Book 3 by Stephanie Penland

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 – 40

The Arrival — Birth Guide

60 – 80% of pregnant women in the usa are considered to be a low risk patient. If you want a more natural birth, then choosing a hospital setting might not be your best option. Deadly Delivery — The Maternal Health Care Crisis in the usa

The

Arrival

Weeks 27 â&#x20AC;&#x201C; 40

m The Arrival

A Womanâ&#x20AC;&#x2122;s Confidence, her ability to give birth, and care for her baby, are either Enhanced or Diminished by every person who gives her care, and the type of environment, she births in.

m The Arrival

Title Page book

section

k The Beginning l The Middle m The Arrival n The Postpartum o The Birth Story

01 The Arrival â&#x20AC;&#x201D; Birth Guide 02 Preparation For the Labor 03 Braxton Hicks 04 Signs of Labor 05 Comfort During Labor 06 Pain in Labor 07 Relaxation During Labor 08 Helpers During Labor 09 First Stage of Labor 10 Second Stage of Labor 11 Final Stages of Labor 12 Breech Birth 13 The Circumcision Decision 14 Keeping the Placenta 15 Cord-Blood Banking

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Excerpt 01 start | Midwife Maria Irillo 2012 Interview, Wise-Woman Child Birth 9 0% of American women don't agree on one thing, so how can they all be agreeing to have their baby the same way. There's something a little bit off about that. And so what I would really like to see about our home maternity care system is for there to be a level playing field where the charge on home birth, the fear about it and natural child birth is alleviated and people learn about safely and how we work. If it were a level playing field it would be more like L choosing home birth, L in a birth-center, and the rest choosing hospital birth. end |

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k Designer Stephanie Penland l Photographers 01 Isaiah Beiser Photography 02 Tres Photography 03 Stephanie Penland 04 Catherine Byrd 05 Istock Photography m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

These books are intended for the pregnant mother to learn and make educated decisions about her heath care during and after the birth of her baby. They are a resource and a way for her to share and engage those around her in a conversation about why she has chosen the type of birth she wants, be it a home-birth or a hospital birth.

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Preparation for the Birth

There is a lot you can do to get ready for the birth of your baby, but perhaps the most important thing is to be informed and up-to-date with evidence based maternity care.

Birth is Not Controlled

Be Prepared

Mindful, & Open

sect ion 02 Preparation for the Birth

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Preparation for the Birth start | Preparation for the Birth — 2011 by Crystal Wolf One can only do so much to prepare for birth. It’s mostly a time to be very in the moment and ride the wave of life and creation! There are a few things you can do to be more prepared in your home, as well as mentally and emotionally. Special Signs When it comes labor time, you will want strong communication skills to come into play. You may also want extra communication options. One suggestion is to sit down together and create some possible signs for labor time. There’s a good chance that the birthing mother won’t be able to verbally express what she wants and needs in any given moment. It should be simple, like holding up a certain number of fingers or blinking a bunch. Things that can be done without switching positions or using two hands. Perhaps even incorporating a grunt system may be helpful. During the early parts of labor this won’t be as necessary for your partner will be able to be verbal. There’s also the possibility that all these signs you create go out the window. It’s important to remember that everything can out the window when it comes birth time! You can have a solid, rehearsed plan and when it comes time to welcome the baby here. Everything disappears as a plan. In Your Home Turning up the water heater thermostat is one of these things. If you will be birthing in a tub or shower you may need the extra heat to maintain a comfortable temperature. Also to have a pot or tea kettle on hand in case you end up in a tub and want some extra hot water added to heat things up more quickly. Of course always use Caution when adding hot water if the woman is already in the tub! Birth List Have everything on your birth list ready and on hand, and easily accessible. But remember that there can be things that are not planned for. Even if everyone knows your wishes, and your plans they should be able to help you through any changes that need to be made with out compromising.

sect ion 02 Preparation for the Birth

Clearing Mental Clutter It helps to keep the house tidy to keep mental clutter to a minimum. It also helps to make some decisions before hand, such as to video or photograph or not video and photograph, music options, who you may or may not want to be present during this intimate time. Overall Emotional Balance Itâ&#x20AC;&#x2122;s best to get clear with what type of a birth you want as well as any worries that may be arising during the pregnancy. If need be work with a hypnotherapist or counselor to clear these blocks, for they can slow down or stop labor in process. Perhaps have a friend on call that you can talk to if fears arise that you need help with during the process. Eating You can eat whatever you want but think of birth as a marathon have easy simple foods around that are highly nutritious and easy to digest. Having premade meals and soups are a good idea in the freezer as well as in the refrigerator. If you need an iron boost even simple sandwich meat can help with that one. end |

m The Arrival

I remember elegant words of wisdom, If labor is like a marathon, then birth is like crossing the finish line. I was so ready for this chapter of my life to be done and a new one to start. Kandice Love Arceneaux mama of Blake Birth Story 05

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k Designer Stephanie Penland l Photographers 01 Isaiah Beiser Photography m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Braxton Hicks

Many people call these false alarm or practice contraction. They are usually not a sign that labor is starting but are there to help prepare your body for real labor. They were named after the doctor Hicks who discovered that they were different then labor contractions.

sect ion 03 Braxton Hicks

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Braxton Hicks Many people call these practice contraction, or a false alarm contraction. They are usually not a sign that labor is starting but are there to help prepare your body for real labor. They were named after the doctor Hicks who discovered that these contractions were something different then labor contractions. Braxton Hick Contractions Usually these don't start until the end of the second trimester. The way it works is your muscles tighten for 30 â&#x20AC;&#x201C; 60 seconds and last as long as two minutes. They are irregular and infrequent. They are unpredictable and have no rhythmic features to them. If they do not increase in intensity and tapper off then disappear its most like a Braxton Hick. This is a good time to practice breathing and birthing techniques. Take out the game and try out different scenarios. Remember these can happen any where at any time there. Also not everyone experiences them. How they Feel It varies with each person. But the most common feelings tend to start in your abdomen or pelvic area and they can cause your belly to contract. They are uncomfortable for some people and others don't mind at all. How to Stop Braxton Hicks Contractions The good news is that unlike real contractions you can change or alter the Braxton Hick. Try changing positions, try laying down or taking a bath, doing something else that is relaxing for your body. Also check to see if you might be dehydrated or under lots of stress. This too can bring them on. If your Braxton Hicks are closer than 12 minutes apart and you are before 37 weeks you need to contact your midwife or doctor as you could be in pre-term labor.

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a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Signs of Labor

Each Birth-Story is unique, just like the woman who is telling it. It's well worth your time to talk to women who have given birth, read their stories, talk to them about their fears, their joys, and what they would have done different or kept the same.

Every Birth-Story Is

Unique and Speical

Beautiful, & Important

sect ion 04 Signs of Labor

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Signs of Labor Every birth-story is as unique to the woman who is telling it. It is well worth your time to talk to women who have given birth, read their stories and talk to them about their fears, their joys, and find out what they would have done different or kept the same. Signs Labor Might Start 01

Breathing Becomes Easier This is sometimes referred to as a Lightening. Meaning your baby has moved down in your belly taking pressure off diaphragm. Howeveryoumightnowhaveincreasedpressureonyourbladderbecauseofit.People might start to notice the changes in how your belly looks and comment on how the baby has dropped.

Bloody Show, Loss of Mucus Plug The mucus plug protects the cervical opening from bacteria. When your body is ready to birth your baby the cervix opens and releases the plug. You may or may not see this slimy almost snot like mucus or discharge. It can be clear, pink or even have some blood in it. Not all women notice this come out.

03 Rupture of Membranes & Your, Water Breaks! Only about 1 in 10 woman experience a dramatic gush of the amniotic fluid. It usually happens at home, often in bed while your asleep or Remember these are just relaxing. Sometimes the amniotic sac breaks or leaks before general things that can labor begins. Your uterus is sitting directly on top of your bladhappen. Your's might not der, which can cause you to leak urine. Sometimes it can be have any warning signs quite difficult to distinguish urine from amniotic fluid. If your or they might be different membranes have ruptured and you are leaking amniotic fluid, than these. it will be an odorless fluid. If you notice fluid leaking, you need to try to determine if it smells like urine or if it is odorless.

sect ion 04 Signs of Labor

If it does not seem to be urine, you would want to contact your healthcare provider. Until you see your physician or midwife do not use tampons, have sexual intercourse or do anything that would introduce bacteria to your vagina. Let your health care provider know if the fluid is anything other than clear and odorless, particularly if it’s green or foul smelling, because this could be a sign of infection. 04 Nesting Spurt of Energy Most women experience this. And if you don't notice it I'm sure those around you will. You'll just wake up and feel energetic, instead of tired and huge, you'll start making lists, or start huge projects to clean. So go ahead just make sure you start projects you can finish as Labor Day is probably just around the corner. 05 Effacement Thinning of the Cervix In the last month of your pregnancy your cervix will start to stretch and thin out. Your lower uterus is getting ready for the delivery. The thin cervix allows your body to dilate. Your health care provider may check for effacement in the final two months of pregnancy. Effacement is measured in percentages. You may hear your health-care provider say, You are 25% effaced, 50% effaced, or 75%. The Braxton Hicks contractions or practice contractions you have been experiencing may play a part in the effacement process. You will not be able to determine your effacement process, this can only be done by a health-care provider’s exam. 06 Dilation Opening of the Cervix Dilation is the process of the cervix opening in preparation for childbirth. Dilation is measured in centimeters or, less accurately, in fingers during an internal, manual, pelvic exam. Fully Dilated means you’re at 10 centimeters and are ready to give birth. In the same way that your health-care provider may be checking for effacement in the last two months, they may also tell you how many centimeters your cervix has dilated. Don't get checked for dilation though unless it's absolutely necessary. Checking dilation does not mean your in labor, it can not tell you when labor will start or how long you have.

m The Arrival

One Sure Sign Consistent Contractions When you begin to experience regular uterine contractions, this is the strongest indication that you are in labor. This is a good time to get out your notebook to record the exact time each one begins and how long they last. These contractions may feel like menstrual cramps or a lower backache that comes and goes, and during early labor they may be as far apart as 20 – 30 minutes. Over the course of several hours your contractions will typically begin occurring at shorter intervals; and you may notice they start happening every 10 – 15 minutes or less. When your contractions are consistently 4 – 5 minutes apart, it is time to call your health care provider. Characteristics

› They become progressively closer › They last progressively longer › They become progressively stronger › A change in activity or position will not slow down or stop contractions. There may be bloody show › Membranes may rupture. Your health care provider will notice cervical changes, such as effacement, thinning, or dilation › Each contraction is felt first in the lower back and then radiates around to the front or visa versa › They are regular, they follow a predictable pattern, such as every eight minutes

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k Designer Stephanie Penland l Photographers 01 Isaiah Beiser Photography m Writers 01 Stephanie 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Comfort During Labor

This may sound like a contradiction, with the words comfort and labor in the same sentence! The fact is that labor is not all pain all the time. Relaxation During Labor â&#x20AC;&#x201D; 2011 by Crystal Wolf

Labor is Labor

Find Peace, &

Embrace it

sect ion 06 Comfort During Labor

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Comfort During Labor start | Comfort During Labor â&#x20AC;&#x201D; 2011 by Crystal Wolf This might sound like a contradiction in terms, the words comfort and la bor in the same sentence! The fact is that labor is not all pain all the time. Trust your Body The contractions that are so vital to bringing your baby to birth come in a very rhythmic manner. There is a period of rest between the contractions, and then the contractions grow stronger to a peak and then recede again. The process is like waves on the ocean â&#x20AC;&#x201D; building, cresting and then going back out to the sea. This image may even be one you choose to use during your labor. Your body knows what to do in order to bring the baby to birth. Sometimes the most difficult part is understanding that pain is a normal part of the labor process. Without this understanding, there can be more fear for you and your support person. Prepare for Labor Using a Doula A doula is a person trained in methods to support you and your partner during labor. It has been found that using a doula often reduces the need for pain medication and decreases the likelihood of caesarean section. One of the best comfort measures for labor is being well prepared before labor begins. If you have thoughts about the things that make you feel comfortable and able to relax, you will be better prepared for the challenges you may face in labor. Lists Help Make a list of what you do now to help you feel calm emotionally and more at ease physically. How do you relax after a bad day at work? Do you listen to music, have a bath, watch TV, have someone rub your back? What else? How you might be able to use these in labor? Try to think of comforts that reach all of your five senses: sight, sound, smell, touch and taste.

sect ion 06 Comfort During Labor

› List comforts you will be able to use in the car to, and at the hospital. › Let your support person know which ones you prefer, so they can better help you in labor.

Birth Ball The birth ball permits you to be in a gravity enhancing position while being supported you and allowing you to move. You can sway or bounce or rock on the ball and not get as tired as you would if you were standing. The gravity enhancing position helps the baby move deeper into the pelvis and could likely shortens the length of labor. Women often comment that they notice a relief of pressure on their lower back when sitting on the ball. When you move on the ball, the receptors in your joints send messages about movement to your brain. These messages reach the brain before the pain message from the contractions, so many women say that they feel less pain while moving on the ball. This rhythmic movement on the ball can be very comforting during a contraction. Toilet The toilet is an excellent place to labor. The position is gravity enhancing and it allows for a woman to empty her bowels or bladder. It helps that you will have to change your position by walking to get there. Gravity, pelvic relief, and movement — what a great combination for a progressing labor. Easy Ways to Help Yourself There are many reasons why some labors can be more difficult than others. Here are three of the easiest things you can do to help yourself, yet these can easily be forgotten during labor so make sure your support person knows to about them. Hydration Keep sipping fluids during labor, water, clear juice or others. Dairy products are not recommended as they can be more difficult to digest and so some women will throw them up. Hunger You need to have enough energy to sustain you through the process of labor. The average time of labor for first time moms is 14 – 20 hours, a time in which you would normally eat three meals! Before you get to the hospital, you can and should eat whatever your body feels like it needs. Once at the hospital, ask your nurse what you can eat if you are hungry, or just eat if you are hungry

m The Arrival

and need to even if they don't recommend it. Your strength and energy are important. There might be some medical reasons you can not eat at the hospital, such as if you need a c-section right away. Your appetite will likely decrease as labor progresses. It is also quite common for women to vomit sometime in labor due to the powerful activity of the uterus so close to the stomach. Having something in your stomach is better than having nothing. Fatigue Rest, rest, and rest some more! Make sure you are taking enough time off work before your due date, if possible. If you are concerned you will be bored at home with nothing to do other than wait for labor to start, then get your hands on some good breast-feeding information or start planning to talk with experts or moms who have been through it so you can be as prepared as possible. Once labor begins, balance movement with rest when you feel you need it so you will have energy for however long your labor takes. end |

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Pain in Labor

Labor is Labor

Find Peace, be

Comfortable

sect ion 06 Pain in Labor

m The Arrival

Pain in Labor start | By Judith A. Lothian, PhD, RN, LCCE The pain of labor and birth worries most women. No one enjoys pain and most of us are willing to go to great lengths to avoid it. The pain involved in childbirth is no exception. What women don’t usually know is that pain is central to nature’s simple, elegant design for labor and birth. Pain is not simply an unfortunate side effect of labor but is an important part of the normal process of labor and birth.

When I first started teaching childbirth education classes we routinely discussed pain in labor as the unpleasant side effect of a large baby moving out of the uterus, through the pelvis and down the birth canal. Only once was I questioned, by a father in my class, about whether pain just might have a purpose. I confidently told him, no, i was wrong. Our understanding of the role of pain in the normal physiology of the birth came out of deeper understanding of the hormonal orchestration of labor. Three hormones play vital roles in the initiation and progress of labor and then facilitate recovery of the mother and ease transition of the baby to life outside the uterus: catecholamine’s stress hormones, oxytocin, and endorphins. The hormone orchestration of labor, especially in the early stages, is quite vulnerable and easily affected by what is happening around you. Animals search out quite, private spaces in which to labor and if they sense danger of any kind, labor stops. We are not very different. Fear, anxiety, not feeling safe increases catecholamine levels and can shut down our labors. As leaves of oxytocin rise, the contractions become stronger and more painful. Women instinctively change positions and try to find comfort in a wide variety of ways in response to the pain of their contractions. Those high levels of oxytocin and the pain that accompanies them send a message to the brain. More hormones, this time endorphins, are released. Endorphins will decrease pain perception, moderate the level of oxytocin, give the uterus, and you little breaks and help the laboring woman go into an almost dream-like state. Endorphins seem to make women become more intuitive, to go into themselves and to get into a rhythm as they cope with one contraction after another. It’s exactly what nature intended!

sect ion 06 Pain in Labor

At the end of labor it is not usual to experience some anxiety with strong, powerful contractions. This sudden anxiety stimulates catecholamine release in the mother and baby. This surge helps you become more alert, more focused and extremely strong as you push your baby out. At this stage, unlike early labor, stress hormones actually help rather than impede the process of labor. If mother has high levels of oxytocin, endorphins and catecholamine’s at birth, baby is born with high levels of catecholamines too as is bright and alert. High levels of endorphins in your breast milk will help ease baby’s transition in the first hours and days after birth. Skin to skin on your abdomen, and baby’s head and hand movements will stimulate your body to continue to produce oxytocin, the hormone that now takes a new role, facilitating milk let-down as well as preventing excessive maternal bleeding. High levels of all these — catecholamine’s, endorphins, and oxytocin — contribute to the feelings of exhilaration, euphoria and joy that women describe holding their babies right after birth. So, what about the pain? From the beginning of your labor, pain lets you know that this is not “just another day.” Knowing you are in labor allows you to arrange for the help and support you will need. Like other mammals we search for a safe, secure place in which to labor, a place where we have help and support. Without pain to signal the start of labor there would be many more babies born in cars, shopping malls and on the street, quite literally. Like other pain in our lives, this pain actually projects us. If we touch a hot stove, we respond immediately by removing out hand. In labor you feel the pain of a contraction and you move, rub, perhaps moan I response to what you are feeling — not too different from the way you respond to pain in your everyday life. As you try to get comfortable the movement, the touching, the moan also helps the progress of labor. Your actions help ease the pain a bit and you manage to get from one contraction to the next even stronger contraction. Being able to handle increasing amounts of pain ensures increasing levels of oxytocin increasingly strong. Powerful and effective contractions and ultimately the release of endorphins, nature’s narcotic. Interestingly, if the pain is removed the oxytocin levels fall and there is no endorphin release.

m The Arrival

In response to the pain you feel your position changes facilitating the babyâ&#x20AC;&#x2122;s turning and moving down through the birth canal. Every time you move the diameters of your pelvis change, the baby gets wiggle room and is generally prodded into the pelvis and through the birth canal. During this journey though the birth canal the pain and pressure you feel your response to it actually help protect your birth canal and the baby. Think of how changing the way you walk in response to the pain of a blister protects your foot from further injury. If you have been given an epidural and do not feel the movement of the baby through the birth canal, and therefore are unable to respond to the pressure, with oohs, and aahs, by moving, by tightening the release of vaginal muscles, the birth canal is more vulnerable to damage. Your movement, at just the right time, eases the pressure on the baby and lows his descent. You donâ&#x20AC;&#x2122;t need to read a book to do this. Your body moves quite naturally if your movement is not restricted in response to what you feel. What does this all mean? The important reality is that pain is a part of a natural, complex system that keeps the uterus contracting, keeps the baby moving down, and keeps your body and your baby protected. Remove the pain by interrupting its flow and progression any place along the way and you remove the signals that are your guide as you move through labor. Why feel pain in labor? The answer is quite simple: it is part of natureâ&#x20AC;&#x2122;s plan for birth. Pain promotes the progress of labor. Responding to pain protects the birth canal and the baby and managing pain ensures high levels of oxytocin and endorphins which are both important for a faster, easier birth as well as an alter baby, and successful breast-feeing.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 – 40

Relaxation During Labor If you can show your true appreciation and love now and throughout the pregnancy that can help build a foundation for when it comes to birth time. It can help keep away animosities and resentments. This doesn’t need to be grand, over-the-top expressions; merely simple yes, you are loved and beautiful gestures. Carry a list in your wallet of accomplishments that took strength for your partner to accomplish. You can pull this sheet out during labor and remind her of how powerfully strong she is. Relaxation During Labor — 2011 by Crystal Wolf

sect ion 07 Relaxation During Labor

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Relaxation During Labor start | Relaxation During Labor — 2011 by Crystal Wolf One of the most important things you can do to help your partner have a relaxing childbirth experience is to start now with pampering and nurturing her. Show your support, and love on a daily basis. Do not do anything you don’t really want to do for that will cause underlying resentment. However, if you can show your true appreciation and love now and throughout the pregnancy that can help build a foundation for when it comes to birth time. It can help keep away animosities and resentments. This doesn’t need to be grand, over-the-top expressions; merely simple yes, you are loved and beautiful gestures. Carry a list in your wallet of accomplishments that took strength for your partner to accomplish. You can pull this sheet out during labor and remind her of how powerfully strong she is. Communication is Key to Helping Everyone knows that the process of labor and birth are one of the most physically demanding things a woman will ever experience. Many woman try to prepare for this the best way they can by doing things like staying healthy, exercising and being well educated on how to handle their labor. The one thing many woman hope they don’t have to deal with is the dreaded back labor. Many women feel powerless to this phenomenon that occurs during many labors, without realizing that there are in fact things they can do to help avoid this pain or relieve it. Back Labor This is a term used to describe when laboring women experience most of their pain and discomfort in their lower back. Although most women will feel some achiness or slight cramping in their back at some point during labor, about 1 in 4 or 25% of women will experience severe discomfort in their lower back that is most intense during contractions and often still painful even between contractions. Back labor often can be accompanied by an irregular contraction pattern, a labor that is slow to progress, and an extended pushing stage. Causes of Back Labor Often back labor can be related to a positioning issue with the baby. Positions such as occiput posterior when baby is facing the mother’s abdomen can cause pressure from the baby’s head to press directly on the mother’s tailbone or sacrum. This can result in intense discomfort during labor.

sect ion 07 Relaxation During Labor

But a baby in an odd position does not always cause back labor and back labor is not always the result of a baby’s positioning. Some research has concluded that a woman who experiences back pain during her menstrual cycle may be more likely to experience back labor, regardless of the position of her baby. Treated or Relieved The best way to relieve back labor is to get mom off her back. If the back labor is thought to be related to fetal position, then techniques should be used to help move baby into a more optimum position. If it is unknown what is causing the back labor, using the techniques for optimum fetal positioning is a great place to start, and then the comfort measures can also be used. Techniques to Help Fetal Position

› Walking › Squatting and lunging › Sitting on a birth ball › Using a rebozo or sheet to shift the pelvis › Pelvic tilts and hula-hoop dancing › Hands and knees and or open knee chest › Sitting backwards on a chair or the toilet

Techniques to Ease Discomfort

› Hot or cold compresses applied to the lower back › Strong counter pressure › Hydrotherapy either by shower or warm bath or birth pool › Heated rice sock › Apply pressure with something that rolls down the back such as water bottle, beverage can, tennis balls or hollow rolling pin

Using a combination of both the techniques for positioning and the comfort measures, increases the chances that the laboring woman will get some relief from her back pain. Taking a comprehensive childbirth class where these techniques are taught and or having professional labor support by a doula can also be very beneficial for a woman experiencing back pain.

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Complications of Back Labor The back labor itself cannot harm the baby or the mom, but research does show that a baby in a non-optimum position, which is the most common cause of back labor, is more likely to have problems descending through the birth canal. This can then lead do interventions and complications such as:

› Need for pain medication if the mother had not received any previously › Extended labor time which can cause the mother to be extremely fatigued › Use of forceps or vacuum › Need for an episiotomy › Cesarean delivery

Can Back Labor be Prevented Obviously a woman can not know beforehand if she will experience back labor until she is actually in labor although some studies do say that a woman who has experienced back labor with a previous baby are more likely to experience it again unless measures are taken to prevent it. However, since back labor is often related to a positioning issue, there are steps that can be taken to help increase the chances of a favorable fetal position. Preventative Measures Do pelvic tilts — get on hands and knees, curl your back up and then bring back to a straight position. This not only helps loosen ligaments, but also provides relief for an aching back after a long day.

› Spend time sitting on a birth ball/exercise ball each day › Sit in positions that keep your knees lower than your hips — don’t spend too much time sitting deep in your couch or other recliner chairs! › Have regular chiropractic and/or massage work done throughout pregnancy › Ask about the position of your baby as you get further into pregnancy

sect ion 07 Relaxation During Labor

During Labor Get off your back!! Being in the supine position, lying on your back, during labor not only can increase the chances of experiencing back labor, it can also make it much more painful. If you need to be lying down, lie on your side or in some sort of tilt position.

› Use gravity friendly positions early in labor — walking, swaying, sitting on a ball, semi sitting or leaning › Pelvic tilts, and other stretches › If you need to be sitting, sit backwards on a chair or toilet

end |

m The Arrival

Obviously, a woman cannot know before hand if she will experience back labor until she is in it. Although some studies do say that a woman who has experienced back labor with a previous baby are more likely to experience it again, measures can be taken to prevent it. Since back labor is often related to a positioning issue with the baby, there are steps that can be taken to help increase the chances of a favorable fetal position. Relaxation During Labor â&#x20AC;&#x201D; 2011 by Crystal Wolf

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k Designer Stephanie Penland l Photographers 02 Edited by Tres Photography 04 Catherine Byrd m Writers 01 Stephanie Penland 02 Crystal Wolf 03 Illana Pearlman n Printer 01 Alpha Graphics 02 Kodak M700 03 Cougar smooth text 80#, Natural o Details 01 Font Archer Pro 02 Chartwell

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Helpers During Labor

For most women, however, there are intense times in labor when it's difficult to know exactly what you want, or to remember any of the comfort measures you practised. This is the time when the support person can take the lead, make suggestions for comfort measures or position changes, remind mom to keep breathing, and assure her she's doing a great job.

sect ion 08 Helpers During Labor

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Helpers During Labor start | Helpers During Labor 2011 Alberta Health Services Brith & Babies Your support person plays a key role in your labor and the birth experience. There are many things your partner can do to help you feel more comfortable so labor can proceed as smoothly as possible. Helping with Breathing Your support person can help you to maintain rhythmic control of your breathing as you cope with the increasing intensity of labour contractions. One of the most important jobs will be to keep you focused on your exhale. It is normal for people who are stressed or in pain to hold their breath. However, holding your breath can cause your body to become more tense, and reduces the oxygen that both you and your baby need during labor. If your support person can keep you focused on your exhale, the inhale will take care of itself, and your rhythm will proceed. There are many patterns of breathing you can use to help get through the stages of labor. It is common to start off breathing in a slow, deep, even pattern, and then to move to shorter lighter breaths as the labor intensity picks up. In the transition phase, close to the start of pushing, many women need to mix up whatever pattern they can concentrate on at the time. Some women find specific patterns helpful while some others find them confusing. The important thing is to keep on breathing. Watch Breathing Patterns Your support person should watch your breathing patterns. Steady, rhythmic breathing helps to calm you. Some women say it gives them a sense of control. Other women say it is more a feeling of letting go. Breathing patterns help you, your baby, your partner and your caregivers. Relaxing Your Body Giving your baby a good supply of oxygen during the contraction. Letting your partner know that a contraction is starting or ending so they know when to help Letting everyone in the room know that a contraction is starting or ending. Many childbirth education programs will teach you different patterns of breathing. It's important for you to find the pattern and rhythm that will work for you. Watch for Hyperventilation If you feel any of these symptoms, slow your breathing rate during contractions or cup your hands over your nose and mouth. Breathing into a paper bag can also help.

sect ion 08 Helpers During Labor

› Sometimes during labor you may breathe too quickly. This is called hyperventilation. If this happens, you may feel: › Light-headed or dizzy › Tingling or numbness in your hands and feet › Muscle spasms or cramps

Know When to Follow and When to Lead A support person who is ready to follow your lead but who can be assertive and encouraging when the time is right is a great help. Most of the time, the support person's job is to follow the mother's lead — talking when she needs a soothing voice, massaging her back when she asks, wiping her forehead with a cool cloth, and responding to the changing moods and needs of labor. For most women, however, there are intense times in labor when it's difficult to know exactly what you want, or to remember any of the comfort measures you practised. This is the time when the support person can take the lead, make suggestions for comfort measures or position changes, remind mom to keep breathing, and assure her she's doing a great job.

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For The Support Person Be Comfortable with Laboring Noises Some women will be very vocal during their labor and that is what is right for them. A woman who is making rhythmic noises and who is moving around during her contractions is not necessarily in great distress. In fact, a woman who follows her body's cues to get into certain positions, breathe in certain patterns, or make certain sounds, is working well with her body as it goes through labor. Giving a Massage Your support person can help you relax by putting their hands on your body. The approach can be as simple as touching your tense muscles with warm, comforting hands and saying, Relax into my hands. Your support person can also give you a massage. Massage is very helpful in distracting you from the pain of uterine contractions. Massage will help you release tension in parts of your body that do not need to be tense, and it can be a wonderful way for a partner to feel included in the labor. Instructions for the Laboring Woman Sit sideways in a chair or straddle a chair facing over the back so your support person can have clear access to your shoulders, back, buttocks and thighs. If facing over the back of a chair, you may want to place a pillow over the back for greater comfort. This will be a good opportunity for you to practice your body breath connection while you relax and enjoy the massage. Remember your support person cannot read your mind, so if they are doing something you don't like, let them know. It is also rewarding for them to feel like they are being helpful, so be sure to praise their efforts Instructions for Your Support Person There are two things you need to remember no matter what kind of a massage you are giving or what technique you are using pressure and tempo. It is important to do the massage as firmly or delicately as she would like. The best way, actually the only way, to know this is to ask if you are doing it, How is this pressure for you? Is this pressure okay? Same approach for tempo. Ask what she likes best, but make sure you do not move so quickly that it causes her to speed up her breathing pattern.

sect ion 08 Helpers During Labor

Massage Techniques With the laboring woman seated, step behind her and place your hands on the tops of her shoulders with thumbs ready to massage the small muscles at the base of her neck. Begin by using your thumbs in a rhythmic motion, as if to knead these two muscles. Remember pressure and tempo, so be sure to ask her how it feels. Slide your hands to the outside of her shoulders and gently, if that is the pressure she desire, squeeze her shoulders when she inhales and release when she exhales. This can be hard to coordinate at first so be patient. With practice you will get it! Continue sliding your hands all the way down her arms to her wrists, gently squeezing to her inhale and releasing with her exhale, pausing a few times in each spot. It may take a minute or more to travel from the top of her shoulders to her wrists. This massage might take the entire contraction to complete. Speed is not the point of the exercise. The point is to help distract her by the rhythmic movement of your touch on her skin. At this point, or perhaps before now, you will need to come around to face her. Be sure you stay as comfortable as possible when you are comforting her, otherwise you may be suffering from a sore back when you meet this darling new baby! If she is sitting, kneel in front of her and take one of her hands in yours. Do not make her move her hand to you. It is your job to reach for it, slowly and gently. Apply even pressure to her hand with both of your hands, one on top of her hand and the other underneath her palm. This will stimulate the receptors in the palms of her hands that release endorphins, the feel good hormones. Hold this pressure steady for about a minute, or the duration of the contraction. Repeat on the other hand and on both feet so she feels evened out. Another great hand massage is taking her one hand in yours and opening her hand so that you can slowly walk through her palm with your thumbs. Again, as in everything you do with massage, pressure and tempo are crucial.

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Remember that it is all about the woman giving birth, if she wants it great, but it she doesn't just go with whatever she's asking.

When finished with the palm of her hand, you can start to milk each finger. Do this by starting at the base of her finger, where it connects to her hand, and gently squeezing it all the way to the fingertip. Do each finger one at a time, as well as the thumb. When you are finished, put her hand back gently and move to the other hand.

Have the laboring woman sit sideways in a chair or straddle a chair facing over the back so you have clear access to her shoulders, back, buttocks, and thighs. Rest your hands on the top of her shoulders. Remember the two basic rules of massage, pressure and tempo. Begin by using the heels of your hands as the points of pressure and just let your fingers drag. The pathway would be from the base of her neck and down both sides of her spine. When you get to her lower back, start again, or proceed by pushing all through her buttocks and then along the tops of her legs and ending at her knees. If you finish at her lower back or her knees or another spot, remove only one hand from the massage and place it at the top before removing the second hand. This way, you will not break the flow of the massage. This is an important aspect of any massage! Another great back massage is to use the same pathway, but instead of the heel of your hands with your fingers dragging, use your fingertips. Use two or three fingers on each hand and make little circles, progressing from her neck to her lower back. It is very easy to get carried away with this one, especially if the laboring women is in intense labor and needs a great deal of support. Remember your massage strategies; Pressure and tempo! When you are doing these circles on her buttocks, it will probably be more helpful to use your fists instead of your fingertips, turn your rings so you do not poke her with them. end |

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

First Stage of Labor

The birth of your child is a wonderful and unique experience. No two deliveries are alike.

There is no way to tell exactly how your delivery is going to be. What we can tell you are the stages you might go through during this process and what you can generally expect.

sect ion 09 The First Stage of Labor

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First Stage of Labor — Evidence Based Pain Going through labor and the birth of your child is a wonderful and unique experience. No two deliveries are alike and there is no way to tell how your delivery is going to be. What we can tell you is the stages you will go through during this process and what you can generally expect. Childbirth can be broken into three stages: First stage Begins from the onset of true labor and lasts until the cervix is completely dilated to 10 cm. Second stage Continues after the cervix is dilated to 10 cm until the delivery of your baby. Third stage Delivery if your placenta. First Stage The first stage of labor is the longest. The First stage is Early labor phase which continues until you are 3 cm. Then active Labor phase begins. Each phase has it's own set of emotions and physical challenges. During this phase you should relax, and save your energy. Take a walk and be at home or in a familiar place. Keep occupied with conversation, or try out the birth game again. Drink lots of water and make sure you eat well, good nutritious food that will help you keep your strength up later. You might also want to keep a loose note on what your contractions are doing. If you can sleep try to. If there are any projects like packing your bags that you didn't get to now would be the time for that, will help you stay occupied as well. What to Expect

› First Stage can last 8 – 12 hrs › Your cervix will efface and dilate to 3 cm › Contractions will last about 30 – 45 seconds, giving you 5 – 30 minutes of rest in between contractions › Contractions are typically mild, somewhat irregular, but progressively stronger and closer together › Contractions may feel like aching in your lower back, menstrual cramps, and pressure or tightening in the pelvis area › Your water may break; also known as amniotic sac rupture, this can happen any time within the first stage › When monitoring contractions observe the following, Grow more intense, and follow a regular pattern, closer together

sect ion 09 The First Stage of Labor

When Water Breaks

› Color of fluid › Odor of fluid › Time rupture occurred

Tips for the Support Person

› Practice timing contractions › Be a calming influence › Offer comfort, reassurance, and support › Suggest activities that will distract her › Keep up your own strength, you will need it!

Of course there is always the possibility you won't experience any of these things. It's entirely possible to go into labor with out loosing or noticing you lost your mucus plug and the waters breaking. start | Best Evidence: Labor Pain, childbirthconnection.org by by Penny Simkin Best Evidence for Labor Pain

Best Evidence When making important maternity decisions, women should have information from the best available research about the safety and effectiveness of different choices. In general, we can be most confident about results of systematic reviews that summarize randomized controlled trials or rct's, a type of study. Unfortunately, for many decisions, we must rely on less definitive research; and many important questions — even in the case of widely used drugs, tests, and procedures — have hardly been studied at all. Although this situation is discouraging, an awareness of weak or missing evidence can help you make more informed choices about care.

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> Best evidence about effects of good labor support > Best evidence about effects of selected comfort measures > Best evidence about effects of mental strategies > Best evidence about effects of injected narcotics opioids > Best evidence about effects of epidural or combined spinal-epidural analgesia

To help women and their caregivers make decisions about labor pain relief that are informed by the best available research, Childbirth Connection has an ongoing labor pain initiative and commissioned a set of reviews published in a special issue of American Journal of Obstetrics and Gynecology 2002. These include systematic reviews about the safety and effectiveness of various methods for labor pain relief and are the main source of information on this page. An Executive Summary describes the project and summarizes key findings Nature and Management of Labor Pain Symposium Steering. Committee 2002. Despite the challenges of conducting research on labor pain relief and limitations within the best available research, the following conclusions seem clear. > A woman's labor pain relief options depend in large measure on where and with whom she chooses to give birth; women in other western industrial nations appear to have more options for labor pain relief than women in the usa Marmor and Krol 2002.

> The factor that best predicts a woman's experience of labor pain is her level of confidence in her ability to cope with labor Lowe 2002.

> Receiving continuous support during labor decreases the probability of using pain medication and increases the likelihood of satisfac tion with the birth experience in North American settings Simkin and O'Hara 2002, a systematic review and more generally Hodnett and colleagues 2004, a systematic review.

> Various non-drug techniques can offer pain relief and comfort in labor and have little or no probability of causing adverse effects. If a concern arises or a woman dislikes a technique, discontinuing it should reverse its effects Simkin and O'Hara 2002, a systematic review of birth.

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> We lack good information to answer many questions about unwant ed effects of pain medications on babies, mothers, and labor Bricker and Lavender 2002 and Lieberman and O'Donoghue 2002 â&#x20AC;&#x201D; system atic reviews, Caton and colleagues 2002.

> The epidural/spinal family has become the most common approach to labor pain relief in the usa. It is the only pain relief method that can completely abolish pain, but it also has a high profile of adverse effects, both minor and major Leighton and Halpern 2002, Lieber man and O'Donoghue 2002, and Mayberry and colleagues 2002.

> Although widely used in the usa and elsewhere, injected narcotics appear to have little effect on pain and considerable potential for adverse effects Bricker and Lavender 2002, a systematic review.

> Nitrous oxide could be a useful method for coping with labor pain, but is rarely available in the usa Rosen 2002, a systematic review.

These four factors make the greatest contribution to women's satisfaction in childbirth.

> Having good support from caregivers > Having a high-quality relationship with caregivers > Being involved in decision-making about care > Having better-than-expected experiences, having high expectations.

Pain relief only becomes important for satisfaction in childbirth when expectations are not met Hodnett 2002, a systematic review.

Best Evidence about Effects of Good Labor Support effectiveness Receiving support from a labor companion decreases the probability of using pain medication and increases the likelihood of satisfaction with the birth experience safety No safety issues have been found Hodnett and colleagues 2004 and Simkin, systematic reviews.

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Best Evidence About effects of Selected Comfort Measures Activity and Positioning effectiveness Studies suggest that women may experience less pain laboring and pushing in upright positions, standing, squatting, all fours. safety No known adverse effects; women should be encouraged to seek comfort in being up and about and changing position as they please unless there are specific medical reasons why they should not Simkin and O'Hara 2002, a systematic review. Touch effectiveness Studies suggest that soothing touch or massage, can help women cope with labor, reduce anxiety, ease pain, and increase comfort. safety No known adverse effects Simkin and O'Hara 2002, a systematic review. Immersion in Water effectiveness Studies of deep tub baths have found inconsistent effects on various indicators of pain; however, many women find deep tub baths soothing and relaxing. safety Studies suggest that prolonged bathing in early labor can slow labor and that water temperatures higher than body temperature can cause maternal fever, at least while the woman remains in the tub; infection in mother or baby doesn't appear to be a problem even with ruptured membranes Simkin and O'Hara 2002, a systematic review. Best Evidence about Effects of Mental Strategies effectiveness Few of the mental strategies have been evaluated, but many women report finding them helpful. safety No known safety issues Enkin and colleagues 2000.

sect ion 09 The First Stage of Labor

Best Evidence about Effects of Sterile Water Injection effectiveness Randomized controlled trials consistently find sterile water injections significantly relieve severe back pain compared with a placebo. Safety The only drawback is stinging at the time of injection Simkin and O'Hara 2002, a systematic review. Best Evidence about Effects of Nitrous Oxide effectiveness Although the best available research is difficult to interpret, many women using nitrous oxide give high ratings for pain relief. safety The most serious known risk, loss of consciousness, can be minimized by avoiding high concentrations of nitrous oxide, limiting use with narcotics, and having women hold the mouthpiece or mask when it falls away, consciousness rapidly returns, Rosen 2002, a systematic review. Best Evidence about Effects of Injected Narcotics Opioids effectiveness Narcotics appear to have limited effect on labor pain; in some settings, a large proportion of women who use narcotics go on to have epidural analgesia, or other pain relievers. safety Research into narcotic safety is inadequate, and what is known is of concern; most studies have evaluated Demerol meperidine, also called pethidine, but the few studies of newer opioids do not show any improvement over Demerol; narcotics. It can cause nausea and depress respiration in laboring women. It can also readily cross the placenta and can depress newborn breathing and affect behavior in a way that appears to interfere with parentbaby interaction and breastfeeding; a drug that reverses respiratory depression Narcan or naloxone, also has drawbacks.

> May be associated with addictive and self-destructive behaviors in the exposed child later in life Bricker and Lavender 2000, a systematic review of birh.

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A nasal spray version of butorphanol Stadol NS is used in some usa maternity settings. The manufacturer's label for this migraine drug, which has been approved by the us Food and Drug Administration, recommends that the drug not be used during labor as it has not been studied for this purpose. Best Evidence about Effects of Epidural or Combined Spinal-Epidural Analgesia effectiveness Epidural and spinal-epidural analgesia are generally highly effective at abolishing pain; women with epidurals are more satisfied with pain relief than women using narcotics by intravenous line or muscle injection; also, women whose epidurals do not include a narcotic component remain fully alert. safety The best available research finds that epidurals:

> Increase the length of the pushing phase of labor. > Increase the likelihood of birth with vacuum extraction or forceps > Reduce the likelihood of spontaneous vaginal birth, that is, birth with neither vacuum extraction, nor forceps, nor cesarean section. > Increase the likelihood of maternal fever, which in turn increases the chance that the baby will have blood drawn to check for infection and will be given antibiotics through an iv intravenous line as a precautio. > Increase the likelihood of serious tearing of perineal tissue into or through the rectal sphincter â&#x20AC;&#x201D; probably due to the increased use of vacuum extraction or forceps. > Can adversely affect newborn behavior compared with unmedicated infants. > Increase the likelihood of newborn jaundice Leighton and Halpern 2002 and Lieberman and O'Donoghue 2002, systematic reviews. Studies disagree or data are not adequate to definitively determine, but epidurals may:

> Increase the length of the cervical dilation phase before pushing of labor. > Increase the likelihood of cesarean section. > Increase the likelihood of postpartum hemorrhage and retained the placenta.

sect ion 09 The First Stage of Labor

> Adversely affect breastfeeding. > Increase the likelihood of inability to urinate and stress inconti nence loss of urine with laughing, coughing, or sneezing in the early days and weeks after birth. > In babies of mothers with fever, increase the likelihood of being born in poor condition and having seizures Leighton and Halpern 2002 and Lieberman and O'Donoghue 2002, systematic reviews. Potential Side Effects of Epidural or Combined Spinal-Epidural Analgesia During Labor Include

> Low blood pressure; this may pose a risk by decreasing blood flow to the baby.

> Inability to move about, even with walking or light epidural; may be due to motor block of lower body, grogginess from narcotics, being attached to equipment, and/or unavailability of support from nursing staff and doctors.

> Inability to urinate. > life-threatening complications severe low blood pressure, respiratory or cardiac arrest, convulsions, severe allergic reaction. Mayberry and col leagues 2002, a systematic review.

> During labor, the narcotic component in the narcotic epidural and the combined spinal-epidural can cause.

> Itching.

> Grogginess Mayberry and colleagues 2002, a systematic review.

Various interventions are used to monitor, prevent, or treat side effects of epidurals, and labors with epidural analgesia are technology-intensive. The following are routinely used with epidural during labor:

> Electronic fetal monitoring efm > Intravenous iv fluids > Frequent blood pressure monitoring Mayberry and colleagues 2002, a systematic review.

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The following interventions are more likely to be used during labor with epidural.

> Pitocin, pit, a drug to intensify contractions. > Drugs for low blood pressure. > Bladder catheter Leighton and Halpern 2002 and Mayberry and col leagues 2002, systematic reviews. As these interventions may have their own side effects, the cascade of intervention is a concern with this pain relief method.

In recent years, anesthesiologists have introduced various changes in technique to reduce side effects of epidurals. These include adjusting timing, using a light dose, and using combined spinal-epidural analgesia. While these alterations are widely believed to have resolved many problems, a systematic look at the studies reveals that either key changes have not had the desired effect or there is insufficient evidence to show that they have Lieberman and O'Donogue 2002, a systematic review.

colophon

a woman-centered birth

book

Evidence Based Practice for Women During Birth

The

Arrival section

Weeks 27 â&#x20AC;&#x201C; 40

Second Stage of Labor

411 is an easy acronym for you to use when measuring contractions. Simply put when they are four minutes apart, lasting one minute, for at least one hour, then call your midwife or doctor, you are in active labor

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Second Stage of Labor When you get to the point where your contractions are close enough so you can use this to help you figure it out. The 411 contractions are four minutes apart, lasting one minute, for at least one hour. When this happens you should call your midwife or doctor. Start utilizing the birthing techniques you learned in the birthing classes about relaxation, and breathing. Keep your body active in switching positions and take a walk or even a nice bath and remember to drink lots of water and go to the bathroom periodically as you may not notice if your body is has to go with all the pressure. Active Labor Phase

› Duration will last about 3 – 5 hours › Your cervix will dilate from 4 cm – 7 cm › Contractions during this phase will last about 45 – 60 seconds with 3 – 5 minutes rest in between › Contractions will feel stronger and longer › This is usually the time that you head to the hospital or birth-center Tips for the Support Person

› Give your undivided attention › Offer verbal reassurance and encouragement › Massage her abdomen and lower back › Keep track of contractions if she is being monitored, ask how the machine works › Go through the breathing techniques with her › Help make her comfortable, prop pillows, get her water, apply touch › Remind her to change positions frequently take her for a walk or offer her a bath › Continue with distractions music, reading a book, playing games › Don’t feel badly if she is not responding to you

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Slow Labor

start | http://www.hencigoer.com/betterbirth/sample/ Award winning medical writer and birth activist Henci Goer gives clear, concise information based on the latest medical studies. Goer will help you compare and contrast your various options and show you how to avoid unnecessary procedures, drugs, restrictions, and tests. In Henci Goer, thinking women have a champion, and maternity caregivers have a challenger. Henci has applied her impressive intellect, wisdom, writing skills, common sense, and wit to produce The Thinking Woman's Guide to a Better Birth. She analyzes and makes sense of a prodigious amount of recent obstetric research, boils it down, and summarizes its findings. And, on the basis of these findings, she makes practical ecommendations for better births. Not one to pull the wool over anyone's eyes, Henci lets the reader in on her whole thinking process, providing scientific references, summaries of the articles, and logical recommendations â&#x20AC;&#x201D; all in a highly readable, user-friendly format. Practical Information for a Safe, Satisfying Childbirth The Slow Labor â&#x20AC;&#x201D; Â Patience is a Virtue Problems with Typical Management Obstetricians treat women laboring slowly the way Peter Pan treated the Lost Boys. He expected everyone to adapt to his ideas of the way things should be. If they didn't, Peter saw to it that they did. For example, the boys entered the Neverland underground home through hollow trees. If a boy didn't fit his tree, James Barrie writes, Peter did something to the boy. So too with obstetric management. Obstetricians have inflexible ideas of how labor ought to go. If your labor doesn't conform to that pattern, typical doctors do something to you to make you fit. There are, as you may gather, a number of drawbacks to this topic of approach. The first is that the standard for labor progress doesn't give you nearly enough time before you are declared over the line. Doctors base their standard on studies from the 1950s and 60s supposedly of normal labors, but many women had interventions that could shorten labor such as oxytocin trade name: Pitocin or pit or forceps delivery. A recent study evaluating healthy women who had no interventions that would affect labor length got very

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different results. For example, the standard says that starting from 4 centimeters cervical dilation, the average first-time mother will take 6 hours to achieve full dilation of 10 centimeters. Doctors set the cutoff defining abnormal progress in dilation at 12 hours for first-time mothers and 6 hours for women with previous births because, according to the standard-setting studies, only 5% of women will take longer than this. However, the new study found that average duration in first-time mothers was 7 1/2 hours, not 6, and the threshold for abnormal, fell at 19 1/2 hours, not 12, in first-time mothers and over 13 1/2 hours, not 6, in women with prior births. The standard also stipulates smooth, linear progress. More than a relatively brief halt is thought to require action. However, averaging many labors together evens out the variations. Individual labors often don't work this way. A second drawback is that obstetric management can obstruct progress. Epidural anesthesia is a notable example of this. Confinement to bed and pushing while lying on one's back may also interfere. Refraining from these things would seem obvious, but mainstream obstetricians rarely recognize their management as the problem. Within the obstetric mindset, all labor difficulties originate in the woman or her baby. Doctors are always the fixers, never the breakers. Finally, doctors have few ideas about what to do. They can rupture membranes, which is supposed to speed things up, although that is debatable see p.250. They can strengthen contractions by giving iv oxytocin, or they can deliver the baby via vacuum extraction, forceps, or cesarean section. This limited repertoire has its own drawbacks. To begin with, weak contractions are only one of several reasons why labor progress may be slow or come to what is in most cases a temporary halt. To cite three â&#x20AC;&#x201D; 01 The baby may be in the occiput posterior position, a hidden factor in as many as half of all cesareans for poor progress. In the posterior position, the back of the baby's head occiput is towards the mothers back. During labor with a baby in the favorable anterior position, contractions push the rounded crown of the baby's head downward against the cervix, which helps open it. However, the posterior baby cant help because the cervix lies against the broad middle of the baby's head.

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Think of it like trying to pull on a tight turtleneck sweater. In addition, most posterior babies cannot fit through their mothers pelvis without swiveling to anterior. 02 Sometimes in early labor the cervix, the neck-like opening of the uterus, impedes progress. During pregnancy, the cervixs job is to keep the baby in against the pull of gravity. In preparation for labor and during early labor, the firm connective tissue in the cervix softens like a dry sponge absorbing water, the cervix shifts forward so as to be in line with the force of contractions, and it effaces, meaning it draws up into the body of the uterus. If the cervix has not finished this process, dilation will proceed slowly if at all. 03 Fear, anxiety, and other psychological issues can also hold up labor. If weak contractions aren't the problem, oxytocin isn't the answer. In addition, rupturing membranes, iv oxytocin, vacuum extraction, forceps delivery, and cesarean section can pose serious risks to baby or mother. These interventions should be the last, not the first â&#x20AC;&#x201D; let alone the only â&#x20AC;&#x201D; resorts, but, unlike most midwives, many doctors don't know any alternatives. As a result of obstetric impatience and injudicious management, in 1995, about one in five usa women who began labor on their own had oxytocin stimulation augmentation, and nearly 176,000 women had cesareans for failure to progress, prolonged labor, labordystocia dysfunctional labor, or ephalopelvic disproportion the baby didn't fit. These diagnoses are all ways of saying the baby didn't come out within somebodys idea of a reasonable time, but reasonable is primarily a matter of philosophy, not physiology, as the enormous variation in the rates of oxytocin use and instrumental and cesarean delivery among caregivers attests. As one editorialist all too aptly put it, Unfortunately, we have spent the last 25 years managing labour without knowing what we do. Active Management of Labor Doctors think they have at last found a way to make labor adhere to their pattern. In recent years active management of labor has swept the English-speaking obstetric world. From the obstetric viewpoint, it has everything to recommend it. Its rigid, precise protocol sounds reassuringly scientific. It is supposed to eliminate cesareans for poor progress even in the face of epidurals, which slow labor down. And best of all, it allows doctors to orchestrate every contraction. However, nothing about active management is as it seems except the control.

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Active management of labor came out of the Dublin, Ireland National Maternity Hospital in the 1970s. According to its developers, it was intended to benefit first-time mothers by preventing prolonged labor. Obstetricians guaranteed that women would not labor for more than 12 hours, that is, 10 hours to dilate and 2 to push out the baby, this being the maximal labor length they thought women could tolerate without pain medication. They never asked women what they thought, though; several studies have shown that women don't like oxytocin because it makes contractions hurt more. Whatever the Dublin doctors believed their reasons for active managment were, their book, Active Management of Labor, reveals who active management really benefits: it spares obstetricians the tedious hours of waiting until full cervical dilation, and it transforms the previously haphazard approach to planning for staffing. Active management attracted attention outside Ireland because in an era where cesarean rates in many countries â&#x20AC;&#x201D; including the usa â&#x20AC;&#x201D; were skyrocketing, the National Maternity Hospital cesarean rate remained stable at about 5% without any apparent disadvantage in maternal and newborn outcomes. Active management was not responsible, however. The cesarean rate was even lower before its introduction. The cornerstone of active management is to rupture membranes once labor is established and give any first-time mother who fails to dilate at 1 cm or more per hour i v oxytocin. It begins at dosages considerably above blood levels produced naturally and ends with dosages that are twice the amount that are permitted in protocols that mimic normal oxytocin levels. The active management oxytocin regimen may seem scientifically precise, but it was not based on any experimental data, and its rationales had nothing to do with science. For example, the Dublin doctors linked the drip rate strictly to contraction frequency to prevent soft-hearted midwives from turning down the drip rate when women complained of the pain. Indeed, the doctors of the National Maternity Hospital state in their book that the laboring womans job in this scheme of military efficiency with a human face is to take orders and not to disturb the labor unit by making the degrading scenes that occasionally result from the failure of a woman to fulfill her part of the contract.. Does Active Management Work? Yes and no. It does tend to shorten labor compared with lower-dose oxytocin regimens, and a few studies have shown it reduces the cesarean rate, although others do not. All this means, though, is

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that if more women can be forced to fit their doctors unrealistic expectations of labor duration — forced to fit their Neverland tree, so to speak — their doctors may operate less often. Also, some of the components that almost certainly contribute to reducing the odds of cesarean for poor progress didn't make the trans-Atlantic crossing. The Dublin protocol mandates a trained woman who never leaves the laboring woman's side. A body of research attests to the benefits of this practice. According to the protocol, women will not be admitted to the labor unit unless they are in progressive labor with effaced cervixes. By contrast, usa. hospitals frequently admit women in very early labor or who are having prelabor contractions. Because progress is normally slow in early labor and nil if the mother isn't in labor, early admission plus impatience often equals unnecessary intervention. As originally conceived, active management assumed a minimal use of epidurals. The Dublin obstetricians believed that the promise of a 12-hour or less labor length would enable women to get through labor without pain medication, another thing they surely didn't consult women about. Epidurals increase the cesarean rate for poor progress even when doctors practice active managment. Active management also has serious drawbacks. First-time mothers are given oxytocin if they don't steadily progress at the average rate — a rate that is probably an underestimate. At one stroke, deviation from the average has been defined as abnormal. Studies have shown that with active management, 40% or more of first-time mothers will receive oxytocin. Telling nearly half of laboring first-time mothers their bodies are incapable of birthing a baby without help could have significant psychological consequences. For example, the use of labor interventions, not surprisingly, links to postpartum depression. And high-dose oxytocin increases the chances of overly long, overly strong contractions, which, by depriving the baby of oxygen, can cause fetal distress and worse. Setting arbitrary time limits on the pushing phase of labor can also lead to unnecessary and potentially risky procedures. In a study of 13,000 labors at the Dublin National Maternity Hospital, the authors reported that three babies delivered by forceps for prolonged pushing phase died of forceps injuries. In this country, doctors generally don't use forceps unless the head is low enough to make forceps relatively safe. However, faced with a time's up situation, they would do a cesarean instead — not exactly an improvement!

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The sad thing about these disadvantages is that active management isn't necessary. Numerous studies have demonstrated that other, less aggressive, regimens work just as well. This, however, begs the real question, which is, Do you need universal amniotomy and liberal use of oxytocin at all? All studies have compared active managment with standard management. This is like comparing the frying pan to the fire. If active management does better â&#x20AC;&#x201D; and it doesn't always â&#x20AC;&#x201D; it's still the frying pan. Midwives, especially those attending births in free-standing birth-centers and homes, have achieved equally low cesarean rates and equally good, if not better, maternal and newborn outcomes with much less use of oxytocin, instrumental delivery, or c-section. In fact, active management makes a good litmus test of whether a practitioner works from the obstetric or midwifery model. If your doctor or midwife thinks its great, head for the door. Rupturing Membranes Amniotomy Oxytocin iv There are several schools of thought behind the various oxytocin regimens for strengthening augmenting labor. Doctors began using iv oxytocin years before researchers had the technology to study its metabolic properties. Older regimens were based on uterine response: start the drip slowly; turn it up every 15 minutes or so until the mother had what seemed to be three adequate contractions in 10 minutes the average rate in normal, progressive labor; and turn the drip down if contractions got too strong, long, or close together. This is probably still the most common method used in the uas today. Low-dose regimens evolved out of research that determined blood levels during functional labor, how long oxytocin took to metabolize, what dosage rate maintained a steady blood level of oxytocin, and how long it took to produce a maximal response when the dose was increased. Low-dose regimens attempt to imitate the natural process, the goal being to reduce the frequency of adverse effects by minimizing the amount of oxytocin used to bring contractions up to par. Proponents of high-dose regimens such as active management think that giving more oxytocin faster will reduce the number of augmentation failures. High-dose regimens start where low-dose regimens typically end. In addition the interval for judging response and deciding whether to turn up the drip is much shorter than the time actually required for uterine muscle to fully respond.

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Vacuum Extraction The apparatus consists of a flexible, plastic cap attached to a handle, tubing, and a vacuum source. The doctor uses vacuum to hold the cap to the baby's head. The doctor then pulls when mother pushes. Vacuum extraction can be used as well to swivel the baby from facing the mothers stomach posterior or side transverse, which is unfavorable for birth, to facing her back anterior. Forceps Delivery To be used safely, the head must be at least partially through the mothers pelvis. The doctor inserts the curved blades on either side of the baby's head, locks them together, and pulls. Forceps can also be used to turn the baby from posterior or transverse to anterior. False Labor Penny Simkin, noted educator and author, uses prelabor contractions instead of false labor because there is nothing false about these very real and sometimes painful contractions, and they do eventually lead to progressive labor. Benefits and Risks of Techniques for Coping with Poor Progress. NonMedical Techniques These include activities such as pelvic rocking or walking, assuming positions such as all-fours or squatting, eating and drinking, massage and acupressure, warm tub baths or showers, and talking. Benefits Studies suggest that activity and positioning can intensify contractions, bring the baby down, expand the pelvis, and turn the baby to the favorable anterior position. Eating and drinking can avoid fatigue and dehydration, which may slow labor. Massage, acupressure, and warm tub baths or showers can ease pain and induce relaxation, which may enhance progress. Warm water immersion has been called the midwives' epidural. Talk can provide comfort, reassurance, encouragement, relieve anxiety, and explore what psychological or emotional issues or adverse environmental elements might be affecting labor. Using these strategies as the primary approach avoids unnecessary use of oxytocin, instrumental delivery, and c-section along with their attendant risks. Risks A full squat may be inadvisable in women with varicose veins or knee joint problems. Women may develop a fever if submerged too deeply for too long in warm water, but this can be alleviated by lifting more of the body out of the water or getting out of the tub, and infection is not a risk with ruptured membranes. As an experiment using a starch-impregnated tampon and iodine in the water proved, bath water does not enter the vagina.

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Explor-ation of possible underlying psychological factors may lead a woman to think that slow progress results from not thinking the right thoughts, which could lead to self-blame. Contrary to common obstetric belief, eating and drinking in labor pose no risks. Nipple Stimulation Benefits Causes secretion of additional oxytocin. Unlike intravenous oxytocin, oxytocin naturally secreted within the brain elevates mood and has amnesiac properties. i v oxytocin cannot cross the blood-brain barrier. Avoids unnecessary use of oxytocin, instrumental delivery, and c-section along with their attendant risks. Risks May produce overly long, overly strong contractions. Stopping or reducing the stimulation will rapidly normalize contractions. Benefits Routine early amniotomy shortens labor by an hour or two. It appears to reduce the incidence of 5-minute Apgar scores below 7 but has no other effects on the infant's condition at birth. It may reduce the use of oxytocin and the number of women who report the most intense degree of labor pain. However, the use of oxytocin, which makes labor more painful, and pain medication, especially epidurals, makes it difficult to determine the relationship between amniotomy and labor pain. Risks Amniotomy increases the incidence of abnormal fetal heart rate patterns. Studies may underestimate this risk because women not having early amniotomy are more likely to receive oxytocin, which also increases the odds of abnormal fetal heart rate patterns. Routine early amniotomy consistently increases the cesarean rate. When data from seven trials in which women were randomly assigned to early amniotomy or not were analyzed meta-analysis, women in the early amniotomy group were 20% more likely to have a cesarean. An additional two studies not included in the meta-analysis also reported more cesareans in the early amniotomy group. The percentage found in the meta-analysis may be low because cargivers in several trials were not able to stop doing amniotomies in the conserve membranes group. Specifically, half or more of women in the

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conserve membranes group in the two biggest trials had amniotomies, albeit somewhat later in labor. If amniotomy does, in fact, lead to c-section, this would tend to minimize the differences in cesarean rates between the two groups. Early amniotomy may also increase the risk of infection. Benefits And Risks Of Amniotomy For Indication Benefits Rupturing membranes may help labor progress, allow closer monitoring when there is concern about the baby, and permit caregivers to determine whether the baby has passed meconium into the amniotic fluid. Risks Studies suggest that early amniotomy may not benefit slowly progressing labors and that late amniotomy may have unpredictable effects. Valerie El Halta, a prominent home birth midwife, suggests one reason why: if the baby is posterior, that is, facing the mother's belly instead of her back, labor often progresses slowly until the baby turns into the anterior position. With membrane rupture, the head may surge downward into the pelvis and get stuck. As for permitting closer monitoring for suspected fetal distress, releasing the amniotic fluid adds to the baby's stress by exposing the umbilical cord to compression during contractions. In addition, one potential cause of fetal distress is that the umbilical cord has slipped between the head and the cervix. Rupturing membranes could then cause prolapse, converting a concerning situation into an emergency. iv Oxytocin Benefits Strengthens contractions by increasing circulating oxytocin levels. May avoid the need for instrumental delivery or c-section. Risks Increases pain. Especially when given in high-dose regimens, oxytocin can produce overly long, overly strong contractions and abnormally high resting uterine-muscle tension, which may deprive the baby of sufficient oxygen. If this is not addressed, it may result in fetal distress abnormal heartrate patterns, brain damage, or death. Treatments include reducing or turning off the drip, giving medication to suppress contractions tocolytics, or if distress continues unabated, cesarean section. With prolonged use, oxytocin increases the risk of postpartum hemorrhage. It may also increase the risk of newborn jaundice. The authors of a recent review of research into oxytocin commented,

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If oxytocin had been discovered in the 1990s we would not sanction its widespread routine use and would conduct further clinical trials. Vacuum Extraction Benefits Adds to maternal pushing efforts and can be used to turn the baby from posterior to anterior. Less likely to injure maternal tissues than forceps and may avoid the need for c-section. Risks Doctors may be more likely to perform an episiotomy, although it is not necessary for this procedure. Episiotomy introduces several maternal risks. As for the baby, the vacuum cup may cut the baby's scalp, although plastic cups are less likely to do this. Vacuum extraction can cause a blood-filled swelling cephalohematoma beneath the cup, which increases the likelihood of developing jaundice. Occasionally, profuse bleeding occurs beneath the scalp subgaleal or subaponeurotic hemorrhage. Unlike the relatively benign cephalohematoma, this bleeding poses a grave risk. Bleeding within the brain is another rare, serious complication. The growing number of reports on serious complications and deaths resulting from vacuum extraction has caused the fda to issue a warning advisory about this procedure. Forceps Delivery Benefits Delivers the baby when the mother cannot accomplish the birth on her own. Forceps can also be used to turn the baby into the favorable anterior position. May avoid the need for c-section. Risks As typically practiced in the usa, forceps poses little risk of life-threatening injury to the baby. However, the baby's face may be cut or bruised, the collar bone broken, or there may be injury, usually temporary, to a nerve complex that controls the arm brachial plexus injury or Erbs palsy or to the nerve that controls the facial muscles. Forceps sometimes also cause cephalohematomas. Forceps delivery increases the risk of shoulder dystocia the shoulders hang up during the birth, which can be life-threatening, but is almost always resolved without incident. Using forceps to rotate the baby 90 or more can cause spinal cord injury. Doctors will almost certainly perform an episiotomy, although it is not always needed, which introduces several maternal risks. Forceps delivery with episiotomy greatly increases the risk of anal tears,

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which, even though repaired, may permanently weaken the anal sphincter. The forceps may also cut or bruise the vaginal wall. For these reasons, forceps increase the probablility of severe pain in the days after birth. Cesarean Section Benefits Deliver the baby when no lesser means will serve, and the baby will be endangered by continuing labor. Risks While relatively safe as major surgeries go, nonetheless, cesarean section poses considerable risks short-term and long-term to the mother and to any future pregnancies. Strategies to Avoid the Need for i v Oxytocin, Instrumental Delivery, and Cesarean Section Have a patient caregiver who sees his or her role as attending your birth not delivering your baby. Sheila Kitzinger, world-famous British author and founder of Britains National Childbirth Trust, says that the most invasive and potentially dangerous technology â&#x20AC;&#x201D; because from it proceeds all others Â is the clock. Have your baby at a free-standing birth-center or at home. Oxytocin use rates and instrumental and cesarean delivery rates are much lower for out-of-hospital births. Hire a professional labor support person. She will know nonmedical techniques to help keep or get your labor back on track. She will also provide continuous support, encouragement, and reassurance to you and your partner. Have confidence in yourself and your body. Doctors tend to instill doubt. The fact that cesarean section is so common these days does the same: if you don't think you can birth your child, it may become a self-fulfilling prophecy. Have realistic expectations of labor length and difficulty. Impatience and frustration are your worst enemy. They can lead you to make choices you may regret.

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Address emotional issues that may be problematic in labor. For an example, women who experienced sexual abuse in childhood or have prior traumatic birth experiences or have strong control issues may sometimes have difficulty surrendering to the labor. If this is true for you, consciousness of this can help you and those with you work out strategies to prevent or cope with their potential effects on labor. Please, though, do not blame yourself if labor is slow and you cant fix it. Avoid Induction of Labor. Unless there are medical reasons to go to the hospital early in labor, stay home until labor becomes active. If you aren't sure, during the day you can go into your caregivers office to be checked, and at night, they can check you at the hospital. don't stay, though, if not much is happening. Studies show that women who are admitted in prelabor or very early labor are more likely to have oxytocin, instrumental vaginal delivery, and c-sections. Refuse a cesarean for poor progress prior to active phase labor. This means at least 3 â&#x20AC;&#x201C; 4 cm dilation if you have had children before and 4 â&#x20AC;&#x201C; 5 cm dilation if you haven't. Both the usa and Canadian obstetricians professional organizations state that cesareans for this reason should not be done in this early stage of labor. Avoid frequent vaginal exams, but when you have them, get information on more than just dilation. Avoid frequent exams because finding there is little or no change in dilation can be intensely disappointing. Find out about the state of the cervix, how far down the baby is, and, if possible, the baby's position. You may be making important progress even though you are not dilating, and often, advances in these areas may be necessary before dilation continues, so don't be dishartened. In labor, stay active, change positions frequently, maintain liquid and calorie intake, use warm tub baths or showers, and avoid flat-on-the-back or nearly flat-on-the-back pushing positions. These strategies promote good progress. You can bathe or shower with an i v as it can be covered with plastic and taped. You can bathe with ruptured membranes. Take steps to rotate a posterior baby. don't wait until you are dilated enough for someone to tell the baby's position by feeling her head vaginally. Assume a posterior baby if contractions are strong but produce little progress. None of these recommendations will hurt if the baby isn't posterior. Activities

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such as climbing stairs, crawling, pelvic rocks, and hip swivels help jiggle the baby around. Assuming an all-fours position, or an open lunge during the cervical dilation phase and all-fours or squatting during pushing uses gravity to swing the baby's back into your belly or the leverage of your legs to expand the pelvis. Likewise, the double-hip squeeze opens the pelvis. Assuming a knee-chest position in early labor this may be too uncomfortable in active labor disengages the head from the pelvis, and the dangle during pushing elongates the torso, both of which give the baby more room to come around. And some midwives may offer to turn the baby manually early on during a vaginal exam. This will be painful but can transform the labor according to midwives who do it. However, there are no formal data on the efficacy or safety of this procedure. Avoid Epidural Anesthesia. Epidurals slow labor, cause persistent posterior babies, and increase the risk of cesarean for poor progress. Nipple stimulation can intensify weak contractions and can avoid the need for iv oxytocin. Stimulating the nipples causes the release of additional oxytocin. Stimulation can be manually, by electric breast pump, or via a tens transcutaneous electronic nerve stimulation unit, a physical therapy device that painlessly delivers a low electric current through pads applied to the skin. If you require oxytocin, make sure it is given a fair trial. A study of a protocol mandating at least 4 hours of adequate contractions on oxytocin in women with arrested labor progress and longer if contractions could not be brought up to par achieved an 8% cesarean rate. This was despite nearly all women having epidurals epidurals slow labor. If, as is not uncommon, cesareans had been done after 2 hours on oxytocin with inadequate progress, the cesarean rate would have been 23%. Refuse an instrumental delivery or cesarean section recommended solely on an arbitrary time limit. Both the Canadian and usa obstetricians professional organizations state there is no need to deliver the baby provided some progress is being made and the baby is doing well. Nonmedical factors often determine the diagnosis and treatment of slow labor. A labor support professional describes the glaring discrepancies between nursing notes and mothers recall versus physicians notes for five clients previous cesareans. She writes that these cases are typical.

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Case 1 The nurse charted complete cervical dilation, a head engaged in the pelvis, and the mother pushing well. The obstetrician wrote he performed the cesarean because the mother was 6 cm dilated and the head was high. The father remembered overhearing the obstetrician tell someone on the telephone to go ahead to the party; he would be there soon. Case 2 The doctor told the mother she was too short for vaginal birth. In labor, he said she was not progressing satisfactorily and insisted that she have an epidural in case a cesarean was necessary. The nurse noted that she started the mother pushing before complete dilation and that she had been pushing for 35 minutes when the doctor decided on the cesarean. He recorded that she was fully dilated yet still had a cervical rim and that she had been pushing for 2 hours. The author comments that the nurse likely started the mother pushing early to try to forestall the cesarean. Case 3 The doctor's notes contained nonsense statements such as the patient never even separated. The nurse charted the baby's head as being 2 centimeters below what the doctors notes indicated. The mother had a cesarean after only an hour of pushing, even though she had had an epidural. Case 4 The mother comments that she agreed to the cesarean only because she was told she had not dilated when, in fact, the nursing notes state she achieved 3-4 centimeters dilation. Case 5 the mother felt no urge to push until they sat her up to do an epidural preparatory to a forceps delivery. They ignored her when she said she now had to push and continued with the epidural. The forceps attempt failed, and the doctor proceeded to a c-section. Almost all hospitals plot labor progress on a graph that has centimeters dilation on the vertical axis and time on the horizontal axis. Researchers found that changing how data looked on the graph could alter obstetrician recommendations. They gave 16 obstetricians six hypothetical equivocal cases sufficiently separated in time that the doctors would not realize they were seeing the same cases twice. In three cases, researchers made it appear that labor was taking longer by increasing the distance between time marks on the horizontal axis in one of the pair. In the other three cases, they either graphed early labor along with active labor or graphed active labor only and

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described early labor in the case notes. Out of 96 decisions, the presentation that visually suggested longer labor resulted in 14 more recommendations for c-section, more for instrumental delivery, and 11 more for giving oxytocin. Intervention rates vary according to the individual practitioner's personal approach. Researchers looked at management according to whether 11 obstetricians had a low, medium, or high cesarean rate. Cesarean rates for poor progress ranged from 3% to 16% in low-risk first-time mothers despite similar maternal and infant characteristics. While doctors in the low cesareanrate group induced labor less often and started oxytocin later in labor, they also used oxytocin more often and in higher doses. From this the authors conclude that oxytocin is the key to reducing cesareans, which, as midwifery statistics attest, isnt so. Another study grouped 550 first-time mothers according to whether their doctors cesarean rate for poor progress was low 6 â&#x20AC;&#x201C; 7%, or high 9 â&#x20AC;&#x201C; 15%,.Women in both groups were equally likely to have epidurals, oxytocin, and to have doctors rupture membranes, all factors influencing progress. However, doctors in the high cesarean-rate group were more than three times as likel, 2.5% versus 8%, to perform a cesarean for poor progress during pushing. Eight babies in the low cesarean-rate group had broken collarbones or facial nerve injuries from forceps deliveries. The authors comment that these might have been avoided by allowing more time to push. Convenience is a Factor A study of cesarean for poor progress in 4,200 firsttime mothers found that more cesareans were performed in the evening than at night during sleep hours or during the day when obstetricians had office hours and scheduled surgeries. A study comparing first-time primary cesarean rates among three hospitals with private physicians and one with salaried physicians working shifts found that fewer cesareans for poor progress were done at two of the private hospitals at night than during the day or evening This did not occur at the hospital where doctors worked shifts or at the other private hospital. Cesarean rates were 6% at the hospital with shifts versus 9% at the private hospital where time of day did not matter and 11% at the hospitals where it did. High-dose Oxytocin Regimens Pose Risks The major risk of high-dose oxytocin regimens is uterine hyperstimulation, that is, overly long, frequent, and strong contractions along with overly high uterine-muscle tension in between contractions. Hyperstimulation reduces the baby's oxygen supply, which can cause fetal distress. Researchers at a hospital using a high-dose protocol found

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that babies were twice as likely to be born with low blood ph, a symptom of oxygen deprivation in labor, when the mother had oxytocin. Several comparisons of high-dose versus low-dose protocols and protocols with short intervals between dose increases versus protocols that have longer intervals between dose increases have found that more women experience hyperstimulation and fetal distress with high-dose, and/or short-interval regimens In one trial of active management, seven women, more than one-third, experienced hyperstimulation, and one had a cesarean for fetal distress. In another trial, staff ignored a case of hyperstimulation, and the baby died. The National Maternity Hospital obstetricians conducted a large study 13,000 labors of electronic fetal monitoring in which they found that newborn seizures, the strongest evidence of oxygen deprivation in labor, were associated with oxytocin use and longer labors, the very labors for which active management prescribes oxytocin. In another active managment study, nurses did not turn down the oxytocin as protocol dictated in 4% of the women experiencing hyperstimulation. If staff ignore hyperstimulation 4% of the time in a hospital with a standardized protocol, what might the percentage be under less controlled circumstances? Oxytocin-caused hyperstimulation may be a particular problem when the baby has passed large amounts of stool thick meconium into the amniotic fluid. The danger with meconium is that the baby will inhale it and develop a life-threatening pneumonia. Researchers studied 250 women with thick meconium whose labors stopped progressing and whose babies were not in distress. Over 40% of women given oxytocin who later had a cesarean for fetal distress had babies who inhaled meconium versus 6% of babies of mothers given oxytocin who went on to vaginal birth, a percentage comparable to the 5% who had cesareans and no oxytocin. The authors speculated that when oxytocin caused uterine hyperstimulation, the baby's oxygen level dropped, causing the baby to reflexively gasp in meconium. Active Management is at Worst, Ineffective, and at Best, Unnecessary While several before-and-after studies have shown statistically significant meaning unlikely to be due to chance reductions in cesarean rates with high-dose oxytocin regimens, four trials randomly assigning women to active management or standard management have not. It is a truism that treatments almost always

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look better in nonrandomized trials because randomized controlled trials eliminate many sources of bias. For example, with before-and-after trials, the intent to lower the cesarean rate and the belief that the new protocol will work can become a self-fulfilling prophecy. Two analyses of outcomes from multiple randomized controlled trials meta-analysis agree that rupturing membranes and aggressive use of oxytocin offer no benefits. In one, researchers evaluated data from trials of the components of active management to determine their efficacy. Rupturing membranes amniotomy shortened labor somewhat but didn't lower cesarean or instrumental delivery rates. Early use of oxytocin increased pain and uterine hyperstimulation, but conferred no benefits. Combining liberal oxytocin use with rupturing membranes shortened labor, but still didn't decrease cesarean or instrumental deliveries. By contrast, a female labor companion doula reduced the use of pain medication, instrumental delivery, and c-section and improved the condition of babies at birth. The authors concluded that female labor companions appeared to be the effective component of active management. In the other meta-analysis, researchers collected 12 trials of active management versus usual care to-talling 5,100 women. They, too, found a reduction in labor length but no reduction in instrumental or cesarean delivery rates with active management. Some of the trials suggested that active management increased epidural and hemorrhage rates. A developer of active management analyzed the usefulness of active management and concluded that active management shortened labor overall by shortening early labor, which normally proceeds at a leisurely pace. Active management had no effect on active labor, the phase of labor where a slow down or halt indicates a possible problem. Undeterred, he and his co-author converted this to a benefit by declaring slow dilation in early labor to be inefficient and correctable by application of active management. Taken together, four small randomized controlled trials, 169 women in all, show that compared with less aggressive management, active management also fails as treatment for longer delays in progress than one hour, the usual delay that triggers oxytocin use. Overall, the cesarean rate was 20% in the active management group versus the 19% in the conservatively managed group.

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Active Management Does Not Eliminate the Adverse Effects of Epidurals Half of the first 1,000 first-time mothers to give birth at the Dublin National Hospital in 1992 had epidurals versus 1% of the first 1,000 first-time mothers in 1973. The cesarean rate, which was 5% in 1973, had doubled to 10% in 1992. Another study of 9,000 first-time mothers giving birth at the Dublin National Hospital in 1990-1994 reported that while the overall cesarean rate was 11%, it was 24% among women having prolonged labor of whom 90% had epidurals.An additional 40% of women with prolonged labor had an instrumental delivery the active management protocol limits pushing phase to 2 hours. Having an epidural increased the likelihood of having a prolonged labor six-fold, 42-fold if the epidural was placed early in labor. A usa study of active versus standard management in 400 first-time mothers found that even though active management helped women with epidurals somewhat, the cesarean rate was still 11% versus 3% in women not having an epidural. Over 85% of all cesareans were in women who had epidurals. Simple, noninvasive strategies may safely and effectively enhance labor progress during the dilation and pushing phases of labor as well as make for a pleasanter labor. I have five studies that compared walking and staying upright in labor with lying in bed and two studies comparing walking with oxytocin augmentation for slow labors. All that can be said for certain is that none found any harm in allowing freedom of activity and position, a statement that cannot be made of oxytocin, and that women who walked liked it â&#x20AC;&#x201D; 99% in a large study that asked women about this. Beyond that it is difficult to draw firm conclusions because the studies all have problems. For an example, one major factor is that women could choose whether and how long to walk. The reasons why women would agree or decline to walk and how long they walked would undoubtedly have to do with the kind of labor they were having, which, then could affect whether walking seemed to help or not. It could go either way. Women having more painful, nonprogressive labors with, say, a posterior baby might prefer to lie down as might women in intense, rapidly progressing labors. A recent, large trial randomly assigning women to walk or not found that women who declined walking had shorter labors, which suggests that the second possibility was the case.

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Three studies concluded that walking had benefits, two of them that first-time mothers had the most to gain. Two trials, one of 370 women and one of only 40 women, that assigned women to walk or to bedrest groups found that first-time mothers who walked shortened labor by about 1 1/2 hours compared with the group assigned to bed rest. A third study analyzed the effect of walking and staying upright in 1,700 women attended by midwives. Women who stayed upright had half the rate of instrumental and cesarean delivery combined 3% versus 6%. Labor was not shortened, but the midwives recommended walking to women making slow progress. The two largest studies, both random assignment trials, found no benefit. The first, of 630 women, found no reductions in oxytocin use, instrumental delivery, or cesarean section. However, only about half of women in the walking group walked in early labor and virtually none walked in late labor. The other, involving 1070 women, found no differences in length of labor, use of oxytocin or pain medication, or instrumental or cesarean delivery. This held true for both first-time mothers and women with prior births. However, in the walking group, nearly one-quarter never walked at all, and of women who walked, half walked less than an hour. Laboring in a Water Tubs I have six studies evaluating warm tub baths in labor. A randomized trial of 110 first-time mothers found a significant improvement in cervical softening and effacement and a trend toward faster dilation in the bath group. Compared with nonbathers, bathing stabilized pain intensity for about half an hour before it began to rise again. Eighty percent of bathers said the bath soothed pain and relaxed them, and 90% would want to bathe in a future labor. Women also tended to have oxytocin less often. Another study compared outcomes between 88 women taking a 1 1/2 to 2 hour bath with 72 similar women who chose not to bathe. Bathers dilated twice as fast in the bath. They hurt more before the bath and experienced greater pain relief from the bath compared with nonbathers. Nonbathers were more likely to have narcotic pain relief and twice as likely to have oxytocin. However, this study did not involve random

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assignment, so there may well be confounding factors. In the third study, researchers compared 89 bathers with 89 similar nonbathers and found that bathers were less likely to receive oxytocin or to have pain medication, but this may be because bathers were participants in a study of in-hospital homestyle care whereas nonbathers received standard care. Researchers in a fourth study randomly assigned 800 women to be offered a bath or not. Only haf the women in the bath group actually bathed and these were more likely to be first-time mothers with less cervical dilation. This may explain why bathing did not shorten labor or lessen oxytocin use. Bath-group women were 25% less likely to use pain medication. Bathers reported that the tub relieved pain and helped them relax. The fifth study found no benefit in 45 women who bathed in labor verus the who didn't.48 In the sixth study, researchers randomly assigned 200 women to bathe either early, before 5 cm dilation, or late, after 5 cm dilation. The early bathers averaged longer labors. However there were more first-time mothers in the early bath group 72% versus 60%, and early bathers were more likely to have epidurals 27% versus 9%, both factors that make for slower labors. And if there were an effect, it could be either that early bathing slowed labor or late bathing speeded it up. None of these six studies plus a seventh that only evaluated infection rates in 540 bathers versus 850 nonbathers found an increased risk of maternal or infant infection. This was despite the fact that all women had ruptured membranes in three of the studies. Women admitted to the hospital in early or prelabor may be more likely to have labor interventions.

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Evidence Based Practice for Women During Birth

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Final Stage of Labor

This is it. Your emotions might be all over the place. This is when a doula and your support persons are really going to come to your rescue. They are there to help you emotionally and physically as this is the hardest phase.

sect ion 11 The Final Stage of Labor

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Final Stage of Labor This is it. Your emotions might be all over the place here. This is when a doula and your support person is really going to come to your rescue. They are there to help you emotionally and physically as this is the hardest phase. But be glad it's also usually the shortest. Your contractions will be much closer together and the urge to push will be undeniable and you should let your care provider know that you are feeling the urge to push.

Transition Phase › Duration will last about 30 min to 2 hours › Your cervix will dilate from 8 cm to 10 cm › Contractions during this phase will last about 60 – 90 seconds with a 30 second – 2 minute rest in between › Contractions are long, strong, intense, and may overlap › This is the hardest phase but thankfully the shortest › You may experience hot flashes, chills, nausea, vomiting, or gas

Tips for the Support Person

› Offer lots of encouragement and praise › Avoid small talk › Continue breathing with her › Help guide her through her contractions with encouragement › Encourage her to relax in between contractions › Don’t feel hurt if she seems to be angry, it’s just part of transition! › Nausea, vomiting › Feelings of fear, helplessness

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Evidence Based Practice for Women During Birth

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The Breech Position

Most of the discussions about breech birth in medical literature ignore the possibility of the undiagnosed breech at all, but it can and does happen. For this reason, it is

vital for midwives, physicians, paramedics, nurses, & emergency medical technicians to be familiar with the basic principles and maneuvers of a breech birth. Three Surprise Breeches 2005 Author Ina May Gaskin CPM ÂŠ 2005 Midwifery Today

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The Breech Position start | Three Surprise Breeches 2005 Author Ina May Gaskin CPM ÂŠ 2005 Midwifery Today Complications may not be what we ask for, but sometimes we get them anyway. I've been blessed to deal with three surprise breech presentations in less than a year. Each birth was instructive in its own way. Always Prepared The first surprise was a first birth for the 38 â&#x20AC;&#x201C; year â&#x20AC;&#x201C; old motherto-be. Two very experienced midwives, my partners, did three vaginal exams in labor. Each time they clearly palpated the baby's head. The mother then chose to labor for the next few hours in the water tub. Later, after the baby had been born, she said that during this period she felt a lot of unusual movements from the baby. In labor, once dilation was complete, the mother wanted to get out of the water. She squatted as she pushed. I was sitting on a chair next to her, and after one powerful push, I reached down to assess with my fingers how far the baby's head had descended. Looking at a dark blob on my withdrawn fingers, I thought, That's not old blood. That's meconium. I knew what that meant. Sure enough, a few more pushes brought down the bottom of a frank breech girl. Her legs, arms and head were all born without real difficulty. This birth taught me that it truly is possible for the babies of first-time mothers to turn from vertex to breech during labor. I have attended several labors of grand multiparous women in which the baby changed from vertex to breech during labor, but this was the first time I had encountered this phenomenon in a first-time mother. Most of the discussions about breech birth in medical literature ignore the possibility of the undiagnosed breech at all, but it can and does happen. For this reason, it is vital for midwives, physicians, nurses, paramedics, and emergency medical technicians to be familiar with the basic principles and maneuvers of breech birth.

sect ion 12 The Breech Position

The Burns-Marshall Maneuver The second breech birth was to be the 12th baby of an Old Order Amish couple. The mother had several complicated births before; most of her births had been long and difficult. She was originally booked with one of my partners, who also works two-day shifts sometimes at an area hospital. My partner's intuition told her that she might miss this birth, so she took me and another partner to meet the woman in case we were needed. Checking the baby's presentation, I found it to be a frank breech. As easy as could be, I nudged the baby's head from breech to vertex position, then asked the mother to get up and walk around for a while, in hopes that the baby would remain head-down. That night the father asked his neighbor to phone me to say that his wife was in labor. When my partner and I reached her side, I found the baby presenting breech again, and the water bag had broken. With the water broken and the baby's bottom deep in the pelvis, external version didn't not seem like a good idea. Labor was hard. The Amish woman walked and walked. Then she sat in her rocking chair for a while. She prayed, supported by her husband, who was very tender and helpful. As is my usual practice in a breech labor, when she began to want to push, I asked her to keep from bearing down until the urge couldn't be squelched. This is my strategy for keeping the cervix at maximum dilation for the after coming head. By the time the mother was ready to push the baby out, she was kneeling on the floor, leaning forward with her torso supported by a chair. I have assisted many breech babies birthed from this position and prior to this birth never had any problem in delivering the head. She pushed and pushed, and little by little, the baby's bottom descended. I wondered briefly what I would do if the baby's head were extended, never having dealt with this complication during a breech labor in the kneeling position.

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As I mentioned earlier, this woman tended to have long, drawn-out labors. Her pregnancies had been close together. At 39, she didn't have the stamina she had when she was younger. Whatever the reason, her uterus no longer contracted effectively enough to help descent once the bottom was born. I had to reach up very high to be able to reach one of the baby's arms and sweep it down across her face. The second arm was easier to extract, but her head remained quite high in the pelvis, chin extended. I reached higher with my fingers â&#x20AC;&#x201D; impossibly high, it seemed â&#x20AC;&#x201D; but before I could reach the baby's mouth. Pressing my fingers against her cheekbones, I tried to flex her jaw onto her chest but couldn't budge it. I wondered briefly if we might be able to establish an airway, but that clearly wasn't going to work either. The head was far too high for that. What did work to free the head was to help the mother turn from the kneeling position to lying on her back on the floor. This change of position made it possible for me to easily flex the head and deliver it, once the mother was lying on the floor. Would it have been easier to do all this on the bed? Yes, I think it would have. I still like the kneeling position for most mothers, but I will keep in mind that it had its limitations for this grand multiparous woman with her sudden inability to push with the half-born baby. I believe the chief factors leading to this difficulty were uterine exhaustion and the slackness of her abdominal muscles. We had to work on the baby for a few minutes. She was born with a heart rate slightly less than 100 and plenty of fluid in her airway. Back blows between the shoulder blades were needed to clear her airway; cpr brought her around so that her 10 â&#x20AC;&#x201C; minute Apgar was 8. From that point on, the baby very did well.

sect ion 12 The Breech Position

It is sad that even in a progressive place like SF there are very few doctors or nurses who have the expertise or are willing to learn how to perform and aid in a breech birth.

Given another breech presentation for a grand multiparous woman, I would probably prefer a delivery position on a bed, with her bottom near its edge. This position is good for use of the Burns-Marshall maneuver, when the after coming head is extended. There are two ways of determining that the head is extended. First, the baby's hairline at the nape of the neck is not visible. That sign alone shouts do not attempt to deliver the head yet, as you could break the babies neck The second way of knowing is that your fingers can feel that the baby's chin is not flexed onto its chest.

The remedy is to make sure that the mother's bottom is right at the edge of the bed. Allow the baby's body to hang, it's a good idea to have a warm receiving blanket around the baby, unsupported for five to 10 seconds. This is usually long enough for the weight of the body to pull the baby's head into the flexed position. Once the hairline is visible, it is safe to deliver the head. Better Safe than Sorry My third surprise breech in a year was with a first time mother who was 35 weeks pregnant when she arrived at our center. An abdominal examination revealed the frank breech presentation of her baby. The plan was to try an external version after she had a good night's sleep. However, her water bag broke that night, and labor began. Although we palpated and estimated her baby to be a little over six pounds, it did not seem wise to attempt an out-ofhospital birth because of the baby's gestational age. The obstetrician on duty at the hospital that day did agree to a trial of labor, but after ten hours and no food, including an hour and a half of oxytocin augmentation, the decision was made to do a cesarean. The baby weighed 6 lb 11 oz, and his head measured 36 cm. Clearly five weeks early, he had transient respiratory distress mild retractions, but after a few hours in the nursery, he latched well onto his mother's breast and stayed with her from then on.

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The lesson of this third birth? It is better to be safe than sorry. While it is possible that this baby could have been safely born at our center, it seemed unwise to attempt an out-of-hospital birth when there had been so little time to form a close relationship with the mother-to-be and her family members. Ina May Gaskin, cpm, is the founder and director of The Farm Midwifery Center in Tennessee usa. She is the author of Spiritual Midwifery 1975 and Ina May's Guide to Childbirth 2003. She was president of Midwives' Alliance of North America m a m a from 1996 to 2002 and is a prominent national and international speaker. She has been a home birth midwife for 34 plus years. end |

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Evidence Based Practice for Women During Birth

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The Circumcision Decision k Problems with the penis, such as irritation, can occur with or without circumcision. l With proper care, there is no difference in hygiene. m There may or may not be differences in sexual sensation in adult men. n There is an increased risk for a uti in uncircumcised males, especially babies under 1 year. o However, the risk for a uti is still less than 1 percent. p Newborn circumcision provides some protection from penile cancer, which only occurs in the foreskin. However, the risk of cancer is very low in developed countries such as the United States. Parents.com

Your Decisions are Key

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Your Research

sect ion 13 The Circumcision Decision

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The Circumcision Decision Congratulations on the birth of your baby boy! Perhaps you already have an opinion on this subject so or maybe not. Take a moment and lets review a few things about circumcision that are not widely known. The decision to have or not have your son circumcised may be a difficult one. You will need to consider the pros and cons of circumcision. Your culture, religion, and personal preferences will also affect your decision. Circumcision Is the removal of the skin covering the access to the head of the penis, the glands called the foreskin. Circumcision is usually performed in the first two to three weeks. Making a Decision The American Academy of Pediatrics does not find sufficient evidence to medically recommend circumcision or argue against it. Despite the possible benefits and risks, circumcision is not essential or detrimental to your sonâ&#x20AC;&#x2122;s health. Typically the decision for a circumcision is usually based on religious beliefs, concerns about hygiene, or other cultural or social reasons. Circumcision is a common procedure in the United States, Canada, and the Middle East. According to the National Center for Health Statistics, 65% of all newborn boys, about 1.2 million babies, are circumcised annually in the United States. Circumcision is less commonly performed in Asia, South America, Central America, and most of Europe. Before making a decision, you should understand how the procedure is performed, what risks are involved, and what the benefits are as well. How it is Performed The procedure takes only about 5 to 10 minutes and will usually be performed in the hospital before you take your baby home. Your baby will be placed in a padded restraint chair and given local anesthesia. A device will be inserted under the foreskin to hold it away, protecting other parts of the penis. The doctor will cut off the foreskin and cover the incision with an antibacterial ointment. When the Procedure should Performed Most doctors recommend that a circumcision procedure be done within the first few days of life; however, others will recommend you wait two or three weeks.

sect ion 13 The Circumcision Decision

How Pain Controlled During the Procedure The American Academy of Pediatrics recommends the use of pain relief measures for the procedure. Some types of local anesthesia used to make the procedure less painful include: a topical cream, a nerve block via injection at the base of the penis, and a nerve block via injection under the skin around the penis shaft. Other non-medical techniques can help reduce the level of stress include securing the child in a padded restraint chair and giving him a sugar-dipped pacifier. Benefits of Circumcision The American Academy of Pediatrics says the benefits of circumcision are not significant enough to recommend circumcision as a routine procedure, and circumcision is not medically necessary. As always it is important to discuss the decision with your doctor. ui Infections Prevention of urinary tract infections in infants. Prevention of penile cancer in adult men. This also may reduce the risk of an std's. Risks of Circumcision The risks of circumcision are minimal. Some boys experience bleeding and infection. Irritation can result from friction by the diapers and ammonia in the urine. Application of petroleum jelly can often relieve irritation. I n rare cases, too much skin is removed from the penis, leading to painful erections in adulthood. Opponents of circumcision claim that removal of the foreskin allows for desensitization of the adult glans and reduced sensitivity during sexual intercourse.

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Warning Signs after Circumcision After your son’s circumcision, you will need to contact your doctor if you notice any of the following symptoms.

› If your son does not urinate normally within 6 — 8 hours after the circumcision › If the Plastibell device, a device that it used during the procedure does not fall off within 10 to 12 hours.

Persistent Bleeding Redness around the tip of the penis that gets worse after three days. Fever Is a sign of infection and if you have the presence of pus-filled blisters or yellowish discharge When should a circumcision procedure not be performed? Examples

› Your doctor may want to delay the procedure or chose not to perform it at all. › If your baby is premature or medically unstable › If your baby was born with physical abnormalities of the penis that need to be corrected surgically, because the forekin may eventually be used as part of a reconstructive operation

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Evidence Based Practice for Women During Birth

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Keeping the Placenta The use of placenta can bring down motherâ&#x20AC;&#x2122;s milk as well as increase the supply of milk. It can tone down stress, if the mother is nervous, feeling stressed. If milk becomes difficult to digest, baby develops gas. Conversely, it can tone down stress in the baby or be used prophylactically to prevent stress prior to festivities or noisy situations. The use of the Placenta can also be used to ease difficult weaning of the baby. Birth Matters 2012 Birth Matters, Changing lives one baby at a time

sect ion 13 Keeping the Placenta

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Keeping the Placenta start | Birth Matters 2012 Birth Matters, Changing lives one baby at a time The placenta is an invaluable part of the postpartum healing process for both mother & child. For thousands of years, the Chinese have revered this powerful substance in their Medical training as regenerative to the essence life, the placenta aids in the recovery from childbirth, provides hormones, augments lactation, shortens bleeding time, and prevents mood jags; ultimately aiding the special postpartum period of bonding and nurturance. Placenta is an Oral Tradition The following is based on the practical experience of countless midwives and practitioners of alternative medicine. Women who use placenta have said it makes them feel nurtured, and report less emotional flux during postpartum. Recently hormones in the placenta have been shown to alleviate postpartum depression. Women heal more quickly from trauma experienced during labor, as well as from caesarean section trauma like incisions in the abdominal wall. While it is difficult to say that the placenta is responsible, there are physiological reasons that may be at work. The placenta is full of natural oxytocins, which are responsible for â&#x20AC;&#x201D; contracting the uterus back to pre-pregnancy size â&#x20AC;&#x201D; minimizing postpartum bleeding. The most common cause of maternal death from birthing is hemorrhage; indigenous peoples successfully treat hemorrhage immediately with a piece of raw placenta placed between the cheek and gum. In addition, the use of placenta can bring down motherâ&#x20AC;&#x2122;s milk as well as increase the supply of milk. It can tone down stress milk, the mother is nervous, feeling stressed, milk becomes difficult to digest, baby develops gas. Conversely, it can tone down stress in the baby or be used prophylactically to prevent stress prior to festivities or noisy situations. Placenta can also be used to ease difficult weaning of the baby. end |

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Evidence Based Practice for Women During Birth

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Weeks 27 – 40

Cord Blood Banking

Your baby’s Cord Blood could be a valuable resource for you or another family member. Whether through a foundation, a non-profit blood banks or medical

institutions, there are many locations that will collect, and process, then use the stem cells from your baby’s cord blood to help you or other people.

cbr cordbloodbanking.com

Your Decisions are Key

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section 15 Cord Blood Banking

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Cord Blood Banking start | cbr cordbloodbanking.com Cord blood is the blood that remains in the umbilical cord and the placenta following birth, which is usually discarded. Cord blood banking uses external facilities as a place to store and preserve your baby’s cord blood. When looking at storing your baby’s cord blood, it is important to use a cord blood bank accredited by the American Association of Blood Banks, a a bb. Reasons for Cord blood Banking The cord blood of your baby serves as an abundant source of stem cells, which are genetically distinctive to your baby and your family. These stem cells function as dominant cells because they contribute to the development of all tissues, organs, and systems in the body. Stem cells can transform into other types of cells in the body and create new growth and development; they are the building block of the immune system. This transformation of cells provides physicians with a way to treat leukemia and some inherited disorders. More diseases and conditions treated by stem cells. Cord blood stem cells have the same ability to treat disease as bone marrow does, however, there is significantly less rejection. Banking your baby’s blood and stem cells in a facility provides you with a type of insurance. Hopefully, you will not need to access your baby’s stem cells to address a medical problem, but using a cord blood bank can give you peace of mind that this valuable resource is there if you need it. The stem cells from your baby’s cord blood may be able to treat certain diseases or conditions of a parent or sibling. How Cord Blood is Collected The cord blood collection process is simple, safe, and painless. It is usually completed in less than five minutes by your health care provider. Cord blood collection does not interfere with delivery and is possible with vaginal or cesarean deliveries. Your health care provider will use one of two options for cord blood collection: syringe or bag method. Syringe Method a syringe is used to draw blood from the umbilical cord shortly after the umbilical cord has been cut. The process is basically the same as drawing blood for a blood test.

section 15 Cord Blood Banking

Bag Method the umbilical cord is elevated to cause the blood to drain into a bag. The syringe or bag should be pre-labeled with a unique number that represents your baby. Cord blood may only be collected during the first 15 minutes following the birth, and should be processed by the laboratory within 48 hours. Processing and Storage Your baby’s cord blood will be processed and stored in a laboratory facility often referred to as a blood bank. The cord blood should be processed and stored in a facility that is accredited by the American Association of Blood Banks, a a bb, for handling stem cells. No Health Risks There are no health risks related to cord blood collection. Cord blood is retrieved from the umbilical cord after it has been cut, preventing any pain, discomfort, or harm. Cord blood collection is safe. Cost of Cord Blood Banking There are usually two fees associated with cord blood banking. The first is the initial fee which includes enrollment, collection and storage for at least the first year, and the second is an annual storage fee. Some facilities offer a variety of options for the initial fee with predetermined periods of storage. The initial fee will range from $900 to $2100 depending on the predetermined period of storage. Annual storage fees beyond the initial storage fee are approximately $100. It is quite common for storage facilities to offer prepaid plans at a discount as well as payment plans to make the initial storage more convenient for you and your family. Choosing not to Cord Blood Bank Your baby’s cord blood could be a valuable resource for another family. Whether it is through foundations, non-profit blood banks or medical institutions, there are numerous locations that will collect, process, and use the stem cells from your baby’s cord blood to help other people. There are no costs to you, and it is just like donating blood. If you do not choose to store your baby’s blood, consider donating. Your donation of cord blood could make a difference in someone else’s life. end |

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There are usually two fees associated with cord blood banking. The first is the initial fee which includes enrollment, collection and storage for at least the first year, and the second is an annual storage fee. Some facilities offer a variety of options for the initial fee with predetermined periods of storage.

The initial fee will range from $900 to $2100 depending on the predetermined period of storage. Annual storage fees beyond the initial storage fee are approximately $100. It is quite common for storage facilities to offer prepaid plans at a discount as well as payment plans to make the initial storage more convenient you and your family. cbr cordbloodbanking.com

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Evidence Based Practice for Women During Birth

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Weeks 27 â&#x20AC;&#x201C; 40

Note Book

Take notes and begin this journey...

Your Decisions are Key

Be Mindful & Make

Good Decisions

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Notes for Book 3t

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