opening that starts out as the size of a kidney bean. Muscles don't flex or tissues stretch without letting your body know it. Contrary to popular belief, it's usually not the contracting uterine muscles that produce the pain. Like any muscle, uterine muscles don't hurt unless they are forced to work in a way they were not designed to. Yet when a muscle is overly tired, the natural chemistry and electrical activity within the muscle tissues get out of balance. These physiological changes produce pain.
Most childbirth pain originates in the stretching of the cervix, vagina, and surrounding tissues as baby passes through. During labor the uterus doesn't squeeze baby out; what really happens is the uterine contractions work to pull the cervical muscle up out of the way so that the baby's head can then be pushed through. (Think of a turtleneck sweater being slowly stretched as you pull it over your head. ) The muscles and ligaments in the pelvis are richly supplied with pressure and pain receptors in the nerves, so the stretching produces powerful sensations that may be interpreted as pain, especially if there is tension in the surrounding muscles.
In order to manage childbirth pain well you need to understand how your body processes pain and how your mind perceives it. The contraction begins, tissues stretch, and the tiny pressure receptors in the nerves are stimulated, sending lightning-fast impulses along the nerves to the spinal cord. Pain receptors are stimulated as well if the surrounding muscles are tense. In the spinal cord these impulses must pass through a sort of gate that can stop some impulses and allow others to pass through into the brain, where they could be registered as pain. So you can influence pain at three sites: where it's produced in the first place, at the gate in the spinal cord, and in the brain where the pain is perceived. In working out your own techniques for pain management, you will want to employ pain-relief measures that can control pain at all three of these sites.
To do this, you can practice relaxation techniques to keep your muscles from getting tired and tense. And you can use efficient positions for labors that keep your muscles working in the way they were designed to. Next, you can close the gate in the spinal cord so the cars can't get through. A pleasant touch stimulus, such as massage, sends positive impulses that can block the transmission of pain impulses through the spinal cord. You can also cause gridlock at the gate by sending through a lot of competing vehicles, such as impulses from music, specific mental imagery, or counterpressure. Finally, you can fill up the receptor sites in the brain so that the pain-cars have no place to park. Blocking access to this third pain-perception site is how pain- relieving drugs work. You can achieve the same effect naturally by manufacturing your body's own painkillers, endorphins.
1. Forget your fears. There is a connection between fear and pain. The efficiency of the magnificent uterine muscle depends upon your hormonal, circulatory, and nervous systems all working together. Fear upsets the balance of these three systems. Fear and anxiety cause your body to produce excess stress hormones that counteract the helpful hormones your body produces to enhance the labor process and relieve discomfort. This results in increased pain and a longer labor. Fear also causes physiologic reactions that reduce blood flow and thus oxygen supply to the uterus. An oxygen-deprived muscle tires quickly, and a tired muscle is a hurting muscle.
2. Address your fears. What specifically do you fear about birth? Do you fear the pain, for example, having had negative experiences with pain in the past? Do you fear having a cesarean or needing an episiotomy? Are you afraid that you will lose control midway through labor? Do you have fears about problems with the baby? List all your fears and alongside each one write what you can do to avoid having the fear come true. Realize, too, that some events and outcomes are beyond your power to change, and resolve not to worry about things you cannot change.
3. Be informed. The more you know, the less afraid you will be. While no two mothers' labors are alike, and each birth a woman experiences is different from the last one, childbirth does follow a general outline. There are sensations (aka "pains") that will always occur between the first contraction and the final delivery of a baby. If you understand what happens and why, and what it probably will feel like, you will not be taken by surprise. Having a sense of what to expect – and when it will end – helps most mothers feel confident that they can handle labor and delivery. A good childbirth class can help you understand what happens and why. There is no class that can tell you what it will feel like specifically to you, because this will depend on each woman's particular situation and her ability to cooperate with the forces of labor. Women can easily be taken by surprise at the intensity of labor. Some decide they do not like it one bit and wind up resisting the forces when fear takes hold.
4. Employ a professional labor support person. An experienced woman, called a PLA, will help you interpret your sensations during labor, offer suggestions for managing your pain, and help you understand and participate in any medical decisions.
5. Surround yourself with fearless birth attendants. Fear is contagious. Be sure you do not allow any fear mongers in the labor room. Don't think that this is the time to finally prove something to your mother; if she has a fearful attitude about labor, better she watch your birth on video afterward than be in the birthing room infecting you with her fears. (Many men, including fathers-to-be, are afraid of birth. They don't understand it, and they find it very upsetting when their mate hurts and they can't "fix" it. It helps to inoculate your mate against fear so that he won't pass the bug onto you. Prepare your partner for the normal sights and sounds of labor. Tell him what may happen if events don't go as planned. A calm birth attendant can give your mate a much-needed break and help him keep focused on his job, which is to support you and share in the birth experience, not to protect you from this perfectly normal process. )
6. Avoid fearful replays. Don't carry scary baggage from your past into the delivery room. Birth has a way of stirring up uncomfortable memories of previous traumatic labors or even of a past sexual assault.
7. Take responsibility for your birth decisions. While a painless childbirth is as rare as a sleep-through-the-night newborn, most pain in childbirth is under your influence – if you are ready for it.
8. Choose your practitioner wisely. Does your doctor or midwife take an active role in teaching you about the birth process and helping you to trust your body to give birth? After each visit do you leave believing your birth will go right? Or does this person create a fearful mindset about birth, filling your mind with all the possibilities of what could go wrong?
9. Understand labor and the birth process. Do you know what happens during contractions, what it is those "pains" actually do? Do you understand how being upright and changing positions during labor can influence how you experience contractions?
10. Understand which technological tools (such as electronic fetal monitoring) are likely to be used during your labor. Are you confident that you are knowledgeable enough to participate in decisions about the use of technology in your labor?
11. Be aware of the options available for medical pain relief, such as drugs and epidural anesthesia.
12. Understand the importance of releasing and surrendering to your body during labor. Are you determined to assume whatever position works for you rather than tensing up, resisting the labor process, or becoming a passive patient and spending a lot of time in the horizontal position?
13. Learn to relax your birthing muscles. Relax is more than just an empty word for helpless bystanders to throw at a mother who is experiencing the most intense physical work of her life. But relax is what you must do to help the work progress. Relaxing all of your other muscles while only your uterus contracts eases the discomfort and speeds the progress of labor. If there is tension anywhere in your body, especially in your face and neck, this tension will spread to the pelvic muscles that need to stay loose during a contraction. Tense muscles hurt more than relaxed ones and they tire sooner. Chemical changes within an exhausted, tense muscle actually lowers the muscle's pain threshold, and you hurt more than if the muscle were working unopposed. When tight muscles resist the relentless, involuntary contractions of your uterus, the result is pain. Exhausted muscles soon lead to an exhausted mind, increasing your awareness of pain and decreasing your ability to cope with it.
14. Learn to relax to balance your hormones for birth. Two sets of hormones help you labor efficiently. Adrenal hormones (also called stress hormones) give your body the extra power it needs in situations that call for tremendous effort, like labor and birth. These hormones are often referred to as the "fight or flight" hormones, and are there for the body's protection. During labor your body needs enough of these stress hormones to help you work hard, but not so many that your body becomes anxious and distressed, causing your mind and muscles to work inefficiently. Stress hormones may even divert blood from the hardworking uterus to the vital organs of the brain, heart, and kidney.
15. Relax to boost endorphins. Another kind of hormone also works for you during labor – natural pain-relieving hormones, known as endorphins. (The word comes from endogenous, meaning produced in the body, and morphine, a chemical that blocks pain). These are your body's natural narcotics, helping to relax you when you're stressed and relieving pain when you're hurt. These physiologic labor assistants are produced in the nerve cells. They attach to pain receptor sites on the nerve cell, where they blunt the sensation of pain. Strenuous exercise increases endorphin levels, and endorphins enter your system automatically during the strenuous exercise of labor, as long as you don't do anything to block them. (Tensing up blocks endorphin release. ) Levels are highest in the second stage of labor (pushing) when contractions are most intense. Relaxing will allow these natural pain- relievers to work for you. Fear and anxiety can increase your levels of stress hormones and counteract the relaxing effects of endorphins. Endorphins stimulate the secretion of prolactin, the relaxing and "mothering" hormone that regulates milk production and gives you a psychological boost toward enjoyment of mothering. Studies have shown that endorphin levels are increased by laughter.
To practice relaxation with your partner, you need to be very comfortable. Collect a bunch of pillows and teach your partner where you like them. Do these exercises in various positions: standing and leaning against your partner, a wall or a piece of furniture, sitting down, lying on your side, and even on all- fours.
1. Tense, and then relax muscle groups. Check your whole body for muscle tension: a furrowed forehead, clenched fists, and a tight mouth are the easiest ones to spot. Then practice releasing each group of muscles from head to toe systematically. Tense, and then relax each muscle group to help you identify the two different states. When your partner cues you with "contraction," think, "relax and release. " Then feel these tight muscles loosen.
2. Practice touch relaxation. This conditions you to expect pleasure rather than pain to follow tension. Find out which touches and what kind of massage relax you best. Do the same head to toe progression as above. Tense each muscle group, and then have your partner apply a warm, relaxed touch to that area as your cue to release the tension. This means you don't have to keep hearing the verbal cue "relax," which eventually becomes irritating. Another goal is to be able to relax a tense muscle when your partner puts just the right touch on that spot before it begins to hurt. Practice: "I hurt here – you press hard (or stroke or touch here). "
3. Use visualization to relax. A clear mind filled with soothing scenes relaxes a laboring body – at least between contractions. It also encourages the production of labor-enhancing endorphins that can help your labor progress. Sports psychologists use mental imagery or visualization to help athletes perform. Follow these steps to use visualization for relaxation during labor:
- Determine the thoughts and scenes you find most relaxing and practice meditating on them frequently throughout the day, especially in the final month of pregnancy. You may find the following scenes helpful: rolling waves, waterfalls, meandering streams, walking along the beach with your mate.
- Think about appropriate images for use during contractions. When a contraction begins, picture your uterus "hugging" your baby and pulling itself up over his or her adorable little head. During the dilating stage, imagine your cervix getting thinner and more open with each contraction.
- Change scenes from painful to pleasant. Grab the pain as if it were a big glob of modeling clay, massage it into a tiny ball, wrap it up, put it in a helium balloon, and imagine it leaving your body and floating up into the sky.
- Between and during the more painful contractions, imagine the prize rather than the pain you have to go through to get it. Picture yourself reaching down as your baby comes out, assisting your birth attendant in placing your baby on your abdomen, and nestling your child against your breasts.
Remember your high school physics: place an object in water and the force of buoyancy equal to its weight lifts it up. To simplify Archimedes' principle, let's put it this way: water gives a pregnant mother a lift. Buoyancy feels like weightlessness. With less weight to support and less muscle tension, your body feels less pain and saves energy for where it is needed – your hardworking uterus.
1. Water relieves. Muscles that weigh less tire less and hurt less. Also, the counterpressure of water can ease the pain of sore muscles, especially during back labor. Recall our earlier discussion about relieving pain by filling the nervous system with pleasant sensations so there's less room left over for painful ones? Being in water is like a continuous body massage, stimulating all the touch receptors in the skin. It would take thousands of gentle fingertips to touch as many skin receptors as the water does when you soak in a nice warm bath.
2. Water relaxes. Immersing most of your body in a warm tub soothes your mind and body, reduces stress hormones, and allows your body's natural relaxing and pain-relieving hormones to take over.
3. Water releases. Changing positions and going with the flow of labor are the most important natural pain relievers and labor enhancers a woman can use. Being in water lets this happen more naturally and easily. Many women laboring on terra firma describe feeling rooted to one spot, afraid to move at all, lest it hurt more. A woman in water is free to float with her body supported until she finds the position that best eases her discomfort. Being in water also seems to free her mind, so she can tap into her deepest instincts and let tension float away. Next time you're in a swimming pool see if this doesn't ring true. Notice how you are free to move your body and clear your mind.
Some hospital maternity suites and birth centers have jacuzzi-sized labor tubs. If the hospital of your choice does not offer one, ask for it. This is just one more way in which women can influence how birth business is done. An alternative is to rent one; check with local midwives or childbirth organizations for information. The tub should be large enough to bring out the mermaid in you – at least 5. 5 feet wide. It's not only being in water that eases the discomforts of labor; it's the freedom to move that gives you the greatest benefit.
Have the water at bath-water temperature, which is usually around your body temperature. Try lounging on your back or side, or kneeling forward on all fours so that the water covers your uterus, at least up to your nipple line. Enter the tub when the intensity of your contractions tells you that you need some relief. For most women the best time to take the plunge is between 5 and 8 centimeters dilatation, when active labor is in full swing. You may also find water labor especially comforting during transition – the most intense stage of labor. The freestyle movements of mother help baby to find the path of least resistance (and least pain). Lying in a labor tub can also be used to accelerate a slow labor. The splashing of the water on your nipples can trigger the release of contraction-stimulating hormones. And water is very effective in easing a fast- and-heavy labor, where the contractions threaten to overwhelm you.
If your labor stalls while you are comfortably floating in the water, get out and walk or squat on land to get your labor going again; re-enter the tub once labor gets going. Be sure to enter and exit the water between contractions and with assistance, so you don't slip. When you feel the urge to push, it's time to get dry. (Babies have been born into the water when there was suddenly no time to exit or because a mother was so comfortable she could not bring herself to leave the water. Babies do just fine, as long as they are lifted up out of the water and placed in mother's arms without delay. Baby simply goes from water to water and doesn't take a breath until his face meets the air. )
Unless your birth attendant advises you otherwise, it's safe to use water labor even after your membranes have ruptured. That's when contractions usually get more intense and you really need the relief of water. Maternity centers with much experience in water labor (and water birth) report no increased rate of infection in women using water after their membranes have ruptured, as long as the mothers are in active labor and proper infection control hygiene is followed.
It is rarely necessary to leave the water for routine tests. If you need an I. V. , a heparin-lock can be used in the veins of your hand, covered with a waterproof plastic bag, and sealed with a rubber band. If intermittent fetal monitoring is necessary, let it be done on a part of your abdomen that you can lift above the water; place a plastic bag over the handheld monitor if you aren't using monitors designed for underwater use.
If your hospital or birth center does not offer a labor tub or you're unable to rent one, at least try sitting in a regular tub or taking a shower. A jet of warm water is often especially effective in easing back labor. Don't expect all the pain of labor to float away into the water. Yet our personal experience and that of other women who have used labor pools suggest that water is one of the most wonderful laborsaving devices available.
A soothing massage, a caring caress, a passionate kiss, even a simple foot rub can be blissful relief to a laboring mother. By stroking the receptor-rich skin and kneading the pressure receptors beneath the skin, you bombard the brain with pleasant stimuli, leaving less room for painful ones.
You won't really know where or how to ask your partner to rub or press till labor day is underway. Yet in the final months some practice rub downs to relieve backache or to help you relax during Braxton-Hicks contractions, and will help prepare you both for labor, when the right touch really counts. Tell your partner that a lot of prenatal practice will condition his hand muscles so they won't tire so easily on the big day.
Using pure plant oil or massage lotion, try different strokes in different areas of the body: firm caressing with the fingertips is preferred on the face and scalp; deep pressure and kneading is welcome for large muscles, such as the shoulders, thighs, buttocks, calves, and feet. Try counterpressure with the heel of your hand for easing the pain in lower back muscles.
The last couple months are not only an opportunity to work out massage strokes that you like, it's also a chance to weed out those you don't. For example, stroking down in the direction of body hair growth is pleasant, whereas light stroking upward, against the hair shaft, may irritate a laboring woman. Help your partner learn the intensity and rhythm of the pressure you enjoy. When you massage him, show him what you like so he'll learn by being on the receiving end.
1. Breathe naturally between contractions, as you do when you are falling asleep.
2. When a contraction begins, inhale deeply and slowly through your nose, and then slowly exhale through your mouth in a long, steady stream. As you breathe out, let your facial muscles relax and your limbs go limp as you imagine the tension leaving your body. Think of this exhalation as a long sigh of release.
3. As the contraction peaks, remind yourself to continue breathing at a relaxed, comfortable rate.
4. Ask your partner to remind you to slow down if you start breathing too fast in response to an intense contraction. Have him take slow, relaxed breaths along with you.
5. If you still find yourself breathing too fast, stop for a minute and take a deep breath, followed by a long, drawn-out blow, as if you are blowing off steam. Do this periodically to remind yourself to slow down.
6. Partners should watch the mother's breathing patterns for cues as to how she is coping. Slow, deep, rhythmic breathing shows that she is handling her contractions well. Fast, spasmodic breathing communicates tension and anxiety. Use massage, model proper breathing, or suggest a change of position.
7. Don't pant. Panting is not natural for humans. (Dogs and cats in labor pant because they don't sweat. It's their way of releasing body heat. ) Panting not only exhausts you, it lessens your oxygen intake and may lead to hyperventilation.
8. Don't hyperventilate. Breathing too fast and too heavily blows off too much carbon dioxide, causing you to feel light-headed and have tingling sensations in your fingers, toes, and face. Some women tend to hyperventilate during the height of intense contractions and need caring reminders to relax their breathing. If you start to hyperventilate, breathe in through your nose and out through your mouth, as slowly as you can.
9. Don't hold your breath. Even during the strain of pushing, the blue in the face, blood-vessel-popping breath holding you see in movies is not only exhausting, but deprives you and your baby of much-needed oxygen.
1. Bring music to birth by. Studies show that mothers using music during labor required fewer pain-relieving drugs than mothers who did not listen to music, because music stimulates a mother's body to release endorphins, the natural pain-relieving and relaxing hormones. Play a medley of already-tested favorites, taking care to choose songs whose rhythms relax rather than rev up your system. Along with your favorite tapes or CD's, bring along a player and fresh batteries.
2. Sit on a birth ball. This is a 28-inch physiotherapy ball, which naturally relaxes the pelvic muscles when you sit on it.
3. Try a beanbag chair. When you shop, try out various beanbag chairs until you find a squishy nest that you can imagine yourself sinking into during early labor. (Never put a baby in a beanbag chair. )
4. Bring along pillows and foam wedges. You will need at least four pillows at the hospital. Thick, tapered foam wedges, available as leftovers at upholstery shops, make relaxing back supports for sitting; a thinner one can be used as a cushion between the bed and your abdomen when side-lying.
5. Try hot and cold packs. Hot packs improve blood flow to tissues; cold packs lessen pain perception in these tissues. You will need both kinds. A hot water bottle or a rubber surgical glove filled with warm water is a fine hot-pack to nestle against your lower abdomen, groin, or thigh to relieve achy muscles, or just to relax you. Packs of frozen veggies, covered with a cloth, work well as cold packs to soothe a hot forehead or numb an aching back.
6. Consult the experts. Be sure to experiment with your bag of tricks at home to see what you think will work. Once you're in labor, try all sorts of combinations – cold pack, counter pressure, all-fours position; side-lying, hot pack, and massage; cold pack here, hot pack there, support with a wedge. You never know what will work until you try it.
Complete pain relief without risk is a promise no doctor can deliver. While today's analgesics and anesthetics are better and safer than ever, there is no such thing as a perfect pain reliever—one that works, yet is perfectly safe for mother and baby. By understanding what obstetrical drugs are available, what benefits and risks they carry, and how to use them wisely, you will best be able to decide which, if any of them, you want to use.
If only there were a perfect analgesic (meaning painkiller) that would act on only the pain pathways in mother and didn't cross over the placenta to baby. Unfortunately, there is no such panacea. When narcotics relieve mother's body of pain, they also affect baby. An additional concern about narcotics is their effect on the mind, impairing the ability to focus. When combined with natural pain relievers, however, properly used medical pain relievers can get a laboring woman back on track by providing temporary relief, which allows her to rest and recharge. Here is what every mother-to-be should know about choosing and using narcotic pain relievers.
How narcotics work. Narcotic analgesics (such as Demerol, morphine, Nubain, Stadol, and Fentanyl) relieve pain by blocking the pain receptors in the brain. Analgesics affect different persons differently. Not only does the degree of pain relief narcotics provide vary from woman to woman, so do the mental and emotional side effects. Some mothers feel a lot of relief within 20 minutes of the shot, some report only slight relief. Others report little pain relief, claiming the foggy mind was worse than a hurting body. Some women enjoy the euphoria narcotics can cause; a floaty feeling that helps them take their mind off their labor. Other mothers find narcotics compromise their ability to make decisions that benefit their labor progress. If a mother's mind is too muddled to participate in managing her labor with movement and changes of position, her labor may be prolonged, as will her pain. Narcotics can also make you feel very sleepy, so much so that you sleep between contractions and wake only as each one peaks, unable to focus and stay "on top" of the contractions.
How narcotics affect baby. When mother gets a drug, baby gets it, too. Let's follow a typical narcotic from the time it's injected into mother to delivery and postpartum, to see how it can affect baby. Within 30 seconds after a narcotic is injected into mother intravenously, it enters baby's circulatory system at around 70 percent of its concentration in mother's blood. Since babies can't talk and tell us how these drugs make them feel, we can only guess from studying external effects. Electronic fetal monitor tracings of babies whose mothers received narcotics during labor show heart rate patterns that differ from normal. Babies' brain wave tracings (electroencephalograms – EEG) change, as do their respiratory movements. Depending on the type, dose, and timing of the drug, babies born under the influence of narcotics sometimes show respiratory depression and require temporary assistance to stimulate their breathing. They may also be a bit groggy as they first enter the world. Bonding may be affected; a drugged mother and a drugged baby don't make a good first impression on each other. These newborns are also slower at learning how to breastfeed. Narcotics given during labor have been detected in babies' bloodstreams up to eight weeks after birth.
How to use narcotics wisely during your labor. You may enter the delivery room studied up on drugs, have mustered up all the alternatives to using them, and still conclude, with your birth attendants, that it would be in the best interest of you and your baby and the progress of your labor to get some medical pain relief. Here are the safest and most effective ways to use analgesics during your labor:
- Select the right drug. With the assistance of your mate and your labor support person, discuss with your doctor or anesthesiologist which drug is best for your particular labor situation. Which one is likely to give you the quickest, most effective pain relief with minimal effects on your baby? In our experience, Nubain is the most effective in taking the edge off the pain, and has the fewest number of side effects.
- Select the right time. Analgesics given too early can slow the progress of labor. In the early stages of labor, narcotics are known to decrease the strength of contractions and slow dilatation of the cervix. If given too late, they can depress baby's breathing. The best time to administer narcotics is when your labor is very active (6-8 centimeters), just before you enter transition, or if your contractions become so overwhelming that you are losing control. Because the effect of narcotics on a newborn's nervous and respiratory system peaks around two hours after they are given, doctors prefer not to give these drugs within two hours of when they expect you to deliver. They want to give the drug time to wear off, at least to the point that it does not compromise baby's ability to breathe after birth. Thus, physicians do not feel it is safe to give narcotics to the mother once the pushing stage has begun. Fortunately, once you have the urge to push, your need for medical pain relief will be greatly diminished. Don't worry, however, if a situation arises in which you must have a narcotic pain reliever during the pushing stage; baby can be given an injection of a narcotic blocker (Narcan) immediately after birth, which at least reverses the effect of the drug on baby's ability to breathe.
- Select the right route. Getting the drug intravenously gives you relief more quickly than an intramuscular injection. Intravenous drugs also wear off faster. After an intravenous injection a mother usually feels some relief within 5-10 minutes; this relief may last around an hour. Intramuscular injections, on the other hand, typically take half an hour to an hour to reach full effect, but the relief may last 3-4 hours. In either case, some mothers notice that the second dose is not as effective as the first. Most women choose the intravenous route; if labor pain is overwhelming enough to require medical relief, you want it to happen fast, and you probably also need intravenous fluids. Request a Heparin-lock, which allows you to move from your bed and to adjust positions more easily, rather than being tethered to a bedside intravenous bottle.
Many women want to hug their doctors for giving them epidurals during labor. The epidural has made most other methods of pain relief obsolete – and has even done away with the belief that you must experience pain to birth a baby. Yet before you grab for this magic medicine, inform yourself about its benefits and risks.
Before you receive an epidural, you will get a liter of intravenous fluids to build up your blood volume and prevent the decrease in blood pressure that sometimes accompanies an epidural.
Your doctor or anesthesiologist will then ask you to sit or lie on your side and curl into the knee-chest position to round your lower back. This widens the space between the vertebrae, making it easier to find the right area for injection. As your doctor or nurse scrubs your lower back with an antiseptic solution, it will feel cold. Next, you will feel a slight stinging sensation as the doctor injects some local anesthetic under your skin to numb the area. When the area is sufficiently numb, he or she will insert a larger needle into the epidural space and inject a test dose to determine if the needle is in the right place and ensure that you are not allergic to the medication. Once the needle is properly inserted, the doctor threads a plastic catheter through the needle into the epidural space and removes the needle, leaving the flexible catheter in place. The pain reliever you and your doctor have decided on is then fed into the catheter. A few minutes later you may feel a shooting sensation, like an electric shock, down one leg. Within five minutes you are likely to begin to feel numb from your navel down, or you may notice that your legs are feeling warm and/or tingly. Within 10-20 minutes the lower half of your body will feel partially or completely numb, depending on the type of medicine used, and the pain of contractions will subside. The exact level of loss of sensation cannot be predicted precisely. Most mothers experience numbness from the navel down, some experience loss of sensation as high as the nipples. A few mothers notice some patchy areas on their skin where they can still feel sensations.
This is the point where most women sing the praises of the epidural, yet this is also the instant at which a woman becomes more of a patient than a participant. Yes, once the pain is relieved you can rest and recoup your energy. But because the lower half of your body can't move, you will need assistance changing positions. Since the sensation to empty your bladder is impaired, a nurse will insert a urinary catheter to take away urine. Because of the possibility of the epidural lowering your blood pressure, the nurse will monitor your blood pressure every two to five minute until it is stable, and then every fifteen minutes. To keep the pain relief even on both sides of your body, the nurse will turn you from side to side. To be sure baby is handling the epidural well, you will be hooked up to an electronic fetal monitor. You will also notice that the doctor or nurse periodically rubs the skin of your abdomen, checking to be sure the drug is giving you sufficient pain relief, but not ascending high enough to interfere with your breathing. Now comes the juggling act of getting you just enough anesthetic to give you pain relief and help you manage your labor, but not so much that it interferes with your labor.
1. A continuous epidural means that a bedside pump continuously infuses your dura with pain-relieving medication. The continuous epidural is the most common type of epidural used because it offers constant pain relief. Unlike an intermittent epidural (see next option), blood pressure is more stable, and a lower dose of medication is needed overall.
2. With an intermittent epidural the medicine is injected periodically as needed, allowing mothers to juggle the level of pain they can tolerate with the degree of movement they desire. Some mothers do not like the roller coaster effect of intermittent injections.
3. Mix and match. The anesthesiologist can mix medicines (anesthetics and analgesics) to match the degree of sensation and movement you want, but there is no guarantee you will get the exact pain relief or movement you desire. Women react differently to pain-relieving medications.
4. Patient-controlled epidural anesthesia (PCEA) allows the mother to self-regulate the amount of relief she receives by pressing a button that allows a preset computer-controlled amount of medication to be injected into the epidural tubing. With PCEA some mothers actually use less medicine, some more, but at least you have a choice.
5. New epidurals. Both mothers and doctors have long dreamed of an epidural that would allow women to enjoy sensation and movement during labor, but without the pain. Dubbed "walking epidurals," these types of analgesia would allow the mother to stand, kneel, squat, and maybe even walk with support.
6. Spinal analgesia or a "walking spinal. " The newest pain reliever in the anesthesiologist's bag of tricks is technically not an epidural, but is known as spinal analgesia or a "walking spinal. " A small amount of narcotic is injected directly into the spinal fluid (not the surrounding dura) in a small enough dose to ease the pain of labor but still allow movement. Mothers can walk with assistance, shower, sit, stand, or squat.
7. Low-dose epidurals. Dubbed "epi-lite," these low-dose narcotic-only or combination narcotic-anesthetic epidurals are designed to relieve some of the pain of labor so an exhausted mother can at least relax enough to get a second wind for pushing. We call epi-lite the "best of both worlds" pain reliever because it relieves much of the pain yet allows you to have some sensation of what's going on in your body and some movement during childbirth.
1. Failure to progress accounts for around 30 percent of cesarean deliveries. It means that labor doesn't progress according to the usual timetable. For various reasons the cervix does not open enough and/or the baby does not descend. Some cases of failure to progress cannot be avoided, such as a very short cord. Most cases, though, are due to inadequate support for the laboring woman and violation of the basic physiology of labor. Of all the reasons for a cesarean, "failure to progress" is the most under your control. No other system in your body "fails" 25 percent of the time. Why should your "delivery" system? Emotional and physical support for the mother, walking during labor, upright pushing, along with the prudent use of medication and technology will help labor progress by increasing the efficiency of uterine contractions rather than interfering with them.
2. Repeat cesarean, meaning you had one previously, is the most common reason for a surgical birth, and this is under your influence as well.
3. Fetal distress is the third most common situation leading to a cesarean delivery. Fetal heart patterns on the electronic fetal monitor may suggest that baby's well-being is in jeopardy unless he or she is delivered quickly. A fetal heart rate that is higher or lower than average is a sign that baby may not be getting enough oxygen or is not recovering well from the decreased heart rate that is normal during contractions. While some of the reasons babies receive insufficient oxygen are beyond your influence, choices you make in labor help determine your baby's well-being.
4. Cephalopelvic disproportion (CPD) is another reason for surgical births. Baby is too big to pass through the pelvic outlet. Laboring and delivering in a more upright position, namely squatting, can enlarge the pelvic outlet, often allowing even a small mommy to deliver a big baby (See related section
1. Inform yourself. There are support groups for mothers who need help grieving about their previous cesarean and are adamant about doing everything within their power to avoid another one. Attend these meetings, and talk to other mothers who have delivered vaginally after a previous cesarean. Besides providing you with practical suggestions during your pregnancy and labor that will increase your chances of delivering vaginally, the information you obtain from this group can empower you to have an easier and more efficient labor.
2. Eat right. Overeating may cause you to gain too much weight and your blood sugar to be too high. Both of these factors increase your chances of having a baby too large to be delivered vaginally.
3. Exercise regularly. In-shape women have faster labors and lower weight gains than couch potatoes.
4. Employ a professional labor assistant. Studies show that mothers who use a professional labor assistant (PLA) are much less likely to have a surgical birth.
5. Be upright. Back lying is the position for surgical birth; the more time you spend on your back, the more likely you are to have one.
6. Get moving. Avoid spending most of your time lying in bed wired to monitors – like a surgical patient. When you get moving, your labor will, too.
7. Trust your body. Believe that your delivery system will work. Believe that your pelvic passages are designed to birth your baby. A fear that you can't go through with the delivery can be a self-fulfilling prophecy, since fear frightens the uterus into not working efficiently. Surround yourself with positive advisors. Even if your family tree or circle of friends is full of cesarean deliveries, know that you can beat these statistics.
Studies show that breech babies have a lower risk of birth injury and newborn complications if delivered surgically rather than vaginally. The main concern in the vaginal delivery of a breech newborn is that, with the feet or buttocks presenting first, the head will not have enough time to mold itself to the pelvic canal and may get stuck once the rest of the body is out. Also, a breech delivery can cause damage to the major nerves leading to the arms and hands. Both of these complications are less likely when baby presents buttocks first rather than feet first (frank breech). Prolapse of the umbilical cord (the cord slips through the cervix before baby's body and gets pinched), an emergency requiring an immediate cesarean delivery, is more common in all breech deliveries.
Baby's being in the breech position does not mean you absolutely must have a cesarean birth. The American College of Obstetricians and Gynecologists officially sanctions vaginal births for breech babies as safe in selective situations. Your doctor will weigh the risks of the surgical versus the vaginal birth and recommend the course of action that is best in your situation. Here are some of the alternatives to explore with your doctor that may make it possible to deliver your breech baby vaginally:
- Consider the possibility that your baby might turn. Around half of all babies start out bottom down early in pregnancy. Most turn head-down by 32-34 weeks. For some unknown reason, three to four percent of babies never turn head- down.
- If your baby hasn't turned on her own by 36-37 weeks, your doctor (or a specialist you are referred to) can attempt a maneuver called external version, in which he or she manipulates your abdomen to turn baby into the head-down position. External version is successful 60 to 70 percent of the time (40-50 percent for first pregnancies), but some babies turn back and require a second attempt.
- Search out a doctor who has experience in vaginal delivery of breech babies. He or she will most likely be affiliated with a hospital that has the technology and support staff to properly care for the baby should a complication occur. Obstetricians and hospital centers with a lot of experience in vaginal breech deliveries usually follow the American College of Obstetricians and Gynecologists Guidelines for breech delivery.
A newborn baby can contract herpes during passage through an infected birth canal, so it is considered prudent obstetrical medicine to deliver all babies whose mothers have active herpes at the time of delivery via cesarean section. Herpes infections are life threatening in newborns. If you have herpes, your doctor may do monthly or weekly vaginal cultures throughout your pregnancy to monitor your body's response to the stress of pregnancy (stress can cause genital herpes to flare up). Women with prior herpes outbreaks actually pass some immunity to their newborns. Women who acquire herpes for the first time during their pregnancy and have active sores at the time of delivery pose the greatest risk of infecting their babies. When you begin labor, your doctor may judge that it is safe for you to deliver vaginally if he or she sees no new herpes sores. If, however, your vaginal cultures continue to show herpes throughout your pregnancy, or you have herpes sores when you begin labor, you will need a surgical delivery.
1. Ask your doctor for a spinal or epidural anesthetic so you can be awake for the birth.
2. Have your partner sit next to you at the head of the operating table. If he's hesitant, remind him that the actual procedure takes place behind a sterile curtain. He won't see anything upsetting.
3. Ask your obstetrician to lift baby high enough so you can see him or her right after delivery. It is a beautiful sight to see your newborn lifted "up and out" during a cesarean birth.
4. Immediately after your baby is delivered and quickly checked over (temperature, breathing and pulse, and heart rates are stable) ask that baby be brought to you to be held and hugged. You may need some help since you may be a bit groggy and one arm may be immobilized for an intravenous. This mother- father-baby bonding time, though brief, is an ideal time for pictures, and the anesthesiologist or attending pediatrician will often act as photographer for you.
5. While your uterus and abdomen are being stitched closed (this takes about 30 minutes) and the operation completed, your husband should accompany baby to the nursery so he or she will not be alone with strangers. This extra father- baby bonding time will have a deep impact on both of them.
6. To decrease postoperative pain, ask your anesthesiologist about using a long-acting analgesic called Duramorph , given in the anesthetic tubing. This do-it-yourself analgesia, called "patient-controlled analgesia" (PCA), is set up so you can administer your own medication through your intravenous. Just turn the pump on and off, as you need relief. This medication is safe for your breastfeeding baby.
7. In most cases baby can be brought to your bedside within an hour or two of surgery. If your husband or a nurse is present in the room and baby is healthy, it's even possible for a cesarean-birthed baby to room in with mother. The best postoperative "pain reliever" is an "injection" of baby in your arms.
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