Childbirth

Childbirth

Remember your first look at Mom?

Okay, so maybe that wasn''''t so memorable. You may have been somewhat confused, since everything outside the womb was kind of new at that point.

Well, then, how about this? Do you remember whether it was a windowed room with nice curtains or a sterile delivery room with a definite pallor to the decor? Do you remember whether Dad was there--bothered, bewildered and bemused, but present at the bedside? And, say, how about Mom''''s bed? Was it a comfy-looking Sealy Posturepedic or something more along the lines of a stirruped platform designed for your longitudinal plunge into the cold, cruel world?

Of course, there might not have been so many environmental options when you were born. But there are now. If you''''re an expectant mother--looking ahead to those none-too-glamorous hours leading up to childbirth--you''''re likely to hear quite a bit about your delivery options.

Choosing Your Team

What type of health care professional is right for you? To figure that out, you need to know whether yours is considered a high-risk pregnancy.

If you have no preexisting medical problem that is likely to be a problem for you or your baby, you could choose a nurse midwife, says Teresa Marsico, certified nurse midwife and associate professor at the University of Medicine and Dentistry of New Jersey­New Jersey Medical School in Newark.

But high risk is a different matter. If you have medical conditions such as diabetes or high blood pressure that complicate your pregnancy, you really need to have an obstetrician manage your care. And if your prenatal exams show that you''''re having twins, that''''s another reason to choose an obstetrician.

During your initial screening for pregnancy, either a medical doctor or a certified nurse midwife can tell you whether you''''re in the high-risk category, according to Charles S. Mahan, M.D., dean of the College of Public Health and professor of obstetrics and gynecology at the University of South Florida in Tampa. If you are, then you''''ll be referred to an obstetrician or perinatologist. If you don''''t fit into the high-risk category, you can choose an obstetrician, family doctor or midwife--depending on which one you feel comfortable with and which agrees with your philosophy and attitude about birth.

Better yet, you may be able to have both. Many doctors and nurse midwives work collaboratively. Most states require that each birthing center be affiliated with a hospital, with obstetricians who can take over the management of complicated pregnancies.

Doctors and midwives may also work together in hospital settings, says David Kliot, M.D., clinical associate professor of obstetrics and gynecology at State University of New York Health Science Center at Brooklyn. A woman who goes to a certified nurse midwife and an obstetrician can have the best of both worlds, agrees Marsico.

If you do have the birth-center option, it can be attractive. Birth centers are often located in renovated homes, where each birthing room has a bed surrounded by regular furniture. It''''s a very homelike atmosphere, sometimes with extra amenities like tubs and whirlpools for use during labor. Your husband and support persons, including children, are allowed to be in the birthing room with you. When you arrive at a birth center in labor, you''''re usually greeted by the nurse midwife who stays with you throughout the birth process.

The birthing rooms contain very simple equipment. "It''''s low-tech, high-touch," says Ruth Lubic, Ed.D., certified nurse midwife and general director of the Maternity Center Association in New York City. Midwives don''''t use electronic fetal monitoring to check the child''''s position. Instead, they use a stethoscope or a procedure called a noninvasive Doppler ultrasound to monitor the baby''''s progress. And the mother can use breathing, spend time in a warm tub or get massage for pain relief.

The birth center is arranged so that you can be transferred quickly to a hospital, if necessary. About 12 percent of women who try to give birth in a birth center get transferred to a hospital, says Marsico.

The Hospitable Hospital

Unlike birth centers, hospitals have on hand the equipment and personnel to handle complicated pregnancies or deliveries that go awry. And that''''s critical when speed is a factor.

"All of us who have practiced obstetrics have seen this happy, wonderful situation turn into a disaster in a matter of seconds," says Edward Linn, M.D., chairman of obstetrics and gynecology at Lutheran General Hospital in Chicago. "It could be your life or your child''''s life. I''''m not saying birthing centers are bad. I''''m saying most of us are uncomfortable with their ability to handle these emergency situations."

At a hospital you''''ll probably be greeted by a nurse or a medical resident whom you don''''t know, says Dr. Kliot. Your doctor may check in now and then, but chances are she will not be with you throughout all the stages of labor.

"When a woman calls and says she is starting labor, a midwife goes and stays with her for the entire labor," says Dr. Mahan. "As an obstetrician, I don''''t do that."

In the hospital electronic fetal monitoring is often used: Sensors are taped to your abdomen, and an electronic device measures your baby''''s heart rate and vital signs, tracking the readings on a monitor. Your labor can be monitored from the nurses station rather than from your bedside. Recent studies have shown, however, that electronic fetal monitoring is not really helpful in low-risk pregnancies, says Dr. Mahan. Some experts now believe that it is better to have a nurse stay at a woman''''s bedside to monitor her and the baby during labor.

The old standard--a big sterile operating room with lots of lights--is not the typical hospital experience anymore, says Lawrence Devoe, M.D., professor of obstetrics and gynecology and director of maternal fetal medicine at the Medical College of Georgia in Augusta. "Most hospitals use labor and delivery rooms that look like real rooms. They have attractive decor, tables and beds that look like real furniture."

A Room for You

If you do have a choice of birth settings, what are the factors to consider? Here''''s what experts say.

Go with what''''s comfortable. If you''''re considering a birth center, you should be really comfortable with the center''''s approach and philosophy, says Dr. Lubic. Emotions can affect the labor, she points out. If you''''d feel more secure with a medical team and equipment on hand, then you should probably choose a hospital instead.

Watch the feedback. Recognize that the input and feedback you get from family and friends can have an impact on you, says Marsico. If you are going to a birth center, and your husband says, "I don''''t know about this," that could build doubt.

Go for orientation. Birth centers typically require an orientation to let you evaluate the risks, says Dr. Lubic. If you go to the orientation and ask questions, you''''ll find out if it''''s right for you.

Check out the hospital. If you decide to have your baby in a hospital, ask questions about how the labor will be handled, says Dr. Kliot. The more information you get beforehand, the better.

Labor Negotiations

Chances are when your grandma had her babies, she didn''''t take a childbirth preparation class. These classes are a relatively new invention--for the couples who learn about labor and childbirth from books, doctors and TV shows rather than firsthand family experience.

When your mom was pregnant, she probably went off to the hospital and came back a few days later with a baby, notes Dr. Linn. As a result, this generation of women often knows little about the details.

Childbirth preparation classes have differing approaches and philosophies. But the same core material is covered in nearly all classes, according to Linda Herrick, R.N., co-director and founder of the Academy of Certified Birth Educators in Olathe, Kansas, an organization that trains and certifies professionals who teach the classes. In most classes you''''ll learn about the phases of labor, your options for pain relief and comfort, relaxation techniques you can use to make labor easier and what role your support person can play in your labor, she says.

But the classes often support a basic childbirth philosophy or approach. There are essentially four methods of childbirth preparation--Grantley Dick Read, Bradley, Lamaze and Sheila Kitzinger. Many classes either draw on several of these methods or all of them, says Herrick.

Method Acting

Grantley Dick Read was one of the first people to introduce childbirth preparation. In Read''''s view, labor and birth involve fear, tension and pain. If a woman is afraid, she will tense her muscles, triggering an increase of pain. Read decided that if the fear/tension cycle could be interrupted, pain could be lessened. He used education, relaxation techniques and medication to help break the cycle, says Herrick.

In the early 1950s Robert Bradley, M.D., introduced his method saying, "Let''''s involve the partner in the labor and delivery process."

"With the Bradley method the husband is brought in as a trained labor coach," says Marjie Hathaway, executive director of the Bradley Method at the American Academy of Husband-Coached Childbirth (AAHCC) in Sherman Oaks, California, and a Bradley instructor for 30 years. "We want men trained in how to help wives give birth. We teach the partner how to rub his wife''''s back, how to help her find positions that will be comfortable and how to communicate with the birth team. He can be an advocate for her in labor so she can have the birth she wants and needs." Across the country, the Bradley method results in about 87 percent unmedicated births, says Hathaway. Bradley classes emphasize good coaching, relaxation and tuning in to your body as ways to deal with the challenges of labor instead of medication.

With the Lamaze method, a woman uses breathing and relaxation techniques as ways of reducing pain. As a matter of fact, Lamaze advocates say that proper breathing is a key to minimizing labor pain.

Sheila Kitzinger, an English social anthropologist, felt that sexuality is a major factor with a new mother. She added a marriage counseling component to childbirth education.

Choosing Your Prep School

Whatever childbirth preparation classes you choose, doctors and midwives agree that you definitely should sign up for some class and go to it. "The prepared individual tends to deal better with childbirth," says Dr. Linn.

Here are some pointers on finding a class and graduating with honors.

Start class early. Seek out your childbirth preparation class very early in your pregnancy, says Herrick. Some women don''''t seek prenatal or childbirth care until the middle or latter stages of pregnancy.

Match your philosophy. Find a prenatal class that fits with your overall philosophy about pregnancy and childbirth, says Herrick.

Look for variety. Does the class emphasize only one childbirth preparation method? Does the class advocate one method of pain relief or one approach to breastfeeding? It''''s an advantage to be in a program that offers a variety of choices, says Herrick. To find out, call before the class begins.

Look for flexibility. Flexible class hours could be a factor in your choice, says Herrick. Is it offered only on weeknights, or are there weekend classes, too? Are there classes throughout the entire course of pregnancy or only in the third trimester?

Shop around. Some classes are sponsored by hospitals, others are offered through a provider''''s practice, while still others are independent. Check out the different options, says Herrick. "We''''re talking about one of the most important events in your life."

Find out who''''s teaching the class and what is covered in the curriculum, agrees Dr. Devoe.

Watch out for bias. Some childbirth preparation classes are sponsored by the hospital in which they are held and therefore have a conflict of interest, says Dr. Mahan. You should find out who funds the class and ask whether the teacher presents all options.

Understanding Your Labor

Many women are concerned about whether they will know when they are in labor, says Marsico. "Labor in and of itself is so individual," she says. Even with the same person, labor with one child can be different than it is with another. But even though nobody can predict exactly what your labor and delivery will be like, it usually has three stages, and there are distinct changes that take place during each of those stages. Being familiar with those stages beforehand can help you know what to expect.

Stage one begins at the start of labor and continues until the cervix is completely dilated. During this stage there are two phases, the latent and the active, says Dr. Linn.

In the latent phase the cervix thins out and is taken up into the uterus. This is known as effacement. Contractions at this time are usually mild, occurring every 15 to 20 minutes and lasting about 60 to 90 seconds. Gradually, the contractions become more regular until they''''re happening about every 5 minutes. The cervix dilates to about four centimeters, which is a little more than an inch.

During the active phase contractions become much stronger and more frequent, coming about every three minutes and lasting about 45 seconds apiece.

Usually, you can tell the difference between the contractions that take place in stage one of labor and the Braxton Hicks contractions that you might get off and on during pregnancy, says Dr. Linn. Braxton Hicks contractions tend to be irregular and, while the uterus may tighten, the contractions are not particularly painful, he says.

The contractions of labor tend to be painful. They build up, go away and then, over a period of time, become regular. When you''''re in labor, the contractions become more regular, occurring closer together, says Dr. Linn.

The second stage of labor ranges from the time the cervix is completely dilated to when the baby is born. When the cervix dilates, reaching a width of ten centimeters (about three fingers'''' width), the baby starts to move down the birth canal and out of the mother''''s body. This movement is urged on with strong contractions that occur about two to five minutes apart, lasting between 60 and 90 seconds. It''''s also at this time that the mother can begin pushing.

The third and last stage of labor involves the delivery of the afterbirth, or placenta.

Delivering the Goods

Advice varies about when a woman should come into the hospital or birth center. "If it is an uncomplicated pregnancy, and the bag of waters is intact, I tell patients to come in when their contractions are ten minutes apart," Dr. Linn says.

Despite the many differences in the pace of labor, there are some things that every woman can do to be prepared for the coming hours.

Drink up. Many women stop eating and drinking, says Dr. Linn, but it''''s important to keep hydrated with juices and water. "I tell them 12 ounces every hour, because you keep losing so much water. When you are dehydrated, the contractions can get stronger without it really being true labor."

Reach for energy boosters. Juices that have natural sugars in them (such as orange juice), warm tea with sugar or hot cocoa helps boost your energy. You need that for your body to work, notes Marsico.

Position yourself. Changing positions during labor can make labor easier and less painful, experts say.

Pain, Pain, Go Away

It''''s no laughing matter having your baby''''s head and body pass through and out your vagina. That head is about the size of a grapefruit.

One thing to consider beforehand is whether you want any kind of pain relief. And if so, what kind?

A nurse midwife is likely to encourage pain relief with certain breathing techniques. During labor the midwife might encourage you to walk around, or she might apply warm compresses to help relieve pain. You may have the option of using the showers, tub or whirlpool at the birth center--or perhaps getting a comforting massage.

If your caregiver is a physician and you are delivering in a hospital, one option you''''ll have is pain relief in the form of a pain-numbing epidural. This medication is injected into the space that surrounds the spinal canal through a tube that is inserted between the vertebrae of the backbone. While an epidural is generally considered a very safe form of anesthesia, some possible risks are involved, says Dr. Linn. If the injection penetrates the covering of the spinal canal (known as the dura), the patient might experience a postanesthetic headache. The patient''''s blood pressure may also drop after the epidural is administered. This can usually be controlled, however, by the anesthesiologist without complication.

Having an epidural may also make the second stage of labor more difficult, because it''''s hard to push effectively if you don''''t feel anything from the waist down. Dr. Linn points out that this may increase your chance of having a cesarean section or needing the assistance of forceps or vacuum extraction. "Patient selection is critical in the safe and effective use of an epidural," he says.

The Undercut

Should you have an episiotomy? Do you need one?

An episiotomy is a small cut that''''s made in the skin between the vagina and rectum--the perineum--to allow an easier and less painful delivery. The incision enlarges the vaginal opening so that the baby''''s head can pass through more easily.

Whether episiotomies are good or bad, necessary or unnecessary, all depends on the health care professional you talk to. Some are adamantly against them, while others think they are okay if that''''s what a woman wants.

Episiotomies are intended to prevent the vaginal opening from tearing on its own during childbirth. But there is no evidence that the procedure prevents severe tears of the perineum. "Contrary to conventional teaching and beliefs, episiotomies seem to cause the very problems that they are intended to prevent," says Michael C. Klein, M.D., professor of family practice and pediatrics at the University of British Columbia in Vancouver.

Dr. Klein and his colleagues studied 697 women in three hospitals shortly after they had given birth and then again three months later. The researchers found that women who''''d had episiotomies were more likely to have tears that ran to or through the rectum. "It''''s much easier to tear a piece of cloth that''''s already been cut than to tear one that''''s intact," Dr. Klein explains. "Once the episiotomy is done, the tissue''''s integrity has been disrupted."

Even if a woman has a spontaneous tear during childbirth, it''''s preferable to having an episiotomy, according to Dr. Klein. His study showed that the women who had spontaneous tears or who remained intact had less pain, fewer sexual problems and less pelvic floor weakness than the women who had episiotomies.

The Case for Cutting

Some doctors, however, view episiotomies as a means for preventing pain and problems rather than causing them. Years ago, when women had six or more children, all the pushing that went along with that amount of childbirth was believed to traumatize the pelvic wall and cause prolapsed uterus and bladder problems later in life. So doctors started doing the incision as a means to prevent trauma to the pelvic wall, says Dr. Linn.

But women don''''t have as many children now as they used to, and they are in much better shape, says Dr. Mahan. "Episiotomies should be avoided as much as possible," he concludes. "Even a small tear will be more comfortable when all is said and done than an episiotomy."

Still other doctors think it really is a woman''''s choice. "Women need to think about what they want," says Sharon Dobie, M.D., assistant professor in the Department of Family Medicine at the University of Washington in Seattle. "My approach is to cut an episiotomy if a woman really wants one, but most of my patients would prefer to not have one." Dr. Dobie says she is able to do most deliveries without cutting episiotomies.

A Checkup on Cesarean Section

While the decision to perform a cesarean is usually not made until labor has begun, your doctor should be able to explain the most likely reasons for doing one, says Dr. Devoe.

The dilation stage of childbirth begins with the onset of labor. Contractions force the baby''''s head against the cervix. The cervix softens, becomes thinner and dilates. As the dilation stage continues, the baby continues descending down the birth canal. The baby''''s head rotates as it enters the pelvic outlet. At expulsion stage the cervix is fully dilated and strong contractions occur every two to three minutes, each lasting about one minute. In the placental stage, the placenta separates from the wall of the uterus as uterine contractions continue. This stage usually happens about 15 minutes after the baby is born.

You''''re most likely to need a first-time cesarean if labor has not progressed the way it should or if labor hasn''''t occurred when it should, says Dr. Devoe. Or a cesarean might be performed if the fetus is in distress, if the doctor thinks the baby can''''t tolerate prolonged labor or if the baby isn''''t getting enough oxygen.

But there may be steps you can take to try to lower your chances of needing a cesarean section. Here''''s what experts suggest.

Check the track record. Make sure you don''''t choose a doctor who has a high rate of cesarean deliveries, says Dr. Mahan. For some doctors the rate is as high as 50 percent, even though it should be closer to 15 percent, he says. And it''''s important to find out the doctor''''s individual rate, not just the hospital''''s overall rate.

Check other sources. You can check with outside sources to find out your doctor''''s cesarean rate, according to Dr. Mahan. "I''''d refer women to a local childbirth education group or La Leche League," he says. (La Leche League International is a private organization that provides education, information and support to mothers and health care workers interested in breastfeeding. To learn more about their services and publications, you can contact them at 1-800-LA-LECHE.) These sources will be happy to tell you a doctor''''s cesarean section rates.

Be sure you can move. One way to lessen your chance of a cesarean is to be sure you will be able to walk and move around during the course of labor, says Dr. Mahan.

Breastfeeding: Giving Nature''''s Fast Food

For babies the myriad advantages of breastfeeding are well-known: It''''s cheap, safe, may protect against chronic diseases, helps prevent allergies, and it''''s more digestible than formula. For moms, breastfeeding not only saves time but also creates a special mother-child bond.

Breastfeeding could even save your life. A survey of 5,878 breast cancer patients and 8,216 healthy women showed that the risk of breast cancer among premenopausal women was 22 percent less for the women who had done breastfeeding. And the risk of breast cancer was lowest for women who had breastfed for the longest cumulative amount of time.

Breastfeeding gained popularity in the 1970s and 1980s, but by 1989 only half of mothers giving birth in hospitals were breastfeeding. One possible reason is that more women are working--and working more hours--so they have less time for breastfeeding. Also, some women complain of sore nipples related to nursing, and others use formula because they fear that the breast milk supply is inadequate.

Betty Crase, director of the Center for Breastfeeding Information at the La Leche League international headquarters in Schaumburg, Illinois, says that mothers should look on the bright side. "The human baby was designed to be breastfed, and the mother was designed to breastfeed. We urge every mother to give serious consideration to what both were designed to do."

Feeding Friendly