1. Introductions Name Due Date Physician What hospital are you delivering at? Why did you choose to take this class? What are you hoping to get out of this class?

2. Why Childbirth Education Is Helpful Incorporates education, breathing, and relaxation. Studies show that education reduces fear. Studies show relaxation and breathing techniques together, reduce pain perception. Gives individual knowledge, confidence, what to expect, options, tools, and roles. Presence of a labor partner can shorten length of labor. Have an idea of a ‘birth plan’; knowing you need to be flexible for the safest and healthiest delivery for mother and baby.

3. Common Terms & Definitions The baby is protected by a “cushion” of amniotic fluid held within a strong set of membranes (amniotic sac / bag of waters) and receives nutrients from the mother by way of the placenta and umbilical cord. The pelvis cradles the uterus. It loosens over time with the help of relaxin. The uterus is a large muscle that holds the baby in the amniotic sac. –The fundus is the upper part of the uterus. –The cervix is the neck of the uterus. It becomes elastic during labor. –Contractions (rhythmic tightening or the uterus) work to thin (efface) and open (dilate) the cervix. They push the baby down the birth canal.

4. Terms and Definitions Continued… Cardinal Movements- specific movement that the baby makes to birth; engagement of the baby’s head, descent of the baby through the birth canal flexion of the baby’s head under the pubic bone, internal rotation of the baby’s head facing mom’s tail bone, external rotation turning of the baby’s head to allow shoulders to pass one by one, and birth of baby.

5. Terms and Definitions Continued… Dilation- opening of the cervix. Dilation is measured in centimeters. When the cervix is completely dilated, it is 10 centimeters. Effacement- thinning of the cervix. Effacement is measured in percents. When the cervix is completely thinned out, it is 100% effaced. Descent- refers to the level of the presenting part of the baby in relation to the mother’s bony pelvis. Descent may also be referred to as “station”. Descent is measured -3 to +3.

6. Signs of Impending Labor Lightening- When baby drops lower into pelvis; you may notice your baby feels lower. Nesting- Energy spurt just before labor begins. Braxton-Hicks- “False Labor” or practice contractions; help to ripen cervix and prepare uterine muscles for labor. They usually feel like tightening in the abdomen. Passage of Mucous Plug- Forms in your cervix to provide a barrier against possible infections. Some women lose their plugs a few weeks to a few days before going into labor.

7. Signs of Impending Labor Continued… Pseudodiarrhea- As your prepare for labor, you may experience frequent soft bowel movements WITHOUT flu-like symptoms. Your body is preparing more room for the descent of the baby through the birth canal. Baby activity- Your baby should not stop moving. As your baby continues to grow he is running out of space. His movements will change from many flips to and movements to more direct movements, such as kicks or punches. Your baby should have at least 10-12 movements in a 24 hr period. If your baby is not as active as usual or the total number of movements is less than 10- 12 for the day, call your MD/CNMW.

8. How Do I Know If I Am In Labor? True Vs. False Labor If you are NOT in the last 4 weeks of your pregnancy and you think you may be in labor, CALL YOU DOCTOR OR MIDWIFE. Start to time your contractions. While you’re timing your contractions, ask yourself the following questions. –Do I think my bag of water is leaking –Are my contractions occurring regularly? (i.e. every 3-5 min.) –Are my contractions getting closer together? –Are my contractions lasting longer than they did an hour ago? (i.e. onset 30 seconds, now 45 seconds) –Are my contractions getting stronger? –Do my contractions feel stronger when I’m walking? –Do my contractions continue when I lie down and increase fluids?

9. Did My Water Break ??? Slow Trickle – High Leak –Use a Kegel Exercise to determine if it is a flow of urine, when in question call your MD/CNM Big Gush – Low Break –Usually no question –Call your MD/CNM immediately Important to Remember Your C – Color O - Odor A - Amount T - Time

10. How Do I Time A Contraction ???

11. Signs & Symptoms of Preterm Labor = contractions before 37 weeks Contractions 6-10 in one hour; with or without pain. A low dull backache. It may come and go or feel like it wraps around your body. This ache is different than the ones you’ve felt as you baby has grown and you posture has changed. Pelvic pressure. A feeling of heaviness or pressure in the pelvis, lower stomach, back or thighs. Change or increase of vaginal discharge. All women have some discharge, but a change to bloody or watery is to be of concern.

12. Warning Signs Bright red vaginal bleeding. Pain with urination. Persistent vomiting, chills, and/or fever. Swelling of face and hands that does not go away. Sudden weight change of 3-5 pounds in one week. Blurring of vision or seeing spots. Headaches that are constant/severe. Severe abdominal pain. Gush or leaking of fluid from vagina. Lack of baby movement. Preterm labor.

13. True Labor –Will get closer, longer and stronger –Will efface and dilate the cervix –Come at regular intervals –Start in the small of the back and radiate toward the front of the pelvis –Increase in intensity –Activity such as walking, rocking, charge of position usually increase contractions –Bloody show is often present with contractions; not bright red –Small leak or gush of fluid from vagina = membranes ruptured Call MD/CNM when contractions every 4-6 minutes apart for an hour or when bag of water breaks, call immediately

14. False Labor –False Labor (Braxton-Hicks Contractions) do not efface or dilate the cervix, but may soften the cervix –Irregular contractions –Contractions vary in length and intensity –Usually center on the abdomen –No bloody show –No cervical change –Walking, rocking, change of position will have no effect or stop it all together

15. Helpful Hints in Determining Labor –Change your position; if you’ve been sitting for a long period of time, get up, empty your bladder, get something to drink, and move around for awhile without becoming fatigued –If you’ve been standing or moving for awhile, empty your bladder, get something to drink and try to lay down, put your feet up

16. Different Relaxation Methods (1) Benefits Conserves energy Reduces fatigue Promotes efficient use of oxygen Reduces levels of stress hormones Assists the natural progress of labor Decreases perception of pain by avoiding tension, fatigue, and oxygen deprivation to the uterine muscles

17. Different Relaxation Methods continued … * (2) Relaxation Methods What relaxes you may not relax someone else Tap into their own creativity What keeps you relaxed? –Ideas: music, water, movement, light, touch, scents

18. Different Relaxation Methods continued … Practicing Relaxation Techniques before Labor Tension Hold and Release. Beginning at your toes, and moving up to your head, flex each of your muscles in turn, making it as tight as possible, then relax it completely. This allows you to feel and recognize tension, and feel the relief of releasing tension. Begin with inhaling a deep breath, then hold breath while tightening muscle, then relax while breathing out, letting out the tension with the air. Progressive Relaxation. Focus attention on your toes and feet. Just let go. Think how warm and relaxed they are. Focus on ankles and calves, think how loose and comfortable they are, and so on, up to your head, relaxing and releasing tension. Practice deep, abdominal breathing while you do this.

19. Different Relaxation Methods continued … Roving Body Check. Breathe in, choosing a muscle to focus on. Breathe out, releasing all the tension in the muscle with the exhale. Breathe in, moving your attention to another muscle. Exhale and relax. (Can be done with your partner calling out which muscle to focus on during the next breath.) Good quick relaxation method to use between contractions. Two-Breath Relaxation. Take in two deep breaths. On the first breath, center your thoughts on relaxing and release any tension in your body. On the second breath, as you exhale, close your eyes, bow your head, and relax deeper and deeper while your partner counts backwards from five to one.

20. Different Relaxation Methods continued … Touch Relaxation. During labor, it’s wonderful if the partner can see where the mom is holding tension (e.g. jaw, hands, or shoulders) and touch her there to encourage her to relax: he might just rest his hand there, or stroke lightly, or do a firm massage. This is most effective if you’ve practiced in advance. Practice tensing muscles, then having him touch the muscle. You release the tension, imagine that it’s flowing out of your body through his hand. When you begin practicing, tell him which muscle you are tensing. When you have practiced more, try playing a game, where he has to guess which muscle you are tensing. Verbal Reminders. Partners can also verbally remind the mother to relax specific body parts. Many women hold tension in their jaws during labor; when the jaw is clenched, it’s difficult to relax the perineum. So, partner can suggest: “Soften your lips, even smile a little, let your jaws relax.” Some women also squeeze their eyes tightly closed on contractions, and will benefit from quiet reminders to “open your eyes, look at me.” Sources: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler, 2001. “Creating Successful Visualizations and Relaxations” by Sylvia Klein Olkin, Childbirth Instructor. “Relaxation: Back to Basics” by Elva Lena Lauer, IJCE 7:3.

21. Exercises to Help You Prepare for Childbirth

22. (1) Tailor sitting What is tailor sitting? This is an exercise that strengthens and stretches muscles in your back, thighs, and pelvis, and improves your posture. It also keeps your pelvic joints flexible, improves blood flow to your lower body, and eases delivery. How do I do tailor sitting? Sit on the floor with your back straight in the "butterfly position" (the bottoms of your feet together and your knees dropped comfortably). As you press both knees gently toward the floor using your elbows, you should feel a stretch in your inner thighs. Don't bounce your knees up and down rapidly. If you find it difficult at first to keep your back straight, use a wall to support your back. Hold the position for 10 or 15 seconds and repeat the stretch 5 or 10 times. Source: The Mayo Clinic

23. (2) Kegel Exercises What are Kegel exercises? –The pelvic floor muscles help support the pelvic organs: the uterus, bladder, and bowels. If you tone them you'll ease many discomforts of late pregnancy such as hemorrhoids and leakage of urine. How do I do Kegel exercises? –Try to stop the flow of urine when you are sitting on the toilet without tightening your abdominal, buttock, or thigh muscles. When you're able to successfully start and stop urinating, or you feel the vaginal muscle contract, you are using your pelvic floor muscle, the muscle you should be contracting during Kegel exercises. You can do Kegel exercises two ways: either by holding or quickly contracting the pelvic floor muscle. To do slow Kegels, contract the pelvic floor muscle and hold for 3 to 10 seconds. Then relax and repeat up to 10 times. To do fast Kegels, quickly contract and relax your pelvic floor muscle 25 to 50 times. Relax for 5 seconds and repeat the set up to 4 times Source: The Mayo Clinic

24. (3) Squatting What is squatting? –Squatting is helpful during labor because it opens the pelvic outlet an extra quarter to half inch, allowing more room for the baby to descend. But squatting is tiring, so you should practice it frequently during pregnancy to strengthen the muscles needed. How do I do squatting? –An exercise called a wall slide is especially helpful. Stand with your back straight against a wall, place your feet shoulder width apart and about six inches from the wall, and keep your arms relaxed at your sides. Slowly and gently slide down the wall to a squatting position (keeping your back straight) until your thighs are parallel to the floor. Hold the position for 5 to 10 seconds, slowly slide back to a standing position. Repeat 5 or 10 times. Source: The Mayo Clinic

25. (4) Pelvic Tilt What is a pelvic tilt? –Pelvic tilts strengthen abdominal muscles, help relieve backache during pregnancy and labor, and ease delivery. This exercise can also improve the flexibility of your back, and ward off back pain. How do I do a pelvic tilt? –You can do pelvic tilts in various positions, but down on your hands and knees is the easiest way to learn it. Get comfortably on your hands and knees, keeping your head in line with your back. Pull in your stomach and arch your back upward. Hold this position for several seconds. Then relax your stomach and back, keeping your back flat and not allowing your stomach to sag. Repeat this exercise 3 to 5 times. Gradually work your way up to 10 repetitions. Source: The Mayo Clinic

26. Labor Phases Early Labor Contractions 5-20 minutes apart. Contractions last 30-45 seconds. May start to dilate 0-3 centimeters. Usually longest part of labor. Usually feel happy/excited. Activity? Comfort Measures? Deep cleansing breaths.

27. Tips for Mom Try to sleep if at night Continue normal daytime activities Take a walk Take a shower, wash hair, shave legs Eat a light meal Relax with contractions Begin slow paced breathing if necessary Assume upright position as much as possible Alternate being up with short rest periods Empty bladder every hour Call physician or midwife Drink plenty of fluids

28. Tips for Labor Partner Time contractions Reassure her (of her readiness for labor) Remind her to relax, use touch relaxation Give encouragement, praise her Help her with her breathing, if necessary Offer fluids frequently Prepare for trip to hospital Encourage walking and position changes Remind her to urinate Use distractions - play cards, games, go to a movie

29. Labor Phases Active Labor-Mom’s endurance is put to the test Contractions 2-4 minutes apart. Contraction lasts 50-60 seconds. Dilating 3-7 centimeters. Rest period becomes shorter. Contractions may start to take your breath away. May be at the point where you start to use a breathing pattern. The more oxytocin that flows, the hotter mom will feel. Not feeling so happy anymore. Activity/Comfort measures? The more active mom can be in her position Promote labor w/movement, position change, fluid intake, empty bladder, relax as much as possible.

30. Tips for Mom Continue relaxation and breathing techniques Use focal point Do effleurage as desired Change position frequently Continue to urinate hourly Adjust pillows for comfort Go to the hospital or birth center Drink fluids frequently

31. Tips for Labor Partner If walking, support her body during contractions Protect your back while massaging by positioning yourself close and lean into her body as you massage Provide cool wash cloth for face Give ice chips or wet wash cloth to suck on Offer fluids frequently Remind her to change positions and urinate Keep her informed of her progress

32. Tips for Labor Partner cont. Cue relaxation Rest when she rests Encourage relaxation and assist with breathing If breathing seems ineffective, suggest changing pattern (make sure breathing is rhythmic) Watch for signs of transition Keep up your energy by snacking on food brought from home

33. Labor Phases “I want to go home. I’m not doing this anymore.” Transition-The Final “Sprint” Contractions 1-2 minutes apart. Rest periods are shorter. Contractions last longer 1 to 1 ½ minutes. Dilating 7-10 centimeters (Complete). Rest period usually shorter than length of contraction. Common to feel panicked, nauseous, body shakes, hot one minute and cold the next, physical exhaustion. Partner’s presence is VERY important. Activity/Comfort measures? Faster breathing. Mood changes, may want to give up. Mental fatigue-How much longer? Help me!

34. Tips for Mom Remember this phase is intense but SHORT Take one contraction at a time Change breathing technique as needed Eliminate cleansing breath if contraction peaks immediately Blow with premature urge to push Use slow-paced breathing between contractions

35. Tips for Labor Partner Do not leave her for any reason! Remind her it is transition-LABOR IS ALMOST OVER- baby is coming-she can do it Praise her lavishly for her efforts Do not be offended by remarks Screen out annoying disturbances Keep conversation to a minimum Communicate with medical staff, keep calm, do not argue

36. Tips for Labor Partner cont. Apply back pressure Call nurse if urge to push is felt Breathe with her-have her mimic you Help her catch contractions at start Help her relax between contractions Be Positive!

37. Labor Massage What is labor massage? Massage is a term given to a variety of physical relaxation techniques that use pressure and movement to help stretch and loosen muscles. Why labor massage works: During labor, tense muscles can cause excessively painful contractions. Massage techniques help to relax muscles, decreasing the sensation of pain. Massage also promotes an overall bodily relaxation, combating the effects of the FEAR- TENSION- PAIN cycle.

38. Labor Massage Continued… How do I use labor massage? 1.It is important to remember that a laboring woman does not want you to start touching her after the contraction has begun. Nor does she want you to rub her back for a few seconds, then rub her arm, then move back to her neck. Both of these mistakes will cause her to become distracted and she will feel more pain than is necessary. Choose a touch pattern and a part of the body and continue that touch through several contractions. 2.Let the woman find a position that is comfortable for HER, then contort yourself to reach which ever areas of her body are most tense. 3.If a part of her body is tickled by your touch, consider that to be an indication of tense muscles. Simply apply deep pressure until the muscle is relaxed, and then you will be able to use lighter touches.

39. Time for a Massage

40. Labor Massage Continued… Sample labor massage Touches: With her hand palm down, support it with one hand while using the other to apply pressure and knead down her index finger. When you reach the end of the finger, stroke from the tip of the finger to the base and then squeeze the whole finger. If she is in a position that gives you access to her face, place your thumbs on the bridge of her nose. Gently stroke under the eyes and up toward the temples. Repeat the motion moving higher each time. Place you hands on either side of the thigh. With your fingers pointing away from you, pull your hands up the sides of the leg. When you reach the top, glide your hands to the other side and pull them down to the knee again.

41. Massage Tools Ideas: Birth Ball Frozen Water Bottle Hot and Cold Packs Knobby Ball Music Rolling Pin Rice Sock Tennis Ball Weighted Ball

42. Breathing & Relaxation Methods Review of Different Breathing Techniques Abdominal Breathing –Rise and fall of abdomen with each breath is calming and promotes more oxygen consumption for mom & baby Patterned Breathing –Focuses away from body; relies on distraction to reduce perception of pain What relaxes one individual may not relax another… Tap into your own creativity; what keeps you relaxed i.e. music, water, movement, light, touch, etc.

43. Breathing & Relaxation* Learning and practicing many different techniques will help in labor and birth, recovering from birth, nursing you baby, as well as other stressful experiences in your daily life.

44. Draw from your own experience: What works for you? Make a mental list. Make a physical list. As you learn more about coping strategies add them to your list.

45. Coping With Labor How do you cope with pain? What do you do to stay relaxed? Contractions needed to birth your baby. Work with them, not against them. Relaxation Techniques will help you control the WAY you work with them, not CONTROL labor.

46. Back Labor One in four women will experience an intense backache during labor contractions. Caused by baby facing pubic bone. Can slow labor and pushing. “Back labor” is sometimes due to the position of the baby’s head (Occipital Posterior-OP or face-up ). Relaxation & Breathing are usually not enough to cope with this.

47. Positions and Movements to Rotate Baby: Side-lying Semi-prone Hands and knees Pelvic Rocking Standing/Walking Slow Dancing The Lunge

48. Helpful Positions for Back Labor Massage Counter Pressure Double Hip Squeeze Knee Press Cold or Hot Compresses Shower or Bath Rolling Pressure over Lower Back

49. Practice Comfort Techniques & Patterned Breathing *

50. Pushing Techniques- Spontaneous pushing vs. Directed Pushing? Spontaneous Pushing: Using natural urge to push, push down when the contraction is at its strongest point Directed Pushing: Counting with breath holding, someone telling mom when to push Some HCP’s will allow you to be on your hands and knees, squatting or side lying; most likely you will be in bed on your back with your legs elevated in stir-ups

51. Pushing Stage Characteristics Baby moves down the birth canal Contractions space out a bit, 2-4 minutes apart, lasting 60-90 seconds long May feel uncontrollable urge to bear down May have a lull between reaching 10 cm and having to urge to push Ideally pushing only with urge to push conserves energy by working in harmony with uterus, not wasting pushing efforts Increased bloody show from cervix when totally dilated Lasts minutes to hours Epidural may blunt urge to push Gradual appearance of presenting part of baby at vaginal opening

52. Pushing Mother’ Reaction –Hard physical work –Excited, happy, tired, cooperative, renewed energy and determination –Timid pushing at first –Great pressure and stretching as head comes down –As perineum becomes numb, may feel burning sensation –Great relief and joy at birth of baby

53. Pushing Labor Partner’s Reaction Relief in getting closer to meeting baby Becomes more of a “cheerleader” sometimes loud, sometimes giving quiet confidence and encouragement Physical support sometimes as much as emotional support

54. Pushing Techniques Contractions are usually spaced farther than Transition contractions As contraction begins, take a breath in and out twice as contraction climbs Third breath either hold for 5-6 seconds and bear down, chin tucked or allow air out through pursed lips.

55. YOU DID IT CONGRATULATIONS ! Baby Baby can be place onto mom’s chest if she so desires and baby is ok. Or, baby will be taken to the warmer where the nurse will check to see if baby is ok. The nurse will take the baby’s vital signs, weigh the baby, measure her length, administer eye ointment and take footprints. Mom After the baby is born the doctor will clamp the cord and ask if the support person wants to cut the cord. He will ask you to gently push in order to deliver the placenta. Your nurse will monitor your vital signs and push on you belly/uterus An ice pad will be applied to the perineum to help with pain and swelling

56. Great relief and joy at birth of baby!

57. Labor Video

58. B – R – A – N - D B-enefits R-isks A-lternatives N-othing/ is it necessary D-ecision

59. Choosing the Appropriate Comfort Measure/Procedure What is it? Why is it being suggested? How will it affect me? How will it affect the baby? How will it affect my care or my labor? What are the alternatives? What will happen if I do not have/do it? If I do have it how can I maximize the benefits and minimize the drawbacks of the procedure or treatment?

60. Pain Management Pain Medicine/Narcotics - Nubain & Stadol (cousins of Morphine) How does it work? It is given in the vein (IV) or in the muscle (IM). The medicine works to lesson the pain by blocking pain messages sent to the brain. When can I get it? During labor or as early as 3cm. What are the benefits? Takes the edge off of the pain and helps you to stay relaxed. May promote labor progress in ACTIVE labor. You are still able to be up and about your room and the halls. What are the side effects for mom? Nausea and vomiting, drowsiness, or dizziness. What are the side effects for baby? Baby may be sleepy or have difficulty crying or breathing at birth. Medication can depress baby’s drive to breathe.

61. Sterile Water Papules Sterile water papules are used for the relief of back labor. A midwife, a nurse, or a physician will inject a small amount of sterile water into four areas just under the skin of the lower back. This is thought to provide nerve stimulation that distracts you from pain. The injections sting a bit. They can provide relief for two to three hours and can be repeated

62. Epidurals How does it work? While sitting up or lying on your side and anesthesiologist gives medication (Liocaine, Bupivicaine or Maracaine/Sufenta) through a small tube that is placed in the first space surrounding the spine. This is the epidural space. Your abdomen and legs become numb.

63. Epidurals Continued… When can I get it? This is a decision made between you and your HCP; usually, not before 3cm or after 8cm What are the benefits? Most women will feel pressure instead of pain It usually does not make you feel drowsy Allows you to rest during labor and in some difficult labor it may transform a horrible experience into a positive one For those who like close monitoring; may feel a sense of comfort May have the ability to rest/sleep, talk on the phone, etc. In some cases may promote labor in labors that have gotten stuck

64. Epidurals Continued… What are the side effects for mom? Numbness or legs; may not get complete coverage Foley catheter in bladder Inability to walk Continuous fetal and blood pressure monitoring May slow labor down; may take longer to get effective pushing Increased chance of episiotomy, forceps or vacuum extraction Possible spinal headache (1:100) and short or long term backache may develop Cost factor (range $500-$3000) What are the side effects for baby? It can affect the oxygen supply to baby if mom’s blood pressure is lowered Increased risk of injury from vacuum or forceps delivery

65. Epidurals Continued… Medication does not get to the baby, may see subtle changes in reflexes, decreased attentiveness and muscle tone, increased fussiness, last for a few days Some research has noted ineffective latch at the breast and disorganized sucking patterns and rooting reflex for a few days after birth.

66. Reflecting on Your Decisions  Make informed decisions  Reflect on it after time passes, but remind yourself you did the best you could with the information and circumstances you had at the time  Pages to review in binder for pain medications and epidural information 55-60

67. Labor Positions Standing Standing and Leaning Forward Walking Sitting Upright Semi-Sitting Sitting, Leaning Forward with Support Hands and Knees Kneeling, Leaning Forward with Support Side-Lying Squatting Sitting on Birthing Ball Supported Squat

68. Labor Positions There’s no perfect position for labor-but frequent changes of position can help you relax & Stay in control of the pain. As you labor progresses try various positions until you find one that helps you feel comfortable Be Creative ! These ideas may help

69. Rocking During labor, rhythmic motions can be soothing. Gently rock while sitting on a birthing ball (a large rubber ball often used as a tool of natural childbirth), the edge of the bed or a sturdy chair.

70. Slow-Dancing Standing or walking can help labor gain momentum — especially in the early stages. Lean on your partner for support during contractions. Or wrap your arms around your partner's neck and start swaying — as though you were slow dancing. This is also a good position for a back rub.

71. Leaning Forward If you're having back pain, leaning forward may feel good. Straddle a chair or lean over a table or countertop. This is another good position for a back rub.

72. Lunging You can lean forward while standing up, too. Raise one foot on a sturdy chair. Gently lean toward the raised foot during the next contraction. If the chair is too high for comfort, use a footstool. You can lunge without accessories, too. Put one foot the length of a step ahead of the other, then bend the forward knee and lean toward it.

73. Sitting with One Foot Up An asymmetrical position can offer variety. Try propping up one foot while you're sitting in a sturdy chair. You may want to lean toward the raised foot during each contraction.

74. Kneeling Sometimes kneeling helps ease back pain. Use a birthing ball or pile of pillows. In the hospital, raise the head of the bed. Kneel on the lower part of the bed while resting your arms and upper body on top of the bed.

75. Squatting Squatting helps open your pelvis, giving your baby more room to rotate as he or she moves through the birth canal. Squatting also may allow you to bear down more effectively when it's time to push. Use a sturdy chair or squatting bar on the birthing bed for support.

76. Semi-sitting Prop yourself up with pillows — or ask your partner to sit behind you for support. During each contraction, lean forward or draw your knees toward your body.

77. Hands & Knees Don't be embarrassed to get on your hands and knees during labor. You'll take the pressure off your spine, which may ease back pain and help rotate the baby into a better position for delivery. A hands-and-knees position may boost your baby's oxygen supply as well. Try it in bed or on a floor mat. To give your arms a break, lower your shoulders to the bed or floor mat and place your head on a pillow.

78. Side Lying When you need to rest, you may want to lie on your side. Place pillows between your knees for comfort. This position maximizes blood flow to your uterus and baby. Lying on your side also helps support your baby's weight, which can ease back pain. Remember, there's no perfect position for labor. Discuss your preferences with your health care provider ahead of time — but be flexible. You may need to experiment during labor to find the most effective positions.

79. Remember to Praise ! P-ositions R-elaxation A-pply (pressure, hot/cold) I-ncrease (comfort measures) S-hower E-valuate

80. Let’s Talk

81. What would you consider Unexpected? What may be unexpected for one may not be for another ?

82. Induction of Labor –If concerning tests or >42 wks = Induction. –The primary reasons for inducing labor are pre-eclampsia, eclampsia, severe hypertension, severe diabetes, Rh sensitization, prolonged rupture of membranes, IUGR, and post-maturity (beyond 42 weeks). –May use prostagladin gel to soften /ripen a cervix that may be long, thick, and closed –May use pitocin a synthetic IV form of natural hormone oxytocin

83. Examining Baby’s Wellbeing Non- Stress Test Contraction Stress Test

84. Additional Monitors External Fetal Monitors & Internal Fetal Monitors

85. Assisted Deliveries – SMM rate 3-5 % of births Forceps Medically indicated when birth is delayed because the mother is unable to push effectively, there is a decrease in uterine contractions or the baby is too large. Vacuum Medically indicated when labor is prolonged because of fatigue or anesthesia has made the mother unable to push effectively, if birthing stage is prolonged because baby is too large and mother’s efforts need assistance, or last minute fetal distress. How do they work? One of the instruments is applied between contractions and when mom pushes the MD pulls. The instrument then comes off when the baby’s head is out. Side Effects? Possible injury to birth canal for mom and may leave marks on baby.

86. Pre-term labor: is the early onset of uterine contractions before 37 weeks. The symptoms of preterm labor can include: (1) Menstrual-like cramps, with or without diarrhea. (2) A feeling of pressure in your pelvis or lower abdomen. (3) A persistent, dull ache in your lower back, pelvic area, lower abdomen, or thighs. (4) Changes in your vaginal discharge, which may increase in amount or become pink or reddish. (5) Persistent, regular contractions of your uterus less than 15 minutes apart. These contractions may be painless, though they make your abdomen feel firm to the touch. (6) Not feeling well, including: Unexplained fever. Fatigue. Uterine tenderness.

87. Pre-term Labor continued … If you have symptoms of preterm labor, see your doctor or certified nurse-midwife for an exam ! 1)Findings from an exam can show whether your amniotic sac has ruptured, you have an infection, or your cervix is beginning to dilate. 2)You may also have urine and blood tests to check for conditions that can cause preterm labor. 3)Fetal heart monitoring and ultrasound can give a good picture of how your fetus is doing. 4)Amniotic fluid can be tested for signs that your fetus’ lungs are developed enough for delivery.

88. Pre-term Labor continued … What are the risks of preterm labor and preterm birth? The premature newborn is at risk of complications when many of the organs—especially the heart and lungs—are not ready to function on their own after birth. The less mature an infant is at birth, the greater the risk of serious medical complications. Premature infants born after 32 weeks of pregnancy are generally considered to be less at risk than those born earlier.

89. Pre-term Labor continued … How is preterm labor treated? 1)Try to delay the birth with tocolytic medication, which may or may not be effective. 2)Try to treat or prevent infection with antibiotics. If your amniotic sac has ruptured, you have a high risk of infection and must be closely monitored. 3)Give you corticosteroid medication to help prepare your fetus's lungs for birth. 4)Treat any other medical complications. 5)Allow the labor to progress.

90. Premature Babies continued… –Most infants born at 36 and 37 weeks' gestation are mature enough to be discharged from the hospital with mother. Many premature infants, however, are too immature to survive without medical care in the NICU. Symptoms of pre- maturity that require hospital care include: Underdeveloped lungs. Inability to breath continuously (apnea) Inability to maintain body heat. Inability to feed.

91. Unexpected Outcomes… –Baby born with physical anomalies. Minimal (web toes); May require special care or correction (club feet, heart defect, Down’s Syndrome); Some are incompatible with life (Genetic Disorders). –In the rare chance the baby is still-born or does not survive, you can not prepare for this now. Staff will be there to help you through your grieving process to teach, to cry, to laugh, to listen. –There are many support groups available.

92. Premature Babies cont…

93. Cesarean Sections A cesarean delivery C-section or is performed when a vaginal birth is not possible or is not safe for the mother or child. In this type of delivery the baby is born through an incision in the abdomen and uterus. It may be necessary to have a cesarean birth if: –Your baby is too large for you to deliver through your vagina –Your cervix has not opened completely –The baby is showing signs of not tolerating labor, which is determined by the baby's heart rate during labor

94. C - Sections continued …

95. What will happen before the C–Section ? What will happen before the C-Section? –An IV will be started if it hasn’t been already –You will be given some medication to decrease stomach acids –All jewelry, contacts, dentures, etc. will have to be removed –A consent form will have to be signed, verbal for emergencies –Types of anesthesia will be discussed by the anesthesiologist –Blood will be drawn for lab work –A urinary catheter will be placed –Your pubic area will be shaved

96. C-Sections continued… What will happen in the delivery room? –Mom goes to the delivery room while the support person changes into scrubs –After mom is on the operating table she will be hooked up to a cardiac monitor in order to monitor her heart rate and rhythm –Mom’s blood pressure will be monitored and a sensor will be on her finger to measure her oxygen level –Mom’s abdomen will be washed with an antiseptic solution and her legs will be covered with sterile towels –Mom may receive oxygen to ensure that she and the baby are getting enough –The support person can come into the room after anesthesia is given and before the incision is made

97. C-Sections continued… What will happen after the C-Section ? Mom’s nurse will monitor vital signs (BP, P, and T); abdominal incision, any vaginal discharge, urinary catheter, IV fluids and surgical pain Helpful hints for mom’s support person Help mom stay calm and relaxed Hold mom’s hand Talk to mom softly Comfort and reassure her Share in the excitement as the baby is born Explain to mom how the baby is doing if she can not see from the operating table

98. Recovery Surgery takes about 30-60 minutes Moved to Recovery Room for the next few hours Baby will be able to be in Recovery Room if stable Will move to Mother/Baby Unit as a family

99. Pain Management Analgesia- necessary to take medications PCA pump- patient controlled analgesia, small dose of narcotic released into IV drip- maintains consistent, safe blood levels of the drug Pills- when able to tolerate food and fluids and pain becomes more manageable

100. Other Comfort Measures Splinting Abdominal Gas Breastfeeding- side lying position can be helpful, keeping pressure off of incision

101. Next Baby VBAC- Vaginal Birth After Cesaerean Depending on reason for C/S, may be able to attempt a vaginal birth in the future with the appropriate support and medical facilities

102. Tips to promote labor progress & avoid a C/S : (1) Mobility- frequent positions changes during labor help promote progress and rotation of baby (2) Fluids- help maintain regular contractions, important to empty bladder once every hour (3) Hydrotherapy- early labor/active labor a shower can promote relaxation (4) Utilize network support- allow other to help you cope; you are not alone (5) Pain management decision- discuss pain medicines and the effect on labor progress for the positive or negative

103. Mock Labor

104. Welcome To Holland This will bear true for a healthy baby on some days just as much as a baby with special needs.

105. Welcome To Postpartum What have you heard about Post Partum?

106. Needs of Parents 1)The need to realize your actual baby is different than your fantasy baby. Real babies have their own personalities. They cry, demand to be fed in the middle of the night and dirty their diapers. 2)The need to learn infant care skills. As you learn and get used to taking care of your baby, you will become more relaxed and feel better as a parent

107. Needs of Parents 3)The need to understand your baby's way of communicating. Since newborns have not yet learned to talk, parents must learn, understand and get used to their baby's cry, body language or infant cues. Behaviors such as opening the eyes wide, turning the head or looking away are ways babies communicate before they can talk.

108. Needs of Parents 4)The need to maintain adult relationships. It is important for the mother and/or partner to spend some time alone away from the baby with each other or with other adults. This is the most difficult for the person who cares for the baby most of the time. 5)Spend some time with your partner as a couple, without the baby. Enjoy a dinner together or an evening out with friends. Take advantage of opportunities offered by friends to baby sit for a few hours.

109. New Mom Care While you're busy nurturing your baby, make sure somebody's helping you out –Light Housekeeping –Meal Preparation –Laundry & Linen Changes –Errands

110. Post-Baby Fashion Wear maternity clothes. Yes, the sad truth of the matter is that you will still be wearing your maternity clothes for at least a bit longer. Don't pack your skinny jeans, or your fat ones either, to wear home after your baby is born. If you don't want to wear home what you wore to the hospital consider packing something that fit you around month five or six of your pregnancy. Nursing bras are from heaven! A nursing bra can make life easier. You'll find it make discreet nursing much easier.

111. Tips for Coping with Fatigue 1.Remain in your bathrobe or lounge wear for the first week at home and rest whenever possible. New babies tend to be more awake at night than during the day for the first 3 weeks, so plan to rest when your baby sleeps. 2.Let others help with household responsibilities like laundry, cooking, shopping, cleaning, etc. When friends offer to help, let them!

112. Tips for Coping with Fatigue 3.If possible, arrange to have your partner take one to two weeks off after the baby arrives. 4.If you have an answering machine or voice mail, you may wish to leave a message stating that you are resting and will call when you have the time to talk.

113. Tips for Coping with Fatigue 6.Make life as simple as possible by using paper plates, take-out food and delivery services. Take it easy. 7.Review your diet to be sure you are eating enough protein and iron. For more information on iron, ask your health care provider.

114. Physical Changes Once a woman gives birth, there is a large change in the amount of certain hormones in her body. As a result, these can cause some of the following most common physical changes: –Retention of fluid/swelling –Initial hair loss (your hair will come in again later) –Hot flashes –Night sweats –Dry skin –Mood swings –Increased urination –Vaginal dryness Empty your bladder every four to six hours and start Kegel exercises as soon as possible.

115. Changes in Your Uterus The uterus begins to return to its pre- pregnant size immediately after delivery. The uterus will shrink to your navel and gradually descend back into your pelvis. Pitocin, a medication that causes the uterus to contract, is frequently given immediately after birth to ensure that the uterus remains firm and helps prevent excessive vaginal bleeding. After-birth pains can also be triggered by breastfeeding.

116. Bleeding Vaginal discharge after birth is a combination of the shedding uterine lining and blood. The discharge usually changes from bright red, to pink, to whitish over the course of several weeks. It is very common for the bleeding to stop and start intermittently as well as to contain clots. Decrease your activity if you notice an increase in the amount of bleeding, as this is a signal for you to slow down and rest more. Use sanitary pads instead of tampons until you have your first menstrual period after birth or until your health care provider advises otherwise.

117. Perineum Perineum cleanliness promotes healing and comfort. Special care in cleansing the perineum (bottom) should be taken as long as postpartum bleeding continues. Your perineum may be sore and slightly swollen after birth. If you have had an episiotomy, your stitches will be tender.

118. For Your Comfort: 1.Wash hands before and after changing pads, before using a peri- bottle, etc. 2.Always wipe from front to back after bowel movements and urination. 3.Wash your perineum daily with soap and water during your shower or bath. 4.Change peri-pads when necessary and also after using the restroom.

119. Hemorrhoids Many women develop hemorrhoids during pregnancy and after giving birth. Hemorrhoids are varicose veins of the rectum caused by the weight and pressure of the baby and the force of pushing. Hemorrhoid pain may be relieved with ice packs, ice cold pads containing Witch Hazel (such as Tucks). Avoid constipation by including fruits, vegetables, and whole grains in your diet, and by drinking lots of fluids.

120. Postpartum Complications Contact your HCP if you have any of the following: Excessive vaginal bleeding (heavier than a pad every hour) or passing blood clots larger than “plum-size”. Vaginal bleeding that has a foul odor. A fever greater than 100* F that lasts longer than a day. Unusual pain or an increase in pain. Burning with urination. Difficulty having a bowel movement. Try not to go longer than 3 days without having a bowel movement.

121. Postpartum Complications Continued… Contact your HCP for: Signs of breast infection –Red, warm painful area on your breast. –A lump on your breast. –Fever –Flu-like symptoms Severe headache Pain in the calf of your leg

122. If You Are Breastfeeding When your milk supply increases, approximately 48- 72 hours after delivery, your breasts may become firm and a little tender. Fullness in your breasts is a result of a naturally occurring increase in blood flow, which prepares your breasts for increased milk production. Frequent nursing will help keep your breasts soft and prevent engorgement.

123. Engorgement Occurs 48-72 hours after placenta comes away from the uterus Breasts will be more full, increased in size, firmer, tender, may feel warm to the touch Can be very uncomfortable; may last for 24-48 hours.

124. If You Are Breastfeeding continued… 1.Nurse the baby frequently (8-12 times/day) in the first 4-6 weeks 2.Prior to each feeding, do light breast massage to help with let down, apply warm i.e. compresses, heating pad on low, or take a warm shower 3.Breathing and relaxation techniques 4.Ibuprofen 5.If baby not a vigorous feeder, pump small amount off after feeding if still uncomfortable and store for later 6.Ice packs after feeding if still uncomfortable

125. If You Are Bottle-feeding If you are not breastfeeding, a snug-fitting bra or towels wrapped tightly around both breasts will help minimize breast engorgement. If your breasts become painful, avoid nipple stimulation and milk expression. Apply ice packs to decrease the swelling and consider taking a mild pain reliever. When showering, avoid warm water directly on your breasts as this may increase milk production.

126. Postpartum Fitness Kegel exercises are a great place to start. Short, slow walks will help your body get ready for more vigorous exercise. A full-fledged return to the aerobic activities you participated in pre-pregnancy usually comes around the time of your postpartum doctor's visit, or after about 6 weeks. So, go slow and don't push yourself!

127. Relationship Issues The First Months of Postpartum Immediate postpartum period a time of rapid physical change for mom A time of intense emotional feeling Communication, problem solving skills, breathing and relaxation techniques used in pregnancy, labor and birth may help you adjust during postpartum

128. Sexual Adjustment… Things to consider… Can be very different from before having a baby Mom may feel physically “touched out” Fear of pain & discomfort Hormone fluctuations Breastfeeding moms may experience different sensations in her breast and nipple due to nursing Presence of baby may add tension and inability to enjoy the moment Contraceptive options

129. Baby Blues –vs- Postpartum Depression

130. Baby Blues Experienced by most mothers in the first 1-5 days postpartum, and lasting 1-4 days. Noticed as extreme sensitivity and increased crying. Many of these mood swings have to do with tremendous hormone changes as well as fatigue/sleep deprivation. It is NORMAL to have feeing of frustration with managing a baby, home, career and relationships.

131. Postpartum Depression Symptoms of PPD include: 1)insomnia 2)weepiness or sadness that persists all day 3)diminished interest in almost all activities 4)difficulty concentrating 5)change in appetite 6)anxiety 7)moodiness and irritability 8)excessive guilt 9)panic attacks (symptoms include heart racing, dizziness, confusion, feelings of impending doom) 10) suicidal thoughts

132. Here are some other ways to cope with depression: * Get help. Part of being a good mother is knowing when to ask for help — so don't be afraid to ask for it during this difficult time. Help can come in many forms, from friends who cook meals and do the vacuuming to therapy. If you're concerned about the way you're feeling, talk to your doctor. And if you think you might hurt yourself or your baby, or if you feel incapable of responsibly caring for your newborn, seek professional help immediately. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

133. Ways to cope with depression: * Share your feelings with others. Find someone you trust and let that person know how you feel. Call a friend. Look for a new mothers group for support. Reach out to other moms — you may be surprised at how many women are experiencing similar feelings. It's also important to talk to your partner if you have one and make sure he knows how you're feeling and what you're worried about. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

134. Ways to cope with depression: * Take care of yourself. Sometimes taking care of your physical self can help you feel better. Have your partner watch the baby so you can take a relaxing shower before he leaves for work, and put on makeup if you usually wear it. Although your maternity clothes may still fit, pack them away. Go on a shopping trip just for yourself and buy something new for your postpartum wardrobe. Wear a favorite outfit on especially difficult days to give yourself a boost. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

135. Ways to cope with depression: * Sleep when the baby sleeps. It's age-old advice, but it works. The rigors of caring for a newborn, coupled with exhaustion and sleepless nights, will almost certainly bring on the blues. To fight fatigue and depression, you must get your rest. Have a relative or friend over during the day, even if only for an hour, and sleep. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

136. Ways to cope with depression: * Venture outdoors. Put your baby in a stroller and take a walk around the block, or meet a friend at a cafe nearby. The fresh air, sunshine, and company will do you and your baby a world of good. If even a brief excursion is too much for you right now, then just go outside, take a deep breath, and sit in the sunshine for a few minutes. It will help. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

137. Ways to cope with depression: * Simplify your life. Your baby's arrival is a good reason to take it easy. Resist the temptation to do the laundry while your baby sleeps, and let the chores wait. Have food delivered, or ask your partner to get takeout on the way home. If you find that the phone rings at inopportune moments (for example, when you're trying to get the baby to sleep, or when you're finally sitting down for a much- needed break), hook up the answering machine and return calls only when it's convenient. Ask a friend to help, and set aside time — even half an hour — for you and your partner to be alone without the baby. All contents copyright © BabyCenter LLC. 1997-2005 All rights reserved.copyright

138. Discussion 1.How do you think your relationship will change after baby? 2.How will you continue to keep your relationship thriving ? 3.What will you do/continue to do for yourself after the birth of the baby?

139. Tour of Babyland

140. What To Pack ??? Mom’s Stuff Nightgown/Jammies Nursing Bra & Underwear Robe & Slippers An outfit to wear home -(Remember: You won’t fit into regular clothes yet.) Comb/Brush Deodorant Shampoo/Conditioner Make-up Toothbrush & Toothpaste Comfort Items; your own pillow rice sock, massage oils, music, radio

141. What to Pack ??? Continued … Dad’s/Partner’s Stuff Snacks Reading material Camera & Extra Film “To Call” List Extra Clothes Baby’s Stuff Baby Book Clothes to go home in Car seat Tips: (1) Pack a bag for labor and one for post-partum/baby. You can leave the post-partum bag in the car. (2) Don’t bring the kitchen sink :)